C&A New Hire Docs

Employment Eligibility Verification

USCIS Form I-9
Section 1. Employee Information and Attestation:

Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.
First Name (Given Name)*
Middle Initial (if any)
Last Name (Family Name)*
Other Last Names Used (if any). Separate multiple names with a comma.
Full Name
Full Address
Date of Birth*

MonthDayYear
Date
US Social Security Number*
Enter 9 digits only; no dashes

- Employee's Email Address
  example@example.com
- Employee's Telephone Number
  Format: (000) 000-0000.
- Address (Street Number and Name)*
- Apt. Number (if any)
- City or Town*
- State*
- ZIP Code*
- A citizen of the United StatesA noncitizen national of the United States (See Instructions.)A lawful permanent resident (Enter USCIS or A-Number.)An alien authorized to work until (exp. date, if any)
- USCIS or A-Number
- Authorized to work until (enter expiration date, if any)
  
  MonthDayYear
  Date
- Which additional information will you provide?
- USCIS A-Number
- Form I-94 Admission Number
- Foreign Passport Number
- Country of Issuance
- I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, inclsuding my selection of the box attesting to my citizenship or immigration status, is true and correct.*
  
  Clear
  Signature of Employee
- Today's Date (mm/dd/yyyy)
  
  MonthDayYear
  Date
- NoYes
- If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.
- Supplement A, Preparer and/or Translator Certification for Section 1
- USCIS Form I-9 Supplement A
  
  OMB No. 1615-0047
  
  Expires 05/31/2027
- Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form 1-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form 1-9.
- 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 Signature of Preparer or Translator
  
  Clear
- Date (mm/dd/yyyy)
  
  MonthDayYear
  Date
- Name
  
  First NameMiddle InitialLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- 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. Signature of Preparer or Translator
  
  Clear
- Date (mm/dd/yyyy)
  
  MonthDayYear
  Date
- Name
  
  First NameMiddle InitialLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- 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 Signature of Preparer or Translator
  
  Clear
- Date (mm/dd/yyyy)
  
  MonthDayYear
  Date
- Name
  
  First NameMiddle InitialLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Clear
  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 Signature of Preparer or Translator
- Date (mm/dd/yyyy)
  
  MonthDayYear
  Date
- Name
  
  First NameMiddle InitialLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code

NoYes

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it
Name of Employer or Authorized Representative
Signature of Employer or Authorized Representative

Clear
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Check here if you used an alternative procedure authorized by DHS to examine documents.
Name of Employer or Authorized Representative
Signature of Employer or Authorized Representative

Clear
Check here if you used an alternative procedure authorized by DHS to examine documents.

List A DocumentList B AND List C Documents

Enter any additional information about the documentation
Check here if you used an alternative procedure authorized by DHS to examine documents.
First day of employment

MonthDayYear
Date
Last Name, First Name and Title of Employer or Authorized Representative
Employer signature*

Clear
Today's Date

MonthDayYear
Date
Employer's Business or Organization Name
Employer's Business or Organization Address, City or Town, State, ZIP Code

Rows	List A Document
Document Title
Issuing Authority
Document Number (if any)
Expiration Date (if any)

Rows	List B Document
Document Title
Issuing Authority
Document Number (if any)
Expiration Date (if any)

Rows	List C Document
Document Title
Issuing Authority
Document Number (if any)
Expiration Date (if any)

- Submit form IT 4 to your employer on or before the start date of employment so your employer will withhold and remit Ohio income taxfrom your compensation. If applicable, your employer will also withhold school district income tax. You must file an updated IT 4 when anyof the information listed below changes (including your marital status or number of dependents). You should contact your employer forinstructions on how to complete an updated IT 4. Your employer may require you to complete this form electronically. Refer to the official form and instructions. You will have a chance to review your completed IT 4 before you submit your final responses.
- School district of residence (See The Finder at tax.ohio.gov):*
  Enter the name of the school district
- School district number (####):*
  Enter the school district number
- Don't know your school district name or number? Use The Finder
- No, I am NOT exempt from Ohio withholodingYes, I am exempt from Ohio withholding
- 1. Are you a dependent on another individual’s Ohio return?*
- if dependent on another's OH return 0, else 1
- 2. Are you single or does your spouse file a separate Ohio return?*
- if single or spouse files separate OH return 0, else 1
- 3. How many dependents do you have?*
  Enter number of dependents
- 4. Total withholding exemptions (sum of line 1, 2, and 3) [auto-calculated]
- 5. Additional Ohio income tax withholding per pay period (optional)
  Enter the additional amount you withheld per pay period
- I am a full-year resident of Indiana, Kentucky, Michigan, Pennsylvania, or West Virginia.I am a resident military servicemember who is stationed outside Ohio on active duty military orders.I am a nonresident military servicemember who is stationed in Ohio due to military orders.I am a nonresident civilian spouse of a military servicemember and I am present in Ohio solely due to my spouse's military orders.I am exempt from Ohio withholding under R.C. 5747.06(A)(1) through (6).
- Under penalties of perjury, I declare that, to the best of my knowledge and belief, the information is true, correct and complete.*
  
  Clear
  Signature
- Date
  
  MonthDayYear
  Date

Disability and Disadvantaged Status Information
For the purpose of Goodwill Industries International, reporting and funding, please voluntarily complete the following questionnaire. Please read the statements and mark “yes” if ANY of the statements apply to you. This information will remain confidential and will not be part of your personnel file.

