Madison County Public Library
NEW STAFF MEMBER CHECKLIST
EMPLOYEE INFORMATION
Name:
Start date:
Position:
Manager:
FIRST DAY
Provide employee with Staff Member Handbook
Provide all forms that must be filled out. Provide time to fill them out..
POLICIES
Review key policies for
Example:






 Personal conduct standards
 Confidentiality
Vacation and sick leave
Holidays
Time and leave reporting
Overtime
Performance reviews
Dress code
ADMINISTRATIVE PROCEDURES




Review general administrative
procedures.
Office/desk/work station
Keys
Mail (incoming and outgoing)
Business cards
 Telephones
 Picture ID badges
 Office supplies
INTRODUCTIONS AND TOURS
Give introductions to department staff and key personnel during tour.
Tour of facility, including:
Tour of other facility to meet
Fellow staff
 Restrooms
 Copy machine
 Fax machines




Library sections
Parking
Printers
Office supplies
 Kitchen
POSITION INFORMATION
Introductions to other staff and understanding of their roles in relation to the new person
Review initial job assignments and training plans.
Review job description and performance expectations and standards.
Review job schedule and hours.
Review payroll timing, time sheets, and policies and procedures.
COMPUTERS
Hardware and software reviews, including:
 E-mail
 Intranet
 Dynix—circulation proc.  Databases
 Catalog: Website
 Internet
STAFF INFORMATION SHEET
DATE: _____________________
NAME__________________________________________________________________
ADDRESS______________________________________________________________
PHONE NUMBER ________________________________ Cell 
Landline  Text ok? 
JOB TITLE_______________________________________________
STARTING DATE_________________________________________
BIRTHDATE______________________________________________
EMERGENCY CONTACT
NAME__________________________________________________________________
ADDRESS_____________________________________________________________
PHONE___________________________
*** Remember to complete a new form if your emergency contact changes
Employee Signature: _________________________________________________________
Updated 8/11/14
Revenue Form K-4
42A804 (11-10)
KENTUCKY DEPARTMENT OF REVENUE
EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
Print Full Name_________________________________________________________________________
Payroll No. __________________________
Social Security No.____________________________
Print Home Address_____________________________________________________________________________________________________________________
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
EMPLOYEE:
Failure to file this form with
your employer will result in
withholding tax deductions
from your wages at the
maximum rate. EMPLOYER:
Keep this certificate with
your records.
1. If SINGLE, and you claim an exemption, enter “1,” if you do not, enter “0”................................................................_________
2. If MARRIED, one exemption each for you and spouse if not claimed on another certificate.
}
(a)If you claim both of these exemptions, enter “2”
(b)If you claim one of these exemptions, enter “1” . ..............................................................................................._________
(c) If you claim neither of these exemptions, enter “0”
3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents):
(a)If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption,
enter “2”; if both will be 65 or older, and you claim both of these exemptions, enter “4”..................................._________
(b)If you or your spouse are blind, and you claim this exemption, enter “2”; if both are blind, and you claim
both of these exemptions, enter “4”.........................................................................................................................._________
4. If you claim exemptions for one or more dependents, enter the number of such exemptions................................._________
5. National Guard exemption (see instruction 1)................................................................................................................_________
6. Exemptions for Excess Itemized Deductions (Form K-4A)............................................................................................._________
7. Add the number of exemptions which you have claimed above and enter the total..................................................
8. Additional withholding per pay period under agreement with employer. See instruction 1............................$_____________ I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date _________________________________ Signed___________________________________________________________________________________
INSTRUCTIONS
1. NUMBER OF EXEMPTIONS—Do not claim more than the correct
number of exemptions. However, if you have unusually large amounts
of itemized deductions, you may claim additional exemptions to avoid
excess withholding. You may also claim an additional exemption if you
will be a member of the Kentucky National Guard at the end of the year.
If you expect to owe more income tax for the year than will be withheld,
you may increase the withholding by claiming a smaller number of
exemptions or you may enter into an agreement with your employer to
have additional amounts withheld. If you claim more than 10 exemptions
this information is sent to the Department of Revenue.
