Fill out the following form accurately indicating your potential and suitability for the job you are applying for.
Please list two (2) references that are familiar with your work life.
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer. Your withholding is subject to review by the IRS.
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.
TIP: To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job
If your total income will be $200,000 or less ($400,000 or less if married filing jointly)
Add the amounts above and enter the total here
(c) Extra withholding. Enter any additional tax you want withheld each pay period
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
2. Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
5. Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103. The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.
OMB No. 1615-0047
U.S. Citizenship and Immigration Services
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 nolater than the first day of employment, but not before accepting a job offer
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Employment Eligibility Verification Department of Homeland Security
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
List A Identity and Employment Authorization
List C Employment Authorization
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
(See instructions for exemptions)
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative
B. Date of Rehire (if applicable)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
All documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
Documents that Establish Both Identity and Employment AuthorizationOR
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
3. Foreign passport that contains a
temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
(1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
4. Employment Authorization Document that contains a photograph (Form
2. Certification of report of birth issued by the Department of State (Forms
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and
3. School ID card with a photograph
5. U.S. Military card or draft record
b. Form I-94 or Form I-94A that has
6. Military dependent's ID card
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
7. U.S. Coast Guard Merchant Mariner Card
4. Native American tribal document
5. U.S. Citizen ID Card (Form I-197)
8. Native American tribal document
9. Driver's license issued by a Canadian government authority
6. Identification Card for Use of Resident Citizen in the United
For persons under age 18 who are unable to present a document listed above:
7. Employment authorization document issued by the
Department of Homeland Security
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
Examples of many of these documents appear in the Handbook for Employers (M-274
Refer to the instructions for more information about acceptable receipts.