Disability (this would include any of the following):

Blindness or Other Visual Impairment: Blindness refers to the total or partial loss of sight. Legal blindness refers to an individual who has a visual acuity of 20/200 or less in the better eye with correction, and/or individuals whose visual field does not exceed 20 degrees.

Deafness or Hearing Impairment: Hard of hearing describes any degree of hearing loss, from light to profound, in a person who may benefit from a hearing aid or some other assistive device. Deafness refers to profound hearing loss in a person who does not have the ability to discriminate speech aurally.

Other Physical Disability: This category includes orthopedic disabilities, arthritis, pulmonary, and cardiac disorders. An orthopedic disability is a disability associated with bone and muscles around the bone. Examples include individuals with amputations, back and spinal cord injuries. Arthritis and rheumatic disease refer to over 100 different diseases that cause inflammation and pain in the joints and can result in loss of mobility. Pulmonary and cardiac disabilities refer to diseases of the lungs and or respiratory system and diseases of the heart or blood vessels respectively.

Neurological Disability: An impairment of the brain and nervous system, this category includes all individuals with head injuries including Tramatic Brain Injury (TBI), Parkinson's disease, Alzheimer's disease, Multiple Sclerosis, and Epilepsy.

Learning Disability other than Autism: A disability that impacts the understanding or use of language, spoken or written, and that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. Learning disabilities include Dyslexia, Aphasia, Developmental Writing Disorders, and Central Auditory Processing Disorders, ADD ADHD.

Developmental Disability other than Autism: A diverse group of cognitive, psychological, physical, sensory, and speech impairments that begin anytime during development up to 18 years of age. Mental retardation is the most common developmental disability. This category also includes Downsyndrome, and fetal alcohol syndrome.

Autism: Autism spectrum disorder (ASD) and autism are both general terms for a group of complex disorders of brain development. These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors. They include autistic disorder, Rett syndrome, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS) and Asperger syndrome.

Psychiatric and/or Emotional Disability: A disability that substantially impairs a person's thought, perception of reality, emotional process or judgment. Examples of psychiatric/emotional disabilities include schizophrenia, bipolar disorder, obsessive-compulsive disorder, anxiety disorders, and depression.

History of Substance Abuse: Is defined as the history of loss of control over use of a mood altering substance and subsequent use despite negative consequences. This category includes drug and alcohol dependency.

Other disabling condition: Other disabling condition not described above.
NoYes

Disadvantaged (this would include any of the following):

Unemployed/Dislocated Worker: Individuals who have previously been in the labor force but who have lost their jobs due to lay offs, plant closings, downsizing, or circumstances.

Incumbent workers/working poor: Workers who currently hold a job who are often seeking to upgrade their skills to obtain a better job or maintain the skills needed for their current job. Working poor is a subset of incumbent workers and is defined as individuals who are in the labor force but earn less than 200% of the poverty level.

Welfare Recipient: Individuals or families receiving assistance through a variety of federal and state programs, which provide cash and non-cash aid to the poor. Such programs include: Temporary Assistance for Needy Families (TANF), General Assistance (GA), Supplemental Security Income (SSI), Pensions for Needy Veterans, Earned Income Tax Credits, Food Stamps, Title XX Social Services, Medicaid, School Lunch Programs, Special Supplemental Food Program for Woman, Infants and Children (WIC), Low Income Housing Assistance and Low Income Home Energy Assistance Program (LIHEAP).

At-Risk Youth: Individuals 16-24 who may be single parents, gang members, school dropouts and/or who exhibit behavior patterns which pose barriers to social integration and employmen.

Person with a Criminal Background: Any adult or juvenile who is or has been subject to any stage of the criminal justice process and who requires assistance in overcoming barriers to employment resulting from a record of arrests or convictions.

Older Workers: Individuals age 55 or above.

Homeless: An individual who: (1) lacks a fixed, regular and adequate residence; or (2) has a primary residence that is: (a) a supervised, publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to be institutionalized; or (c) a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings. (McKinney Act (P.L. 100 77, sec. 103(21) 101 sat. 485 [1987])).

Non English Speaking/English as a second language: Individuals where the predominant language spoken in the home is not English.

Lack of Literacy: Individuals who lack basic reading or comprehension skills in their primary language.

Lack of GED/ High School Equivalency: Individuals who lack basic education to the level of high school equivalency.

Lack of Market-Valued, Post-Secondary Credential: A post-secondary credential is awarded in obtain employment or advance within an occupation.

Other Disadvantaging Condition: Any other condition not previously listed.
NoYes

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Employment Eligibility Verification

Section 1. Employee Information and Attestation:

Supplement A, Preparer and/or Translator Certification for Section 1

Form W-4 Employee's Withholding Certificate

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