INSTRUCTIONS — 2 — (OPTIONAL) ADDITIONAL WITHHOLDING ALLOWANCES. If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim . one or more additional. withholding allowances.
INSTRUCTIONS — 2 — (OPTIONAL) ADDITIONAL WITHHOLDING ALLOWANCES. If you expect to itemize deductions on your California income tax return, you ...
Production Company
START FORM / DEAL MEMO
EMAIL COMPLETED FORMS TO YOUR PAYROLL COORDINATOR
Production Title
Employee Name (Last, First, Middle Initial)
Social Security Number
Permanent Address
Apt#
City
State
Zip
Mailing Address (If Different From Above)
Apt#
City
State
Zip
IF AN AGENT, OR OTHER 3RD PARTY RECIPIENT, SHOULD RECEIVE THE CHECK PAYMENT(S), THEN A SIGNED 'CHECK PAYMENT AUTHORIZATION' MUST BE ATTACHED.
1st Phone Number (Circle Type)
Home Cell Office
/
/
Date of Birth (Required)
YES NO Minor? (Circle One)
YES NO U.S. Citizen? (Circle One)
2nd Phone Number (Circle Type)
Home Cell Office
Email Address
MALE FEMALE NON-BINARY Gender (Circle One)
WHITE
BLACK
ETHNIC CODE (Please check one)
HISPANIC
ASIAN
NATIVE AMERICAN
OTHER
Union / Local No.
Position / Job Classification
Hourly Daily Weekly Rate per: (Circle One)
$$$ Rate
Labor Accounting Code
Fringe Accounting Code
Holiday Accrual Code
Work State Guaranteed Hours:
/
/
Start Date
Box Rental Rate *
Box Rental Accounting Code
(Must Attach Box Rental Inventory)
Per Diem Rate
Per Diem Accounting Code Other Payments / Terms
In order to ensure compliance under the Affordable Care Act, please check the applicable employment classification box below. PLEASE NOTE: The classification will impact healthcare eligibility.
Full Time Employee of the company?* Variable Hour Employee of the Company?**
Corporate Owner of the company? Officer of the Company?
Employee Signature
Date
Authorized Signature
Date
* Full Time Employee - Such employee must be hired with (a) no intention of having periods of unemployment, seasonality or variability in employment, and (b) expected to work a consistent 30 hours or more per week ** Variable Hour Employee - If an employer cannot determine whether the employee is reasonably expected to work an average of at least 30 hours per week because the employee's hours are variable OR they
know the employee is expected to terminate employment within 60 days of hire, the employee should be considered a Variable Hour Employee
CALIFORNIA 12121 Wilshire Blvd, Suite 205
Los Angeles, CA 90025 310.789.2001
GEORGIA 550 Pharr Road, Suite 207
Atlanta, GA 30305 404.465.3383
GREENSLATE OFFICES
NEW MEXICO 100 Sun Avenue N.E., Suite 650 Albuquerque, New Mexico, 87109
505.823.6888
NEW YORK 150 West 30th Street, Suite 405
New York, NY 10001 212.206.1099
LOUISIANA 1 Galleria Blvd, #1925
Metairie, LA 70001 504.702.1901
Clear Form
EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE
Complete this form so that your employer can withhold the correct California state income tax from your paycheck.
Enter Personal Information
First, Middle, Last Name
Social Security Number
Address City, State, and ZIP Code
Filing Status
SINGLE or MARRIED (with two or more incomes) MARRIED (one income) HEAD OF HOUSEHOLD
1. Total Number of Allowances you're claiming (Use Worksheet A for regular withholding allowances. Use other worksheets on the following pages as applicable, Worksheet A+B).
2. Additional amount, if any, you want withheld each pay period (if employer agrees), (Worksheet B and C) OR
Exemption from Withholding
3. I claim exemption from withholding for 2020, and I certify I meet both of the conditions for exemption. OR
Write "Exempt" here
4. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act and the Veterans Benefits and Transition Act of 2018.
(Check box here)
Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.
Employee's Signature ____________________________________________________________
Date
Employer's Section: Employer's Name and Address
California Employer Payroll Tax Account Number
PURPOSE: This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation.
