EFTA00525179.pdf

EMPLOYMENT APPLICATION Position Applying for. O Full-Time O Part-rune O Seasonal SMTWIFSat. Hours Available: and/or its affiliate , is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, sec, national origin, age, veteran sta tus, disability, or arty other legally pautedcrl status. NAME First Middle Last Soda! Security Number I Are you at least 18 yeas of age O Yes O No Present Street Address Gty State Zip Previous Street Address Gty State • Zip Phone Number Alternative Phone Number Are you a US. Citizen or can you provide verification of your legal right to work in the United States O Yes O No Position Desired CI Full Time o Part Tune Date Available for work Have you ever been employed by O Yes C. No Position: - ? Dales: • Lin names of friends or relatives now employed b.) aid/or Ss affiliate List office machines you an opera ie andude WPM and Shorthand) List other equipment you can operate Do you have any special skills or training related to the position scraght? EDUCATION Name of Institution Gty dr State Grcle Last Year Corn pitted High School 9 10 II 12 College 1 2 3 4 Graduate School • . Degree received O Yes O No Other MILITARY SERVICE BRANCH Rank Attained Dale Entered Date of Disdurge EFTA00525179 EMPLOYMEWI: Include all previous jobs starting with the present or most recent. . May we contact your pr ent employer? 0 Yes O /go .. Employer Pesition Held & Duties Adam, Phone No. Supervisor Dales Employed FP= To: Pay Rale Snarling: Wimp Sensor. for Leasing z Employer Position Held &Dutim Address Phone No. - Supervisor Daus Employed From: To: Pay Rate Stating: • Ending: Reason for Leasing 3. Employer Position Held &Duties Address Phone No. Supervisor . Dates Employed From: • To: Pay Rate Staniar _ EnclInF Roson for Laving Have you ever been convicted of a felony or a misdemeanor (other than minor traffic violations)? O Yes 0 No If yes, Please =plain: PLEASE READ TIDS STATEMENT CAREFULLY I agree to comply withal) rules of this Company. I understand that any falsification or omission of information provided on this application or while inteniewing win be grounds for dim-Lissa/ from employment, even if not discovered until after my separation from the Company. / authorize a thorough investigation to be made in conjunction with this application concerning my character, general septa lion, personal characteristic and mode of living. whichever maybe applicable. I understand this investigation may include personal interviews with third parties, such as family members, business assodates,financial sources,friends,neighbors or others with whom I am acquainted. I/lam hind, I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time, at the option of theCompany or myself. lurrierstandthatnoother representativeof theCompanyother than thePresident of N.A. Property, Inc. has the authority to modify this ageement in any way, and that any such modification must be in a writing signed by both the ?cadent and myself. I have read and affirm the above statement as my own. Sign> ruse One :re. 1 /t I EFTA00525180 LIS. Department or Justice Immigration mid Naturalization Service CiMS No III$.066 Employment Eligibility Verification Please 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 eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. Tube completed one signed by employee at the tame employment begins. Print Name Lest First Middle Intl el Maiden Name Addros (Street Name and Number) Apt a Date or Binh (inondildny/year) City State Zip Code Social Secunty • 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 pentxty of perjury, 0 A citizen o national of the 0 A Lawful Permanent Resident An amen authorized to (Alien i or Admission V) that I am (check one of the following)* United States (Allen X A work until / / Employees Signature Date (monrh/dayryeat) Preparer andlor Translator Certification. (ro be compieted and sinned a Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury. that I have assisted in the comp). on of rats form and that to me best of my knowledge the informerion is true and correct. Prepare: 5/Translator s Signature i Print Name Address (Sven mane and Number. City, State, Zip Code) Date (monfh/day/yeat) 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 capitol/on date, a any. of the document(s) List A Document lilt Issuing authority. Document 0 t.§ Expiration Date (if any) —1- 1 t., ; —1_1_ Y.:.: Document a. 