2. CHANGES IN EXEMPTIONS—You may file a new certificate at
any time if the number of your exemptions INCREASES.
You must file a new certificate within 10 days if the number of
exemptions previously claimed by you DECREASES for any of the
following reasons.
(a) You are divorced or legally separated from your spouse for
whom you have been claiming an exemption or your spouse claims his
or her own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption
is taken over by someone else, so that you no longer expect to furnish
more than half the support for the year.
(c) Your itemized deductions substantially decrease and a Form
K-4A has previously been filed.
OTHER DECREASES in exemption, such as the death of a spouse
or a dependent, do not affect your withholding until the next year, but
require the filing of a new certificate by December 1 of the year in which
they occur.
3. DEPENDENTS—To qualify as your dependent (line 4 on reverse), a person
(a) must receive more than one-half of his or her support from you for the year,
and (b) must not be claimed as an exemption by such person’s spouse, and (c)
must be a citizen of the United States, or a resident of the United States, Canada,
or Mexico, or (d) must have lived with you for the entire year as a member of
your household or be related to you as follows:
your child, stepchild, legally adopted child, foster child (if he lived in your
home as a member of the family for the entire year), grandchild, son-in-law,
or daughter-in-law;
your father, mother, or ancestor of either, stepfather, stepmother, father-inlaw, or mother-in-law;
your brother, sister, stepbrother, stepsister, brother-in-law, or sister-in-law;
your uncle, aunt, nephew, or niece (but only if related by blood).
4. PENALTIES—Penalties are imposed for willfully supplying false information
or willful failure to supply information which would reduce the withholding
exemption.
•
•
•
•
www.revenue.ky.gov
Form W-4 (2016)
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. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2016 expires
February 15, 2017. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2016. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . .
▶
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)
H
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
2
Last name
Home address (number and street or rural route)
3
Single
Married
2016
Your social security number
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2016)
Page 2
Form W-4 (2016)
Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
1
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your
income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300
and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and
not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . .
$12,600 if married filing jointly or qualifying widow(er)
2
Enter:
$9,300 if head of household
. . . . . . . . . . .
$6,300 if single or married filing separately
3
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
4
Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
5
Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
6
7
8
9
10
}
Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note: Use this worksheet only if the instructions under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . .
1
2
3
Note: If line 1 is less 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
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
6
7
8
$
$
9
$
Table 2
All Others
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $6,000
6,001 - 14,000
14,001 - 25,000
25,001 - 27,000
27,001 - 35,000
35,001 - 44,000
44,001 - 55,000
55,001 - 65,000
65,001 - 75,000
75,001 - 80,000
80,001 - 100,000
100,001 - 115,000
115,001 - 130,000
130,001 - 140,000
140,001 - 150,000
150,001 and over
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$0 - $9,000
9,001 - 17,000
17,001 - 26,000
26,001 - 34,000
34,001 - 44,000
44,001 - 75,000
75,001 - 85,000
85,001 - 110,000
110,001 - 125,000
125,001 - 140,000
140,001 and over
0
1
2
3
4
5
6
7
8
9
10
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code
sections 3402(f)(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
properly 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 intelligence agencies to combat terrorism.
If wages from HIGHEST
paying job are—
$0 - $75,000
75,001 - 135,000
135,001 - 205,000
205,001 - 360,000
360,001 - 405,000
405,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,420
1,600
All Others
If wages from HIGHEST
paying job are—
$0 - $38,000
38,001 - 85,000
85,001 - 185,000
185,001 - 400,000
400,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,600
You are not required to provide the information requested on a form that is subject to the
Paperwork Reduction Act unless the form displays a valid OMB control number. Books or
records relating to a form or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending
on individual circumstances. For estimated averages, see the instructions for your income tax
return.
If you have suggestions for making this form simpler, we would be happy to hear from you.
See the instructions for your income tax return.