Beginning January 1, 2020, Employee's Withholding Allowance Certificate (Form W-4) from the Internal Revenue Service (IRS) will be used for federal income tax withholding only. You must file the state form Employee's Withholding Allowance Certificate (DE 4) to determine the appropriate California Personal Income Tax (PIT) withholding.
If you do not provide your employer with a withholding certificate, the employer must use Single with Zero withholding allowance.
CHECK YOUR WITHHOLDING: After your DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form.
EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4 and the state DE 4. You may claim exempt from withholding California income tax if you meet both of the following conditions for exemption:
1. You did not owe any federal/state income tax last year, and
2. You do not expect to owe any federal/state income tax this year. The exemption is good for one year.
If you continue to qualify for the exempt filing status, a new DE 4 designating EXEMPT must be submitted by February 15 each year to continue your exemption. If you are not having federal/state income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new DE 4 by December 1.
Member Service Civil Relief Act: Under this act, as provided by the Military Spouses Residency Relief Act and the Veterans Benefits and Transition Act of 2018, you may be exempt from California income tax on your wages if
(i) your spouse is a member of the armed forces present in California in compliance with military orders;
(ii) you are present in California solely to be with your spouse; and
(iii) you maintain your domicile in another state.
If you claim exemption under this act, check the box on Line 4. You may be required to provide proof of exemption upon request.
DE 4 Rev. 49 (2-20) (INTERNET)
Page 1 of 4
The California Employer's Guide (DE 44) (PDF, 2.4 MB) (edd.ca.gov/pdf_pub_ctr/de44.pdf) provides the income tax withholding tables. This publication may be found by visiting Forms and Publications (edd.ca.gov/Payroll_Taxes/Forms_and_ Publications.htm). To assist you in calculating your tax liability, please visit the Franchise Tax Board (FTB) (ftb.ca.gov).
If you need information on your last California Resident Income Tax Return (FTB Form 540), visit the Franchise Tax Board (FTB) (ftb.ca.gov).
NOTIFICATION: The burden of proof rests with the employee to show the correct California income tax withholding. Pursuant to section 4340-1(e) of Title 22, California Code of Regulations (CCR), the FTB or the EDD may, by special direction in writing, require an employer to submit a Form W-4 or DE 4 when such forms are necessary for the administration of the withholding tax programs.
PENALTY: You may be fined $500 if you file, with no reasonable basis, a DE 4 that results in less tax being withheld than is properly allowable. In addition, criminal penalties apply for willfully supplying false or fraudulent information or failing to supply information requiring an increase in withholding. This is provided by section 13101 of the California Unemployment Insurance Code and section 19176 of the Revenue and Taxation Code.
DE 4 Rev. 49 (2-20) (INTERNET)
Page 2 of 4
WORKSHEETS
INSTRUCTIONS -- 1 -- ALLOWANCES*
When determining your withholding allowances, you must consider your personal situation: -- Do you claim allowances for dependents or blindness? -- Will you itemize your deductions? -- Do you have more than one income coming into the household?
TWO-EARNERS/MULTIPLE INCOMES: When earnings are derived from more than one source, under-withholding may occur. If you have a working spouse or more than one job, it is best to check the box "SINGLE or MARRIED (with two or more incomes)." Figure the total number of allowances you are entitled to claim on all jobs using only one DE 4 form. Claim allowances with one employer.
Do not claim the same allowances with more than one employer. Your withholding will usually be most accurate when all allowances are claimed on the DE 4 filed for the highest paying job and zero allowances are claimed for the others.
MARRIED BUT NOT LIVING WITH YOUR SPOUSE: You may check the "Head of Household" marital status box if you meet all of the following tests: (1) Your spouse will not live with you at any time during the year; (2) You will furnish over half of the cost of maintaining a home for the
entire year for yourself and your child or stepchild who qualifies as your dependent; and (3) You will file a separate return for the year.
HEAD OF HOUSEHOLD: To qualify, you must be unmarried or legally separated from your spouse and pay more than 50% of the costs of maintaining a home for the entire year for yourself and your dependent(s) or other qualifying individuals. Cost of maintaining the home includes such items as rent, property insurance, property taxes, mortgage interest, repairs, utilities, and cost of food. It does not include the individual's personal expenses or any amount which represents value of services performed by a member of the household of the taxpayer.