'P .r., ....! Expiration Date (if any) 1._.1 ES CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-fisted document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) and that to the best of my knowledge the employee is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.) Signature of Employer or Authouted Representative OR List B AND List C —1_1 Print Name Tide Business or Organization Name Address atreer Name and Number. City. Stale, Zip COON Oato (month/day/year) Section 3. Updating and Reverification. To be completed and signed by employer A New Name Of OpPecalge) 8. Date of rehire Imontfirday/yeadfif affilCibki C. If employee's previous gam of work authorization has expred. provide ihv information below foe the document that establishes swim employment eligibility. Document Trite _ Document sr E .pvatlon Date Of any): / / I attest, under penalty of pertuey, that to the best of my knowledge, Mrs employee in eligible to work in the United 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 AuthonZed Representative Date (nontlildayiyear) Form1.91Rn I Page' EFTA00525181 LISTS OF ACCEPTABLE DOCUMENTS LIST A Documents that Establish Both Identity and Employment Eligibility 1. U.S. Passport (unexpired or expired) 2. Certificate of U.S. Citizenship (INS Form N-560 Of N-5611 3. Certificate of Naturalization (INS form N-550 or N-5701 4. Unexpired foreign passport. with 1-551 stamp or attached INS Form 1-94 indicating unexpired employment authorization 5. Permanent Resident Card or Alien Registration Receipt Card with photograph (INS Form I-151 or I-551) 6. Unexpired Temporary Resident Card (INS Form I-6881 7. Unexpired Employment Authorization Card (INS Form 1-688A1 8. Unexpired Reentry Permit (INS Form 1-3271 9. Unexpired Refugee Travel Document (INS Form 1-5711 10. Unexpired Employment Authorization Document :ssued by the INS which contains a photograph (INS Form I-6673B1 OR LIST B Documents that Establish Identity AND 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 For persons under age 18 who are unable to present a document listed above: 10. School record nr report card 11. Clinic, doctor or hospital record 12. Day-care or nursery school record LIST C Documents that Establish Employment Eligibility U.S. social security card issued by the Social Security Administration (oilier than a card stating it is not valid for employment) 2. Certification of Binh Abroad issued by the Department of State (Form FS-545 or Form 05.13501 3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (INS Form 1-1971 6. ID Card for use of Resident Citizen in the United Stales (INS Form 1-179) 7. Unexpired employment authorization document issued by the INS (other than those listed under List Al Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-2741 Ft= I 9:51.t: ittreterr enc. 3 EFTA00525182 NOTIFICATION/RELEASE OF INFORMATION FORM The purpose of this form is to notify you that consumer report will be conducted on you in the course of consideration for employment with: Last Name: First Name: Middle Name: Social Security #: State of Issue: Current Address: City: State: Zip: In connection with this request I authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to information about my employment, education, consumer credit history, driving record, criminal record and general public history to the person or company with which this form has been filed, or their agent. This releases the aforesaid parties from any liability and responsibility for collection of the above information. APPLICANT'S SIGNATURE: DATE: EFTA00525183 CONFIDENTIALITY AGREEMENT In order to induce NES, LLC ("NES") to consider the undersigned for employment or engagement as an independent contractor to provide services, including, without limitation, services with respect to NES, Jeffrey Epstein ("Epstein") and any of the Epstein Companies (as hereinafter defined) and real property directly and indirectly owned or occupied by NES, Epstein or any of the Epstein Companies (the "Properties"), and in consideration of any employment or engagement that the undersigned may obtain with NES, Epstein or any of the Epstein Companies, whether with respect to the Properties or otherwise, and any compensation or other remuneration to be hereafter paid to the undersigned in connection therewith, the undersigned, (hereinafter sometimes referred to as the Applicant"), acknowledges that the Applicant has been informed of the Applicant's obligations hereunder and that such obligations are a condition to the consideration by NES, Epstein or any of the Epstein Companies of the Applicant's employment or engagement, and to any employment or engagement that the Applicant may obtain, and the Applicant hereby agrees as follows: Section 1. Term of Employment; Termination. In the event that the Applicant is hereafter employed or engaged as an independent contractor by NES, Epstein or any of the Epstein Companies, the Applicant agrees and understands that nothing in this Agreement shall confer any right on the Applicant with respect to the grant or continuation of the Applicant's employment or engagement as an independent contractor. The Applicant further agrees and understands that, in the event that the Applicant is employed or engaged as an independent contractor, any breach of this Agreement by the Applicant will result, in addition to any and all other remedies which may then be available to NES, Epstein or any of the Epstein Companies, as the case may be, in the Applicant's immediate termination. Section 2. Confidentiality Obligations of the Applicant. 