Page 2
Form W-4 (2014)
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
Enter an estimate of your 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
1
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1950) of your
income, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income is over $305,050
and you are married filing jointly or are a qualifying widow(er); $279,650 if you are head of household; $254,200 if you are single and not
head of household or a qualifying widow(er); or $152,525 if you are married filing separately. See Pub. 505 for details . . . .
$12,400 if married filing jointly or qualifying widow(er)
2
Enter:
$9,100 if head of household
. . . . . . . . . . .
$6,200 if single or married filing separately
3
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
4
Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
5
Withholding Allowances for 2014 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
6
7
8
9
10
}
Enter an estimate of your 2014 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $3,950 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . .
1
2
3
Note. If line 1 is less 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
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2014. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2014. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
6
7
8
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
Married Filing Jointly
Enter on
line 2 above
$0 - $6,000
0
$0 - $6,000
0
1
6,001 - 13,000
6,001 - 16,000
1
2
13,001 - 24,000
16,001 - 25,000
2
3
24,001 - 26,000
25,001 - 34,000
3
4
26,001 - 33,000
34,001 - 43,000
4
5
33,001 - 43,000
43,001 - 70,000
5
6
43,001 - 49,000
70,001 - 85,000
6
7
49,001 - 60,000
85,001 - 110,000
7
8
60,001 - 75,000
110,001 - 125,000
8
9
75,001 - 80,000
125,001 - 140,000
9
10
80,001 - 100,000
140,001 and over
10
100,001 - 115,000
11
12
115,001 - 130,000
13
130,001 - 140,000
14
140,001 - 150,000
15
150,001 and over
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code
sections 3402(f)(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
properly 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 intelligence agencies to combat terrorism.
If wages from HIGHEST
paying job are—
$0
74,001
130,001
200,001
355,001
400,001
- $74,000
- 130,000
- 200,000
- 355,000
- 400,000
and over
Enter on
line 7 above
$590
990
1,110
1,300
1,380
1,560
All Others
If wages from HIGHEST
paying job are—
$0 - $37,000
37,001 - 80,000
80,001 - 175,000
175,001 - 385,000
385,001 and over
Enter on
line 7 above
$590
990
1,110
1,300
1,560
You are not required to provide the information requested on a form that is subject to the
Paperwork Reduction Act unless the form displays a valid OMB control number. Books or
records relating to a form or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending
on individual circumstances. For estimated averages, see the instructions for your income tax
return.
If you have suggestions for making this form simpler, we would be happy to hear from you.
See the instructions for your income tax return.
RECEIPT OF BUILDING KEYS
Date:
I,___________________________________________(name of employee)
hereby acknowledge receipt of the following keys:
1.____________________________________________
2.____________________________________________
3.____________________________________________
4.____________________________________________
5.____________________________________________
6.____________________________________________
I understand that I am responsible for the above-listed keys. Missing and/or
lost keys are to be reported to your supervisor within 24 hours. Reassignment
of keys can only be authorized by your supervisor, his/her supervisor, or the
library director. Failure to follow the above procedure could result in
disciplinary action up to and including termination.
Employee signature ________________________________________
Date_____________________
Witness signature _________________________________________
Date
Getting Started
Use Paychex Employee Services to access your:
• personal and payroll information
• copies of Forms W- , or
Access to this information
depends on the services your
employer subscribes to.
• check stubs.
Important Reminders:
Paychex Employee Services is compatible with Adobe® Flash® Player
version 10.1 or higher. If needed, download the latest version at
http://get.adobe.com/flashplayer.
Your Web browser’s pop-up blocker must be set to allow pop-ups from
Paychex Employee Services.
If you don’t already have access to Paychex Employee Services, you must register
for a user name and password at http://benefits.paychex.com.
Click Register for a new account to get started. (͟)
Getting Started Paychex Employee Services
© 2010 Paychex, Inc. All rights reserved. EAO-4001-1011
benefits.paychex.com
1
You must enter the required information to set up an account for Paychex
Employee Services.
Make sure to record your selected user name, challenge question answers,
password, and security image. You will use this information to log in to Paychex
Employee Services.
Click Submit (3) to save your registration information.
An asterisk (*) (1) indicates a
required field.
Click the question mark (2)
to find out more about a
particular field.