WORKSHEET A
REGULAR WITHHOLDING ALLOWANCES
(A) Allowance for yourself -- enter 1
(A)
(B) Allowance for your spouse (if not separately claimed by your spouse) -- enter 1
(B)
(C) Allowance for blindness -- yourself -- enter 1
(C)
(D) Allowance for blindness -- your spouse (if not separately claimed by your spouse) -- enter 1
(D)
(E) Allowance(s) for dependent(s) -- do not include yourself or your spouse
(E)
(F) Total -- add lines (A) through (E) above and enter on line 1 of the DE 4
(F)
INSTRUCTIONS -- 2 -- (OPTIONAL) ADDITIONAL WITHHOLDING ALLOWANCES
If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year's FTB Form 540 as a model to calculate this year's withholding amounts.
Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not taxed on this worksheet.
You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $1,000, or fraction of $1,000, by which you expect your estimated deductions for the year to exceed your allowable standard deduction.
WORKSHEET B
ESTIMATED DEDUCTIONS
Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage income not subject to
withholding.
1. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in the schedules in the FTB Form 540 1.
2. Enter $9,074 if married filing joint with two or more allowances, unmarried head of household, or qualifying widow(er) with dependent(s) or $4,537 if single or married filing separately, dual income married, or married with multiple employers
2.
3. Subtract line 2 from line 1, enter difference
= 3.
4. Enter an estimate of your adjustments to income (alimony payments, IRA deposits)
+ 4.
5. Add line 4 to line 3, enter sum
= 5.
6. Enter an estimate of your nonwage income (dividends, interest income, alimony receipts)
6.
7. If line 5 is greater than line 6 (if less, see below [go to line 9]); Subtract line 6 from line 5, enter difference
= 7.
8. Divide the amount on line 7 by $1,000, round any fraction to the nearest whole number
8.
Add this number to Line F of Worksheet A and enter it on line 1 of the DE 4. Complete Worksheet C, if needed, otherwise stop here.
9. If line 6 is greater than line 5;
Enter amount from line 6 (nonwage income)
9.
10. Enter amount from line 5 (deductions)
10.
11. Subtract line 10 from line 9, enter difference
11.
Complete Worksheet C
*Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California PIT withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner in a domestic partner relationship within the meaning of section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center at 1-888-745-3886.
DE 4 Rev. 49 (2-20) (INTERNET)
Page 3 of 4
WORKSHEET C
ADDITIONAL TAX WITHHOLDING AND ESTIMATED TAX
1. Enter estimate of total wages for tax year 2020.
1.
2. Enter estimate of nonwage income (line 6 of Worksheet B).
2.
3. Add line 1 and line 2. Enter sum.
3.
4. Enter itemized deductions or standard deduction (line 1 or 2 of Worksheet B, whichever is largest).
4.
5. Enter adjustments to income (line 4 of Worksheet B).
5.
6. Add line 4 and line 5. Enter sum.
6.
7. Subtract line 6 from line 3. Enter difference.
7.
8. Figure your tax liability for the amount on line 7 by using the 2020 tax rate schedules below.
8.
9. Enter personal exemptions (line F of Worksheet A x $134.20).
9.
10. Subtract line 9 from line 8. Enter difference.
10.
11. Enter any tax credits. (See FTB Form 540).
11.
12. Subtract line 11 from line 10. Enter difference. This is your total tax liability.
12.
13. Calculate the tax withheld and estimated to be withheld during 2020. Contact your employer to request
the amount that will be withheld on your wages based on the marital status and number of withholding
allowances you will claim for 2020. Multiply the estimated amount to be withheld by the number of pay
periods left in the year. Add the total to the amount already withheld for 2020.
13.
14. Subtract line 13 from line 12. Enter difference. If this is less than zero, you do not need to have additional
taxes withheld.
14.
15. Divide line 14 by the number of pay periods remaining in the year. Enter this figure on line 2 of the DE 4.
15.
NOTE: Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not agree to withhold the additional amount, you may increase your withholdings as much as possible by using the "single" status with "zero" allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on Form 540-ES with the FTB to avoid a penalty.
THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 2020 ONLY
SINGLE PERSONS, DUAL INCOME MARRIED WITH MULTIPLE EMPLOYERS
MARRIED PERSONS
IF THE TAXABLE INCOME IS
OVER
$0 $8,809 $20,883 $32,960 $45,753 $57,824 $295,373 $354,445 $590,742 $1,000,000
BUT NOT OVER $8,809
$20,883 $32,960 $45,753 $57,824 $295,373 $354,445 $590,742 $1,000,000 and over
COMPUTED TAX IS OF AMOUNT OVER...