2.1 Defmition of Confidential Information. (a) For purposes of this Agreement, the term "Confidential Information" shall mean any "Business Information" (as hereinafter defined) and any "Personal Information" (as hereinafter defined) about any of: (i) the Properties or any other real property owned or occupied directly or indirectly by any of NES, Epstein or any of the Epstein Companies; (ii) NES, (iii) Epstein; (iv) any and all corporations, limited liability companies, trusts, limited partnerships, general partnerships or other entities with which Epstein is affiliated ("Epstein Companies"); (v) any of the members, managers, directors, officers, shareholders, limited partners, general partners, trustees, beneficiaries, employees, contractors or agents of NES, Epstein or any of the Epstein Companies; (vi) any person residing at, visiting or staying for any duration at any of the Properties; and (vii) any personal associate, business associate or client of any of the persons described in the above clauses (ii) through (vi), inclusive; previously or hereafter gathered or learned by the Applicant directly or indirectly during the course of the any interactions between the Applicant, on the one hand, and any of NES, Epstein and/or any of the Epstein Companies, or any representatives of NES, Epstein or any of the Epstein Companies, on the other hand, including, without limitation, during the course of Applicant's application for employment or engagement by NES, Epstein or any of the Epstein Companies and/or in connection with any employment or engagement of the Applicant by NES, Epstein or any of the Epstein Companies. EFTA00525184 (b) For purposes of this Agreement, the term "Business Information" shall mean information of any type which is commonly considered of a confidential nature and includes, but is not limited to, any information (whether in oral, written, photographic, electronic or other recorded form) regarding the existence, identities, contact information, and business records of; the business plans of; mechanized or nonmechanized systems of accounting of; IT related systems or information of; methods of doing business of; vendor information (including, without limitation, existence, identities, contact information, records, fees, and disbursements of, and services and materials provided by, any and all vendors, contractors, consultants, and professional advisors) of; confidential business lists and other proprietary data of; assets of; investment strategies, transactions, records, procedures and history of; financial records of; the skills, business activities, compensation and financial net worth of; and any other information of a similar nature about; any of the persons or entities set forth in Section 2.1(a) (the "Classified Parties"). (c) For purposes of this Agreement, the term "Personal Information" shall mean information of any type which is commonly considered of a personal nature and includes, but is not limited to, information (whether in oral, written, photographic, electronic or other recorded form) regarding the identities of; contact information of; personal characteristics of; physical descriptions of; non-business activities of; IT systems and information of; personal assets of; personal records of; personal plans of; personal lifestyles of; relationships of; friends of; relatives of; individuals who associate with or who are invited to associate with; and any other information of a similar nature about; any of the Classified Parties; and shall also include, without limitation, the appearance and exterior and interior layout of, any and all improvements on, and furniture, furnishings, and other items of personal property contained anywhere in or on, any of the Properties or any other real property directly or indirectly owned or occupied by NES, Epstein or any of the Epstein Companies. 2.2 Confidential Information Shall Not Be Discussed. At all times hereafter, the Applicant will hold in the strictest confidence and will not, directly or indirectly, use, communicate, publicize, lecture upon, publish or in any manner disclose any Confidential Information, unless NES has expressly authorized in writing such use, communication, publicizing, lecturing, publication, or disclosure. The Applicant hereby assigns to NES any and all rights the Applicant may have or acquire in any Confidential Information and acknowledges that all Confidential Information shall be the sole and exclusive property of NES. The Applicant further agrees and acknowledges that under this Agreement, the Applicant is obligated to use the Applicant's best efforts to ensure that no Confidential Information is used, communicated, publicized, lectured upon, published or disclosed by any persons employed or engaged by the Applicant or under the Applicant's supervision or control. To the extent that the Applicant has any doubts, either now or in the future, as to whether information the Applicant possesses is Confidential Information as defined herein, the Applicant will contact NES, for written clarification and approval before divulging or using such information in any manner whatsoever. Third Party Information Shall Not Be Disclosed. The Applicant understands that the Applicant may receive Confidential Information from third parties, as well as from NES. The Applicant acknowledges and agrees that Confidential Information which the Applicant receives from third parties is to be treated in the same manner as Confidential Information received from NES and that all of the Applicant's obligations hereunder apply to all Confidential EFTA00525185 Information received, regardless of its source. 