When registering, you will be asked to enter your social security number and ZIP
code. The information you enter here must match what your employer has in the
payroll records. If it does not, you will not be able to continue with the
registration. Contact your employer to verify the information on file.
Getting Started Paychex Employee Services
© 2010 Paychex, Inc. All rights reserved. EAO-4001-1011
benefits.paychex.com
2
Once registered, go to http://benefits.paychex.com to log in. From the Message
Center, select Personal and Payroll Information (1) or Check Stub/W-2’s. (2)
Access to these options depends on the products your employer
subscribes to.
You may also log in to
Paychex Employee Services
at www.paychex.com. Use the
login section at the top right
of the screen.
Once in the application, click Learn More (3) to access additional information
about each of the screens.
If you have questions about the information on your check stub or Form W-2,
contact your employer. If you have questions about user name and password
resets and accessing the site, review the Site Access FAQs on the login page of the
Paychex Employee Services Web site.
Getting Started Paychex Employee Services
© 2010 Paychex, Inc. All rights reserved. EAO-4001-1011
benefits.paychex.com
3
Direct Deposit Enrollment/Change Form
Company Name____________________________________ Client Number____________________
Employee/Worker Name_____________________________ Employee/Worker Number__________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer.
EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a
copy of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of
Account

Checking

Savings

Checking

Savings
Bank Account
Number*
Routing/Transit Number
Financial Institution
(“Bank”) Name
I wish to deposit (check one):
 ______ % of Net
 Specific Dollar Amount $ _______
 Remainder of Net Pay
 ______ % of Net
 Specific Dollar Amount $ _______
 Remainder of Net Pay
One of the following is required to process this enrollment (check one):

Voided check with name imprinted (no starter checks)

Deposit slip (only accepted if the verbiage “ACH R/T” appears before the routing number)

Bank letter or specification sheet (the signature of your local bank representative MUST be included)
 Other Bank Documentation – If this box is checked the employer must sign this confirmation:
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions
processed by Paychex, Inc.
Employer Signature:_____________________________________ Date _______________
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more
information specific to your account.
COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Bank Account Number*
Routing/Transit Number
Financial Institution
(“Bank”) Name
Change My Deposit Amount to:
 From _____% to____% of Net
 From $ ______ .00 To
$_____.00
 Remainder of Net Pay
 From _____% to____% of Net
 From $ ______ .00 To
$_____.00
 Remainder of Net Pay
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit
transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the
accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named
account.
Employee/Worker Signature ______________________________________ Date ________________
Note:
Digital or Electronic Signatures are not acceptable.
DP0002 12/13
CHOOSE A
BETTER WAY
BRC11637.indd
Creative Designation:
Choose one:
Last Save Date: 1-5-2012 11:35 AM
User Name: Kubis, Harry X
Station Name: WWIL124173
TO GET PAID
Job Info
Segment:
Fulfillment
Campaign:
Paychex
Cell:
None
WR #:
110121
Partner:
TSS
PremiumID: None
Instead of waiting in line to cash your paycheck, have your pay
automatically deposited to a Chase Pay Card Plus account.
It’s safe, fast and easy...plus it saves you money!
Get cash 24 x 7 at ATMs worldwide
Enroll in the Chase Pay Card Plus
program today!
RPC:
None
Creative
Format ID:
None
There is no cost to enroll in the Chase Pay Card Plus program. Simply
complete this application today and return it to your payroll department.
Component
Spec ID:
None
Campaign
Date:
None
Make purchases anywhere Visa® debit cards are accepted
Shop online, by phone or mail order
Pay your bills online
Eliminate the hassle and costs of cashing a check
No lost or stolen checks
No credit check required
Chase Payroll Card Fee Schedule
Receive payroll deposits from multiple employers
Get your money anywhere, anytime
With the Chase Pay Card Plus program, your funds are electronically
deposited to your Chase Pay Card Account each pay period, where
your funds are FDIC insured. You then have immediate and convenient
access to your money at over 900,000 automated teller machines
(ATMs). You can enjoy surcharge-free access at over 51,000 Chase
and Allpoint® ATMs in the U.S., and at millions of locations that accept
Visa debit cards.