PLUS
1.100% 2.200% 4.400% 6.600% 8.800% 10.230% 11.330% 12.430% 13.530% 14.630%
$0 $8,809 $20,883 $32,960 $45,753 $57,824 $295,373 $354,445 $590,742 $1,000,000
$0.00 $96.90 $362.53 $893.92 $1,738.26 $2,800.51 $27,101.77 $33,794.63 $63,166.35 $118,538.96
IF THE TAXABLE INCOME IS
OVER
$0 $17,618 $41,766 $65,920 $91,506 $115,648 $590,746 $708,890 $1,000,000 $1,181,484
BUT NOT OVER
$17,618 $41,766 $65,920 $91,506 $115,648 $590,746 $708,890 $1,000,000 $1,181,484 and over
COMPUTED TAX IS OF AMOUNT OVER...
PLUS
1.100% 2.200% 4.400% 6.600% 8.800% 10.230% 11.330% 12.430% 13.530% 14.630%
$0 $17,618 $41,766 $65,920 $91,506 $115,648 $590,746 $708,890 $1,000,000 $1,181,484
$0.00 $193.80 $725.06 $1,787.84 $3,476.52 $5,601.02 $54,203.55 $67,589.27 $103,774.24 $128,329.03
UNMARRIED HEAD OF HOUSEHOLD
IF THE TAXABLE INCOME IS
OVER
$0 $17,629 $41,768 $53,843 $66,636 $78,710 $401,705 $482,047 $803,410 $1,000,000
BUT NOT OVER
$17,629 $41,768 $53,843 $66,636 $78,710 $401,705 $482,047 $803,410 $1,000,000 and over
COMPUTED TAX IS OF AMOUNT OVER...
PLUS
1.100% 2.200% 4.400% 6.600% 8.800% 10.230% 11.330% 12.430% 13.530% 14.630%
$0 $17,629 $41,768 $53,843 $66,636 $78,710 $401,705 $482,047 $803,410 $1,000,000
$0.00 $193.92 $724.98 $1,256.28 $2,100.62 $3,163.13 $36,205.52 $45,308.27 $85,253.69 $111,852.32
If you need information on your last California Resident Income Tax Return, FTB Form 540, visit Franchise Tax Board (FTB) (ftb.ca.gov).
The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, CCR, section 4340-1, and the California Revenue and Taxation Code, including section 18624. The Information Practices Act of 1977 requires that individuals be notified of how information they provide may be used. Further information is contained in the instructions that came with your last California resident income tax return.
DE 4 Rev. 49 (2-20) (INTERNET)
Page 4 of 4
Employment Eligibility Verification
Department of Homeland Security U.S. Citizenship and Immigration Services
USCIS Form I-9
OMB No. 1615-0047 Expires 10/31/2022
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 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number City or Town
State ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
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.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions)
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.
QR Code - Section 1 Do Not Write In This Space
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator.
A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(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.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State ZIP Code
Form I-9 10/21/2019
Employer Completes Next Page
Page 1 of 3
Employment Eligibility Verification
Department of Homeland Security U.S. Citizenship and Immigration Services
USCIS Form I-9
OMB No. 1615-0047 Expires 10/31/2022
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.")
Last Name (Family Name) Employee Info from Section 1
First Name (Given Name)
M.I. Citizenship/Immigration Status
List A Identity and Employment Authorization
Document Title
OR Document Title
List B Identity
AND
List C Employment Authorization
Document Title
Issuing Authority
Issuing Authority
Issuing Authority
Document Number
Document Number
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy)
Additional Information
QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy)
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.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial Date (mm/dd/yyyy)
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.
Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)
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.
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
Form I-9 10/21/2019
Page 2 of 3
LISTS OF ACCEPTABLE DOCUMENTS 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.
LIST A
Documents that Establish Both Identity and
Employment Authorization OR
LIST B
Documents that Establish Identity
AND
LIST C
Documents that Establish Employment Authorization
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
a. Foreign passport; and
b. Form I-94 or Form I-94A that has 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.
