I-9 Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins Print Name: Last First

OMB No. 1615-0047; Expires 08/31/12 Form I-9, Employment Eligibility Verification

Last

First

Middle Initial

Maiden Name

Address (Street Name and Namber)

Apc. ,

Date of Birth (month/day/year)

Date

City

State

Zip Code

Social Security #

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

1 attest, under penalty of perjury. that am (check one of the following)

A citizen of the United States A noncitizes national of the United States (see instructions)

A laveful permanest resident (Aller #)

An alien authorized te work (Alica # or Admission #)

Employee's Signature

until (expiration date, if applicable month/day/year)

Date (monti/day/year)

Date

Preparer and/or Trauslator Certification (To be completed and signed if Section / is prepared by = person other thate the employee Tettest, ander penalty that / have assisted in the completion of that form and that to the best of ay knowledge the information a the and correct. Prepacers/Translator's Signature

Prepacers/Translator's Signature

Print Name

Address (Street Name and Namber. City. State. Zip Code)

Date

Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C. as listed on the reverse of this form, and record the title, number, and expiration date. if any. of the document(s

Document title

Issuing authority

Document #

Expiration Date a

Date

List C

Document #

Expiration Date (

Date

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be geneine and to relate to the employee named, that the employee begam employment on (month/day/year) and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee begam employment Signature of Employer or Authorized RepresentativePrint Name

(month/day/year)

Business or Organization Name and Address (Streer Name and Namber, Cary. Stase, Zip Code) IRS-HCO, 5333 Getwell Rd., Memphis, TN, 38118 Section 3. Updating and Reverification (To be completed and signed by employer A New Name @ applicable)

Signature of Employer or Authorized Representative

Print Name

Tide

Date

A New Name @ applicable)

c. If copployee's pervious grant of work authorization has expired, provide the information below for the document that establishes current employment authorization

B. Date of Rehire to applicable)

Date

Document Title

Document #

Expiration Date a

Date

Signature of Employer or Authorized Representative

Document Title: Document #: 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 gensine and le relate to the individual Signature of Employer or Authorized Representative Date (month/day/year)

Date (month/day/year)

Date

Form 1-9 (Rev. 08/07/09) Y Page 4