TRANSACTION
CARDHOLDER FEE
ATM
withdrawal (U.S.)3
$1.50 per transaction
ATM withdrawal (outside U.S.) 3
$3.00 per withdrawal
Point-of-Sale transactions:
PIN and Signature-based
FREE
Over-the-counter cash withdrawals
5 free per month,
then $5.00 thereafter
ATM balance inquiry (U.S.)
$1.00 per inquiry
ATM balance inquiry (outside U.S.)
$3.00 per transaction
Document Size:
Trim Width: 8.5”
Trim Height: 11”
Fold Position: None
Folded Size: None
Fonts & Images
Fonts:
Zurich BT (Light Extra Condensed),
MetaBook (Regular), Berthold Akzidenz
Grotesk (Light, Italic, Bold, Bold Italic),
Times New Roman PS (Roman), Helvetica
(Bold)
Images:
77778_bkgd_rCMY_mancar.eps (CMYK;
638 ppi, 639 ppi; 47%)
77778_CV_rCMY_000000V4126.eps
(CMYK; 476 ppi; 62.89%)
05686_logo_vCMY_ChaseLogo.eps
ADDITIONAL SERVICES
Monthly paper statement (optional)
$1.00
Monthly statements via Internet
FREE
Replace lost/stolen card
$15.00 per card
Inks:
Your purchases are protected
Expedited card delivery
For the first 90 days from the purchase date, Visa’s Purchase
Security1 will repair or fully reimburse you for eligible items paid entirely
with your Chase Pay Card to a maximum of $500 per consumer
product and $50,000 per cardholder. Additionally, Visa’s Zero Liability
Policy2 protects you from unauthorized purchases. If your Card is ever
lost or stolen, you are automatically protected without losing the funds
in your Account.
Declined transactions (U.S.) $1.00 per transaction
Copy of Statement
$10 per request
Check to close account
$12.00 per account
Inactivity fee
(after 90 days of inactivity)
$3.00 per month
Foreign exchange
conversion rate
3.5% per international transaction
This protection is valid in cases of theft or damage due to fire, vandalism, accidentally discharged water or
weather. Certain restrictions and limitations may apply.
1
2
.S.-issued cards only. The Visa Zero Liability Policy does not apply to commercial card or ATM transactions, or
U
to PIN transactions not processed by Visa or Interlink. See your cardholder agreement for more details.
Chase Pay Cards are issued by JPMorgan Chase Bank, N.A.
© 2011 JPMorgan Chase & Co. All rights reserved.
JPMorgan Chase Bank, N.A. Member FDIC.
$25.00 includes card
4
Notes:
PID#: 99999935
WEB ONLY - NO CF
Cardholder fees apply to both the primary and
secondary cardholders.
3
henever you use any ATM there is a “network” or “ATM withdrawal fee”. Additionally non-Chase banks may charge
W
you a “surcharge” typically between $1.00 and $3.00 for using their ATM. You can avoid a surcharge by using a
Chase ATM or Allpoint ATM.
BRC11637
BRC11637.indd 1
Cyan
Magenta
Yellow
Black
FPO Tech Notes
1/5/12 11:42 AM
Chase Pay Card Plus Application
Unless otherwise noted, all fields are required and must be filled in to process
this application. You must be a U.S. Resident to enroll in the
Chase Pay Card Plus program.
Federal law requires all financial institutions to obtain, verify and record
information that identifies each person who applies for a card. What this means
for you: when you apply for a card, you will be asked for your name, address, date
of birth, and other information or documentation that will allow us to identify you.
I. CARDHOLDER INFORMATION
I. SECONDARY CARD (OPTIONAL)
LEGAL FIRST NAME
LEGAL FIRST NAME
MI LAST NAME
PERMANENT ADDRESS (NO P.O. BOXES)
CITY
ZIP
CARD MAILING ADDRESS (IF DIFFERENT FROM PERMANENT)
CITY
MI
STATE
CITY
STATE
E-MAIL ADDRESS (OPTIONAL)
SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER
DATE OF BIRTH (MM/DD/YYYY)
MOTHER’S MAIDEN NAME
UNITED STATES CITIZEN NON-UNITED STATES CITIZEN
If you are not a U.S. Citizen, please provide one or more of the following
forms of identification.
