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Classified Substitute Packet 5/24/2017

Pamela Conklin Superintendent

2751 De Ronde Drive Fairfield, CA 94533

(707) 437-4604

Cambridge Elementary School 100 Cambridge Dr, Vacaville

(707) 446-9494

Center Elementary School 3101 Markeley Ln, Fairfield

(707) 437-4621

Foxboro Elementary School 600 Morning Glory Dr, Vacaville

(707) 447-7883

Golden West Middle School 2651 De Ronde Dr, Fairfield

(707) 437-8240

Scandia Elementary School 100 Broadway St, Travis AFB

(707) 437-4691

Travis Community Day School 2785 De Ronde Dr, Fairfield

(707) 437-8265

Travis Elementary School 100 Fairfield Ave, Travis AFB

(707) 437-2070

Travis Education Center 2775 De Ronde Dr, Fairfield

(707) 437-8265

Vanden High School 2951 Markeley Ln, Fairfield

(707) 437-7333

Governing Board Riitta DeAnda

John Dickerson Ivery Hood

Angela Weinzinger Jamilah Whiteside

Dear Applicant:

Thank you for your interest in working in our District as a substitute classified employee. A substitute employee plays a vital role in the delivery of quality support for educational services.

PLEASE NOTE: A substitute position is on-call, as needed.

REQUIREMENTS:

Attached application packet completed and signed

*The Applicant Data Record is an optional form used for statistical purposes only.

Fingerprint clearance from the Department of Justice.

*Applicants must have Request for Live Scan Service form from Travis USD, which can be obtained from the District Office.

Verification of a negative tuberculosis test within the past four (4) years

*The Family Health Services of Solano County offers TB skin tests. Family Health Services

2201 Courage Drive Fairfield, CA

(707) 784-2010 $23.00 Fee

No Appointment Necessary Monday, Tuesday, & Wednesday

9–11 a.m. & 1–4 p.m. *THIS INFORMATION IS SUBJECT TO CHANGE

For employment eligibility verification (see lists of acceptable documents on I-9, attached) please bring:

• One item from group A (i.e., passport) OR one from group B (i.e., driver’s license) AND social security card

Instructional Assistants Clerical Bus Driver

• Transcripts showing a minimum of 48 college units or proof of passing the No Child Left Behind (NCLB) Para-Educators test.

• For more information on the NCLB test, call 707-399-4800

• Typing test • Clerical test • For testing

information, please call Express Personnel Services at 707-863-8200.

• Current Class A or B license

• First Aid certificate • Medical certificate • DMV (H-6) printout

TRAVIS UNIFIED SCHOOL DISTRICT APPLICANT DATA RECORD

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. The Travis Unified School District is an Equal Opportunity Employer. Solely, to help us comply with governmental record keeping and other legal requirements, the District requests that you fill out this Applicant Data Record. It will be kept in a confidential file separate from the application for Employment. Date: ____________________ Position(s) Applied For: _________________________________________________________________ _____________________________________________________________________________________ Referral Source: Advertisement Friend Relative Edjoin

University Placement Office Other

Name: _____________________________________________ Phone: __________________________ Last First M.I. Address: ____________________________________________________________________________ Number Street City State Zip

Sex: Female Male

Race/Ethnic Group: If Asian or Pacific Islander is marked

Black or African American (600) on the left, then select all that apply American Indian or Alaskan Native (100) Chinese (201) Guamanian (302) Asian/Asian American Japanese (202) Samoan (303)

Filipino/Filipino American (400) Korean (203) Laotian (206)

Hispanic/Latino (500) Vietnamese (204) Cambodian (207)

Pacific Islander (PI) Asian Indian (205) Other Asian (299)

White Hawaiian/Other PI (301) Hmong

Check if any of the following are applicable:

Vietnam Era Veteran Disabled Veteran Handicapped

In addition to the federal minimum individual categories, California Government Code Section 8310.5 requires state agencies to collect data for each major Asian and Pacific Islander group, including, but not limited to, Chinese, Japanese, Korean, Vietnamese, Asian Indian, Laotian, Cambodian, Filipino, Hmong, Hawaiian, Guamanian, Samoan, and Tahitian.

CLASSIFIED SUBSTITUTE EMPLOYMENT APPLICATION 2751 De Ronde Drive, Fairfield, CA 94533‐9710

707.437.4604 / 707.437.8122 (Fax)

EQUAL OPPORTUNITY EMPLOYER 1 Revised 3.9.16

Position(s) Applying for:

PERSONAL DATA

Last Name First Middle

Present Address City Zip Email Address

Home Phone Cell Phone Do you have Base Access?