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
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
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
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
9. Driver's license issued by a Canadian government authority
1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
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
4. Native American tribal document
5. U.S. Citizen ID Card (Form I-197)
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
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
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.
Form I-9 10/21/2019
Page 3 of 3
NOTICE TO EMPLOYEE
Labor Code section 2810.5
EMPLOYEE
Employee Name: Start Date:
EMPLOYER
Legal Name of Hiring Employer: Is hiring employer a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing Company; or Professional Employer Organization [PEO])? Yes No
Other Names Hiring Employer is "doing business as" (if applicable):
Physical Address of Hiring Employer's Main Office:
Hiring Employer's Mailing Address (if different than above):
Hiring Employer's Telephone Number:
If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity for whom this employee will perform work: Name: Physical Address of Main Office: Mailing Address: Telephone Number:
WAGE INFORMATION
Rate(s) of Pay:
Overtime Rate(s) of Pay:
Rate by (check box): Hour Shift Day Week Salary Piece rate Commission
Other (provide specifics):
Does a written agreement exist providing the rate(s) of pay? (check box) Yes No
If yes, are all rate(s) of pay and bases thereof contained in that written agreement? Yes No
Allowances, if any, claimed as part of minimum wage (including meal or lodging allowances):
(If the employee has signed the acknowledgment of receipt below, it does not constitute a "voluntary written agreement" as required under the law between the employer and employee in order to credit any meals or lodging against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.)
Regular Payday:
DLSE-NTE (rev 9/2014)
WORKERS' COMPENSATION
Insurance Carrier's Name: Address: Telephone Number: Policy No.:
Self-Insured (Labor Code 3700) and Certificate Number for Consent to Self-Insure:
PAID SICK LEAVE
Unless exempt, the employee identified on this notice is entitled to minimum requirements for paid sick leave under state law which provides that an employee:
a. May accrue paid sick leave and may request and use up to 3 days or 24 hours of accrued paid sick leave per year; b. May not be terminated or retaliated against for using or requesting the use of accrued paid sick leave; and c. Has the right to file a complaint against an employer who retaliates or discriminates against an employee for
1. requesting or using accrued sickdays; 2. attempting to exercise the right to use accrued paid sick days; 3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code; 4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any policy or
practice or act that is prohibited by Article 1.5 section 245 et seq. of the California Labor Code.
The following applies to the employee identified on this notice: (Check one box) 1. Accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq. with no
other employer policy providing additional or different terms for accrual and use of paid sick leave. 2. Accrues paid sick leave pursuant to the employer's policy which satisfies or exceeds the accrual, carryover, and use
requirements of Labor Code§246. 3. Employer provides no less than 24 hours (or 3 days) of paid sick leave at the beginning of each 12-month period. 4. The employee is exempt from paid sick leave protection by Labor Code §245.5. (State exemption and specific
subsection for exemption):
ACKNOWLEDGEMENT OF RECEIPT (Optional)
(PRINT NAME of Employer representative)
(PRINT NAME of Employee)
(SIGNATURE of Employer Representative)
(SIGNATURE of Employee)
(Date)
(Date)
The employee's signature on this notice merely constitutes acknowledgement of receipt.
Labor Code section 2810.5(b) requires that the employer notify you in writing of any changes to the information set forth in this Notice within seven calendar days after the time of the changes, unless one of the following applies: (a) All changes are reflected on a timely wage statement furnished in accordance with Labor Code section 226; (b) Notice of all changes is provided in another writing required by law within seven days of the changes.
DLSE-NTE (rev 9/2014)
150 West 30th Street, Suite 405 New York, NY 10001 212.206.1099 Tel 212.206.1070 Fax
Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize GreenSlate to initiate automatic deposits to my account at the financial institution named below. I also authorize GreenSlate to make withdrawals from this account in the event that a credit entry is made in error.
Further, I agree not to hold GreenSlate responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
This agreement will remain in effect until GreenSlate receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
Account Information
Name of Financial Institution:
Routing Number: Account Number:
Checking ("X") Savings ("V")
Signature
Print Name (Primary)
Date:
Authorized Signature (Primary):
Date:
Authorized Signature (Joint):
Date:
Please attach a direct deposit form issued by your bank or a voided check and return this form to the Payroll Department.
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