2.4 Return of Documents. Upon demand by NES, and upon the expiration or termination of any employment or engagement as an independent contractor of the Applicant by NES, regardless of the reason or basis, if any, for such expiration or termination, the Applicant will deliver to NES any and all documents, written materials, notes, drawings, photographs, specifications and any other materials of any type or nature whatsoever (whether in written, photographic, electronic or other recorded form) which the Applicant has in the Applicant's possession or control, and all drafts, copies and electronic file copies of all or any part thereof, which may constitute, include, reflect or disclose any Confidential Information. Section 3. Review of Agreement. The Applicant acknowledges that the Applicant has read this Agreement, and that the Applicant has had the opportunity to review it and consult about it with the Applicant's own counsel if the Applicant so desires, before signing it. Section 4. Conflicts. 4.1 Avoidance of Conflict of Interest. If the Applicant is or subsequently becomes employed by NES, Epstein or any of the Epstein Companies (rather than being engaged as an independent contractor), the Applicant agrees that during the term of any such employment, so long as the Applicant is employed on a full-time basis, the Applicant will not, without the express written consent of NES, engage in any employment with any third party, or engage in any other business activity that would in any way conflict with the performance of the Applicant's duties of employment. 4.2 No Conflicting Obligations. The Applicant warrants and represents that the Applicant has not heretofore violated any provisions of this Agreement and that the Applicant has not entered into, or made, and agrees that the Applicant will not enter into or make, any written or oral agreement, undertaking, promise, or representation that conflicts with or violates the provisions of this Agreement or otherwise impairs the Applicant's ability to strictly perform the Applicant's obligations under this Agreement or to fully comply with the provisions of this Agreement. The Applicant further warrants and represents that the Applicant is not subject to any subpoena, injunction, decree, writ or order of any court or other authority or to any other duty or responsibility, legal or otherwise, which conflicts with the provisions of this Agreement or otherwise impairs the Applicant's ability to strictly perform the Applicant's obligations under this Agreement or to fully comply with the provisions of this Agreement. The Applicant shall immediately inform NES should the Applicant subsequently become subject to any such subpoena, injunction, decree, writ, order, duty or responsibility. Section 5. Remedies. 5.1 Equitable Relief. The Applicant acknowledges that the Confidential Information constitutes unique and confidential information of NES and the Classified Parties and in the event of a breach or a threatened breach of this Agreement, NES and any affected Classified Parties, will be irreparably harmed and there will be no adequate remedy at law. Therefore, in 3 EFTA00525186 addition to any and all other rights and remedies NES and any such Classified Parties may have, NES and such Classified Parties shall be entitled to injunctive or other equitable relief in the event of a breach or threatened breach hereof and the Applicant hereby waives any right to assert as a defense that there is an adequate remedy at law. 5.2 Liquidated Damages. In addition to any and all other rights, remedies or damages available at law or in equity, the Applicant agrees that if any court of competent jurisdiction finds that the Applicant has breached any of the provisions of this Agreement, the Applicant will pay NES or any affected Classified Party the sum of One Hundred Thousand ($100,000.00) Dollars, as liquidated damages and not as a penalty. The Applicant recognizes and understands that it would be difficult or impossible to calculate the actual amount of damages resulting from such a breach, and acknowledges that the sum of One Hundred Thousand ($100,000.00) Dollars would be reasonable under the circumstances. Section 6. General Provisions. 6.