Yes No

Have you ever been employed by Travis Unified School District before? Yes No

If yes, please provide the dates:

Do you speak another language besides English? Yes No

If yes, what language(s):

Do you have any friends or relatives working in the district? Yes No

If yes, list the name(s):

Are you legally eligible for employment in the United States? Yes No

(If offered employment, you will be required to provide documentation to verify eligibility.)

Have you ever been involuntarily terminated or asked to resign from the employment of a school district?

Yes No

If yes, attach confidential letter of explanation.

EDUCATION

Name of Institution Location From – To Units/Degree Major

Under Graduate College

Graduate College Work

Total Semester or Quarter Units After Bachelor’s Degree: Thesis Topic:

CLASSIFIED SUBSTITUTE EMPLOYMENT APPLICATION (continued)


EMPLOYMENT – List each job held. Start with your present or last job. Include military service assignments and

volunteer activities. (Exclude groups which indicate race, color, religion, sex or national origin)

Employer Dates Work Performed

From To

Address

Job Title Hourly Rate/Salary

Supervisor Name Telephone Number

Reason for Leaving


From To

Address



Reason for Leaving


From To

Address



Reason for Leaving

Summarize special skills, qualifications, and/or experiences:

CLASSIFIED SUBSTITUTE EMPLOYMENT APPLICATION (continued)


List professional, trade, business, or civic activities and offices held. (Exclude groups which indicate race, color, religion, sex or national origin)

Give name, address, and phone number of three (3) references not related to you. If you need additional space, please continue on a separate sheet of paper.

State any additional information you feel may be helpful to us in considering your application. (A resume may be attached to this application or additional sheets may be used.)

The following information is REQUIRED for your application to be considered. Your answers will not necessarily disqualify you from consideration, except for affirmative responses to certain enumerated sex and/or drug convictions and/or convictions for committing serious and/or violent felonies. Explain all “Yes” answers in the spaces below.

Have you ever been convicted of a felony or misdemeanor, other than a conviction related to marijuana if it is more than two years after the date of the conviction, or do you currently have a felony or misdemeanor charge pending? Convictions include a plea of guilty, nolo contendere (no contest) and/or a finding of guilty by a judge or a jury.

Yes No If “Yes,” list all convictions including, but not limited to convictions for “driving under the influence,” and convictions for sex and/or drug offenses listed in California Education Code Sections 44010 and 44011, except for convictions related to marijuana if it is more than two years after the date of the conviction. Include any serious or violent felony conviction in any state or jurisdiction as enumerated in California Penal Code sections 667.6(c) and 1192.7(c).

Agreement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements in this application for employment as may be necessary in arriving at

an employment decision. In the event of employment, I understand that false or misleading information given on my application or

interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulationof the school district.

Signature Date

EMERGENCY NOTIFICATION INFORMATION Human Resources

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710 Emergency Notification_5.12.16

Name: Please Print Social Security Number: Last 4 Digits Print below the name, address and telephone number of two people you wish to be contracted should you become disabled at work due to illness or injury. 1st Contact Name of Emergency Contact Relationship Mailing Address City State Zip Telephone Number of Emergency Contact (Please include area code) Home Work Cell 2nd Contact Name of Emergency Contact Relationship Mailing Address City State Zip Telephone Number of Emergency Contact (Please include area code) Home Work Cell Signature Date

ACKNOWLEDGEMENT OF RECEPT

Medical Provider Network and Employee Predesignation

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710 Acknowledgement of Receipt MPN_5.12.16

By signing below, I, , acknowledge that

I have been provided with the important notification regarding Travis Unified School District’s Medical

Provider Network (MPN) for treatment of work-related injuries only.

I understand that if I have any questions regarding this letter, I can contact the MPN Designee as

indicated on the letter for additional information.

Signature Date For district use only: MPN letter provided to employee by: Employee name Date

PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

• on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated;

• the doctor is your regular physician, who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist, pediatrician,obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, andretains your medical records;

• your “personal physician” may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries;

• prior to the injury your doctor agrees to treat you for work injuries or illnesses;• prior to the injury you provided your employer the following in writing: (1) notice that you want your

personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name andbusiness address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by: _________________________________________________________________ (name of doctor)(M.D., D.O., or medical group) _________________________________________________________________ (street address, city, state, ZIP)

__________________________________________________ (telephone number)

Employee Name (please print): _____________________________________________________________________________________________

Employee's Address: _____________________________________________________________________________________________

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:

Employee's Signature ________________________________Date: __________

Physician: I agree to this Predesignation:

Signature: _________________ ___________________________Date: __________ (Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).

Title 8, California Code of Regulations, section 9783.

Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014)

CERTIFICATE OF MEDICAL EXAMINATION OF APPLICANTS FOR FIRST EMPLOYMENT IN A CALIFORNIA SCHOOL DISTRICT

OR COUNTY SUPERINTENDENT OF SCHOOLS OFFICE

Travis Unified School District

____________________________ _____________________________ ______________________________ Last Name First Middle ________________________________ ___________________ _____________ ____________ Street Address City State Zip To the Physician: The medical examination required of a person employed in a certificated position for the first time in a California school district or county superintendent of schools office to determine freedom from any disabling disease unfitting the person to instruct or associate with children should be evaluated on the basis of functions which will be required of the applicant upon employment. A brief description of functions is attached to this form. Disabling disease should be considered in terms of (1) evidence of lack of ability to demonstrate average physical and emotional capacity for the functions involved; (2) evidence of disability which periodically may disable the individual, for example, rheumatoid arthritis, uncontrolled diabetes, asthma, and (3) evidence of long‐term disability which may progressively deteriorate, for example, malignancy, multiple sclerosis.

Check Every Item Yes No Details (Relate to functions to be performed)

1. Is there evidence of disabling disease of the musculo‐skeletal, cardio‐vascular, nervous, gastro‐intestinal, genito‐urinary, endocrine systems?

2. Is there evidence of disabling disease affecting vision, hearing or speech?

3. Is there evidence of disabling metabolic disease?

4. Is there evidence of infectious disease in a communicable state?

5. Is there evidence of drug dependency including alcoholism?

6. Is there evidence of any other disabling disease?

On the basis of my medical examination, _______________________________, the above‐named individual is free from disabling (Date)

disease, except as noted above which I believe unfits the individual to instruct in the position for which application is being made or to associate with children. Signature of Physician_______________________________________________ Date____________________________________ Printed Name of Physician___________________________________________ License No._______________________________

CERTIFICATE OF MEDICAL EXAMINATION OF APPLICANTS FOR FIRST EMPLOYMENT IN A CALIFORNIA SCHOOL DISTRICT OR COUNTY SUPERINTENDENT OF SCHOOL OFFICE

Summary of Legal Provisions (Education Code Section 44839)

A medical certificate, in a form prescribed by the State Board of Education, showing that a person employed for the first time in a California school district or county superintendent of schools office in a position requiring certification qualifications, is free from any disabling disease unfitting the applicant to instruct or associate with children is required. The Education Code also provides that:

The medical certificate shall be submitted directly to the governing board or county superintendent by a physician and surgeon listed under the Business Professions Code.

The medical examination shall have been conducted not more than six months before the submission of the certificate.

The pre‐employment medical examination shall be at the expense of the applicant.

The medical certification shall become a part of the personnel record of the employee and shall be open to the employee or his/her designee.

OATH OR AFFIRMATION OF ALLEGIANCE Human Resources

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710 Oath or Affirmation of Allegiance_5.12.16

All Personnel E 4112.3 4212.3 4312.3 I, , do solemnly swear (or affirm) that I

will support and defend the Constitution of the United States and the Constitution of the State of

California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the

Constitution of the United States and the Constitution of the State of California; that I take this

obligation freely, without any mental reservation or purpose of evasion; and that I will well and

faithfully discharge the duties upon which I am about to enter.

I understand that as a public employee I am a disaster service worker pursuant to Government Code

3100 and 3102 and that I am required to take this oath before entering the duties of my employment.

In the event of natural, manmade or war-caused emergencies which result in conditions of disaster or

extreme peril to life, property or resources, I am subject to disaster services activities to me by my

supervisor.

Employee Signature Date Certified by: (Person who administers oath) Exhibit Version: June 12, 2007

California Public Employees’ Retirement SystemCustomer Account Services DivisionRetirement Account Services SectionP.O. Box 942709Sacramento, CA 94229-2709TTY: (877) 249-7442888 CalPERS (or 888-225-7377) phone • (916) 795-4166 fax www.calpers.ca.gov

PERS-CASD-801 (12/12)

MEMBER RECIPROCAL SELF-CERTIFICATION FORMComplete the following information and return this form to your Human Resources Office within 10 business days:

EMPLOYEE NAME: ______________________________________________________________________ (Last) (First) (Middle)

SOCIAL SECURITY NUMBER OR CalPERS ID NUMBER: ______________________________________

NAME OF MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _______________________________

PERMANENT SEPARATION DATE FROM MOST RECENT RECIPROCAL RETIREMENT SYSTEM: ____________________________________________________________________________________________

FIRST MEMBERSHIP DATE IN ANY PRIOR CALIFORNIA PUBLIC RETIREMENT SYSTEM THAT IS SUBJECT TO RECIPROCITY: ______________________________________________________________

(Check the applicable statement)

_____ I have not been a member of another California Public Retirement System within the last six months.

_____ I was a member and am retired from the _______________________________ Retirement System and subsequently became employed by a CalPERS-covered employer.