Please select a form of identification:
PASSPORT
MOTHER’S MAIDEN NAME
UNITED STATES CITIZEN NON-UNITED STATES CITIZEN
If you are not a U.S. Citizen, please provide one or more of the following
forms of identification.
Please select a form of identification:
U.S. ALIEN ID CARD
PASSPORT
TYPE
COUNTRY OF ISSUANCE
NUMBER
NUMBER
Paychex
Cell:
None
WR #:
110121
Partner:
TSS
Monthly paper statement (optional) — in addition to accessing my Chase Pay Card Plus transaction activity online or via Customer Support, please mail me
a monthly Pay Card activity statement to the mailing address I have provided above. I understand there is a $1.00 monthly charge for this statement option.
II. CARDHOLDER AGREEMENT— Return your completed, signed and dated application to your employer.
The Authorization Agreement for the Chase Pay Card Plus account will authorize my employer to directly deposit my periodic salary/compensation payments, net of required
tax withholdings, other required withholdings or authorized deductions (a “Payroll Payment”) into my Chase Pay Card Plus account (the “Account”) at JPMorgan Chase Bank,
N.A. (“Chase”) and to initiate (if necessary) debit entries and adjustments for any credit entries in error to my Account. I understand that I may withdraw a portion or the entire
amount of a Payroll Payment deposited by my employer from time to time in cash via an Automated Teller Machine (subject to certain withdrawal limits as discussed in the
Program Terms, Conditions and Disclosures), applicable Point-of-Sale (POS) terminals and wherever Visa® debit cards are accepted. By signing this application, I hereby
authorize Chase to issue a card to me. I agree that activating my card shall constitute my agreement to: (1) The Program Terms, Conditions and Disclosures that accompany
my card and (2) changes to, or replacements for, those Program Terms, Conditions or Disclosures that may be sent or made available to me from time to time. I also hereby
authorize Chase to debit my Chase Pay Card Plus account, without notifying me, for the fees described in the fee schedule that is part of this application, or as such fees may
change from time to time. Chase may change those fees at any time.
CARDHOLDER’S SIGNATURE
DATE
III. BRANCH USE ONLY
COMPANY NAME
RPC:
None
Creative
Format ID:
None
Component
Spec ID:
None
Campaign
Date:
None
Images:
None
EXPIRATION DATE (MM/DD/YYYY)
BRC11637.indd 2
Campaign:
Fonts & Images
Fonts:
Berthold Akzidenz Grotesk (Bold, Bold
Italic, Light, Italic), MetaBook (Regular),
Times New Roman PS (Roman), Helvetica
(Bold)
EXPIRATION DATE (MM/DD/YYYY)
* Contact your employer for an additional secondary cardholder form.
COUNTRY OF ISSUANCE
Fulfillment
Document Size:
Trim Width: 8.5”
Trim Height: 11”
Fold Position: None
Folded Size: None
OTHER GOVERNMENT ISSUED ID
OTHER GOVERNMENT ISSUED ID
TYPE
Segment:
PremiumID: None
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER
ZIP
E-MAIL ADDRESS (OPTIONAL)
PRIMARY PHONE NUMBER
U.S. ALIEN ID CARD
Job Info
LAST NAME
PRIMARY PHONE NUMBER
ZIP
Creative Designation:
Choose one:
Last Save Date: 1-5-2012 11:35 AM
User Name: Kubis, Harry X
Station Name: WWIL124173
PERMANENT ADDRESS (NO P.O. BOXES)
STATE
BRC11637.indd
CLIENT ACCOUNT NUMBER
1/5/12 11:42 AM
Inks:
Cyan
Magenta
Yellow
Black
FPO Tech Notes
Notes:
PID#: 99999935
WEB ONLY - NO CF