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of New York applicable to contracts executed, delivered and to be fully performed in such jurisdiction, without giving effect to the principles of conflicts of law. 6.2 Severability. If one or more of the provisions of this Agreement are deemed invalid or unenforceable by law, then the remaining provisions hereof will continue in full force and effect, without regard to the invalid or unenforceable provision or provisions hereof, as the provisions of this agreement are intended to be and shall be deemed severable. 6.3 Survival. The provisions of this Agreement shall continue in full force and effect, regardless of whether the Applicant is ultimately employed or engaged by NES, Epstein or any of the Epstein Companies, and if the Applicant is so employed or engaged, the provisions hereof shall survive the expiration or termination of any such employment or engagement of the Applicant, regardless of the reason or basis, if any, for such expiration or termination. 6.4 Binding Effect. This Agreement and all of the provisions hereof shall inure to the benefit of, and be enforceable by, NES, and its successors and assigns, and shall be binding upon the Applicant and the Applicant's heirs, personal representatives, successors and assigns. This Agreement is intended for the benefit of and to be enforceable by NES and by the Classified Parties as third-party beneficiaries of this Agreement. 6.5 Waiver. No waiver of any provision of this Agreement shall be valid unless expressly given in writing, signed by the party against whom such waiver is sought to be enforced, and specifying the specific instance and the specific purpose for which such waiver is given. Each such waiver, if any, shall be effective only for the specific instance and for the specific purpose for which it is given. No waiver by NES or any Classified Party of any breach of this Agreement shall be a waiver of any preceding or succeeding breach. No waiver by NES or any Classified Party of any right under this Agreement shall be construed as a waiver of any other right. Neither NES nor any Classified Party shall be required to give notice to enforce strict adherence to all of the terms and 4 EFTA00525187 provisions of this Agreement. 6.6 Headings. The headings contained herein are for convenience only and shall not control or effect in any way the meaning or interpretation of the provisions hereof. 6.7 Entire Agreement. This Agreement sets forth the entire agreement and understanding between NES and the Applicant relating to the subject matter hereof and supersedes and merges all prior discussions between them relating to the subject matter hereof. No modification of, or amendment to, this Agreement will be effective unless in writing signed by the party to be charged therewith. If the Applicant is hereafter employed or engaged by NES, Epstein or any of the Epstein Companies, any subsequent change or changes in the Applicant's duties, salary or other remuneration will not affect the validity or scope of this Agreement. Signed: Print Name: Date: Address: 5 EFTA00525188 Form W-4 (2019) Future developments. For the latest information about any future dovolopmonts related to Form W-4, such as legislation enacted after it was published, go to v./ww.im.90v/FonnW4. Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. You may claim exemption from withholding for 2019 if both of the blowing apply. • For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and • For 2019 you expect a refund of an federal income tax withheld because you expect to have no tax liability. If you're exempt, complete only lines 1, 2. 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2()20. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding. General Instructions If you aren't exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. You can also use the calculator at invvtictoos/W4App to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you're having withheld compares to your projected total tax for 2019. If you use the calculator, you don't need to complete any of the worksheets for Font W-4. Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you fie your tax retum, and you might owe a penalty. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you're married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-EamersrMultiple Jobs Worksheet before beginning. Nonwage Income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES. Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions. Adjustments, and Additional Income Worksheet on page 3 or the calculator at wivacirs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim. Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you're unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status. Line E. Child tax credit. When you file your tax retum, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other Income, including income earned by a spouse if you are filing a joint return. Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a chid tax credit can't be claimed, such as a qualifying child who doesn't meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total. Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Fa., W-4 I Owne r elate Teary Nernst Revenueffenic• Employee's Withholding Allowance Certificate iii Whether you' entitled to claim a certain number of allowances or exemption from withholding Is re subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. OMB No. 1545.0074 2019 I Your first narne and mddie initial Last name 2 Your social security number Home address (number and street or rural route) 3 DSinges [Warned El Married, but withhold at higher Single rate. Now downed fang separately. check "married, but withhold at higher SAO. rats' City or town, stale. and ZIP code 4 If your lost name differs from that shown on your social security cord. check here. You must call 800.7724213 for a replacement card. Ile• D 5 Total number of allowances you're claiming (from the applicable worksheet on the following pages) . . . . 5 6 Additional amount, if any, you want withheld from each paycheck 6 $ 7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, • This year I expect a refund of all federal income tax withheld because I expect to have no tax liabiity for exemption. and If you meet both conditions, write "Exempt" here P 171 Under penalties of perjury, I declare that I have examined this certificate and. to the best of my knowledge and baler, it is true, correct. and complete. Employee's signature (This form is not valid unless yOu sign it) r• a Employer's tume and address IF-mak/yen Cannata boxes 8 and to J sending to IRS arid candour bones B. 9. and 10 a mincing to State Directory of New Sent Date ev 9 Fest date of Sal pigment 10 EMPIDYer demitation number For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cm. No. 102200 Form W-4 poi% EFTA00525189 Form W-4 (2019) Pogo 2 income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return. Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter "-0-" on lines E and F if you use Worksheet 1.8. Deductions, Adjustments, and Additional Income Worksheet Complete this worksheet to determine If you're able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so. your refund at the end of the year will be smaller, but your paycheck will be larger. You're not required to complete this worksheet or reduce your withholding if you don't wish to do so. You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends. Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irtgay/W4App. If you use the calculator, you don't need to complete any of the worksheets for Form W-4. Two-Earners/Multiple Jobs Worksheet Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you don't complete this worksheet, you might have too little tax withheld. If so, you will awe tax when you file your tax return and might be subject to a penalty. Figure the total number of allowances you're entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim as allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn 560,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero ("-0-1 on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details. Mother option is to use the calculator at vnywirs.gov/W4App to make your withholding more accurate. Tip: If you have a working spouse and your incomes are similar, you can check the "Married, but withhold at higher Single rate" box instead of using this worksheet. if you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the "Married, but withhold at higher Single rate" box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions. Adjustments, and Additional Income Worksheet. Instructions for Employer Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes If necessary. New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8. 9. and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn't previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.ecthhs.govicsstemployers. If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer's name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee's first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer's service for at least 60 days, enter the rehire date. Box 10. Enter the employer's employer identification number (EIN). EFTA00525190 Form vi-e Nom page 3 Personal Allowances Worksheet (Keep for your records.) A Enter "r for yourself A B Enter 9' if you will file as married filing jointly B C Enter "1" if you will file as head of househOld C { • You're single, or married filing separately, and have only one job; or D Enter "1' if: • You're married filing jointly, have only one job, and your spouse doesn't work; or 1 D • Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. E Child tax credit. See Pub. 972, Child Tax Credit, for more information. • If your total income win be less than $71,201 ($103,351 if maned filing jointly), enter "e for each eligible child. • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter "r for each eligible child. • If your total income will be from $179,051 to $200,000 ($345,851 to $400.000 if married filing jointly), enter "1" for each eligible child. • If your total income wil be higher than $200,000 ($400,000 if married filing jointly), enter --0-- E F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information. • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter "1' for each eligible dependent. • If your total income will be from $71,201 to $179.050 ($103,351 to $345,850 if married filing jointly), enter "1" for every two dependents (for example. "-0-- for one dependent, "1" if you have two or three dependents, and "2" if you have four dependents). • If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter --0-" F G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here. If you use Worksheet 1-6, enter --O-" on lines E and F fil H Add lines A through G and enter the total here P H For accuracy, complete all worksheets that apply. • If you plan to itemize or claim adjustments to income and want to reduce your withholding. or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below. • If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married 11kg jointly), see the Two-Earners/MultIple Jobs Worksheet on page 4 to avoid having too little tax withheld. • If neither of the above situations applies, stop here and enter the number from line H on fine 5 of Form W-4 above. Deductions, Adjustments, and Additional Income Worksheet Note: 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 2019 itemized deductions. These include qualifying home mortgage interest, charitable contributions, slate and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See Pub. 505 for details 1 $ { $24,400 if you're married filing jointly or qualifying widow(w) 2 Enter: $18,350 if you're head of household 2 $ $12200 if you're single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter --0-" 3 $ 4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any additional standard deduction for ago or blindness (see Pub. 505 for information about these items) . . 4 5 Add lines 3 and 4 and enter the total 5 6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) 6 7 Subtract line 6 from line 5. If zero, enter "-0.". If less than zero, enter the amount in parentheses . . 7 8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses. Drop any fraction a 9 Enter the number from the Personal Allowances Worksheet, line H, above 9 10 Add lines 8 and 9 and enter the total here. If zero or less, enter'-0-". If you plan to use the Two-Earners/ Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 EFTA00525191 Tenn W-412019) Pago 4 Two-Earners/Multiple Jobs Worksheet Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here. 1 Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3. the number from tine worksheet) 10 of that 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you're married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don't enter more than "3- 2 3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter'-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3 Note: If line 1 is loss than line 2, enter "-0-" on Form W-4, line 5. page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet 4 5 Enter the number from line 1 of this worksheet 6 6 Subtract line 5 from line 4 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $ 8 Multiply fine 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you're paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019. Enter the result here and cn Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others I wages from LOWEST Enter on a wages from LOWEST Enter on If wages from HIGHEST Enter eve II wages from HIGHEST Enter on laWin9 it 04— Eno 2 above payrg job we— ate 2 above PaPn9 job are— !no 7 above pa/Ing job we— Ito 7 above RsaNagusszAziagatug.. tg10313138tpitglagtkkgs i, 2NAlsillAPmigagSP$PSE4sP il§§§§§gtM§§§§§§§§ 0 SO - $7,000 JON&W,I+OWM-40Na4N+0 SO - S24,900 5420 SO - $7,200 5420 I 7,001 - 13,000 24,901 - 84,450 500 7,201 • 38,975 500 2 130)1 • 27,500 84,451 • 173,900 910 36.976 • 81,700 910 3 27,501 - 32,000 173,901 - 326,950 1,000 81,701 - 158.225 1.000 4 32,001 • 40,000 326,951 • 413,700 1,330 158,226 • 201.600 1,330 5 40,001 - 60,000 413,701 - 617,850 1,450 201,601 - 507000 1.450 6 60,001 • 75,000 617,851 and over 1,540 507.101 and over 1,540 7 75.001 - 85.000 5 88.001 - 95.000 9 95,001 - 100,000 10 100,001 - 110,003 II 110,601 • 115.000 12 115,001 - 125,010 13 125,001 - 135,000 14 135,001 - 145,000 15 145.001 - 160,00) 16 160,001 • 150,003 17 1800(11 and over 111 19 Privacy Act and Paperwork Reduction Act Notice. We ask or the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(0(2) 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 property completed form will result in your being treated as a single person who claims no withholding allowances; 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 inteligence agencies to combat terrorism. You aren't required to provide the information requested on a form that's 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 con ents may become material in the administration of any Internal Revenue law. Generally, tax retums and return information are confidential, as required by Code section 8103. 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. EFTA00525192