_____ I was a member of the _____________________________ Retirement System and became employed by a CalPERS-covered employer within six months after separating from employment with the previousreciprocal retirement system.

I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulations of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must complete and return the “Election to Coordinate Retirement When Changing Retirement Systems,” (PERS-MSD-255) Form to CalPERS.

I hereby certify that the foregoing information is true and correct and any information found to be incorrect may require corrections to my account in the California Public Employees’ Retirement System including, but not limited to, my date of membership. CalPERS may make any necessary corrections to my account to ensure I am properlyenrolled and eligible to receive the correct retirement benefits.

______________________________________________ ______________________________SIGNATURE OF EMPLOYEE DATE

TO BE COMPLETED BY EMPLOYER ONLY:

NAME OF CalPERS AGENCY: CalPERS BUSINESS PARTNER ID:

______________________________________________ _______________________________________

CalPERS MEMBERSHIP ELIGIBILITY DATE ORIGINAL HIRE DATE WITH YOUR AGENCY:WITH YOUR AGENCY:

______________________________________________ _______________________________________

DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM GIVEN TO EMPLOYEE: ________________DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM RECEIVED FROM EMPLOYEE: ________________________________________________ _________________ _____________(Please Print) DESIGNEE OF EMPLOYER TITLE DATE

________________________________________________________________________________________DESIGNEE’S SIGNATURE

PERS-CASD-801 (12/12)

MEMBER RECIPROCAL SELF-CERTIFICATION FORMInstructions

Reciprocity is an agreement among public retirement systems to allow members to separate from onepublic employer and enter into employment with another public employer within a specific time limitwithout losing some valuable retirement and related benefit rights.

The Public Employees’ Pension Reform Act of 2013 (PEPRA), effective January 1, 2013, requires a CalPERS covered employer to determine the applicable PEPRA retirement benefit formula for new employees. CalPERS refers to all members that do not fit within the PEPRA definition of a “new member1” as “classic members” who are subject to the Public Employees’ Retirement Law (PERL).PEPRA allows a member after January 1, 2013, to retain his/her classic member retirement benefitstatus if the member continues his/her membership in all previous California Public Retirement System(s) by leaving his/her service credit and contributions (if any) on deposit, and the memberenters into employment that results in CalPERS membership within six months of separating from the most recent California Public Retirement System. Classic member status also requires the membership date to be on or before December 31, 2012, in a California Public Retirement System in which reciprocity is established.

EMPLOYER INSTRUCTIONS

1. Employers must provide the Member Reciprocal Self-Certification Form to all new employeesupon eligibility for membership.

2. Employers must sign and date the Member Reciprocal Self-Certification Form on the date the form is given to the employee.

3. Upon receipt of the completed Member Reciprocal Self-Certification Form, the employer will enter the date the employee returns the form.

4. The employer will enroll the new employee into CalPERS membership through my|CalPERS based on the information provided on the Member Reciprocal Self-Certification Form. my|CalPERS will determine the proper retirement benefit formula. If an employer believes the retirement benefit formula is incorrect, employers may contact CalPERS at 1-888-225-7377.

5. It is the responsibility of the employer to retain the completed Member Reciprocal Self-Certification Form in the employee’s employment records for auditing purposes.

1 A new member is defined in PEPRA as any of the following:• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has

no prior membership in any California Public Retirement System.• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has

a break in service of greater than six months with another California Public Retirement System that is subject to Reciprocity.

• A member who first established CalPERS membership prior to January 1, 2013, who is rehired by a different CalPERS employer after a break in service of greater than six months.

PERS-CASD-801 (12/12)

EMPLOYEE INSTRUCTIONS

1. The Member Reciprocal Self-Certification Form will assist your employer in determining whether you are considered a new member or a classic member under PEPRA.

2. As the new employee, you must complete, sign and date the Member Reciprocal Self-Certification Form to self-certify your most recent service in a reciprocal California Public Retirement System,your first membership date in any previous California Public Retirement System and yourpermanent separation date from the most recent California Public Retirement System; or indicate that you are not a member of any California Public Retirement System that is subject to Reciprocity.

3. As the new employee, you must return the Member Reciprocal Self-Certification Form to yourPersonnel Office within 10 business days of employment.

4. The completion of the Member Reciprocal Self-Certification Form does not establish reciprocityand is not a request to establish reciprocity. In order to request that reciprocity be established,visit the CalPERS web-site at: www.calpers.ca.gov and download the publication: “When You Change Retirement Systems”, PUB-16. It is the responsibility of the employee to complete and send the “Election to Coordinate Retirement When Changing Retirement Systems,” PERS-MSD-255 Form to CalPERS.

Reciprocal 1937 Act Counties Reciprocal Public Agencies

Alameda Sacramento *City of Concord Contra Costa San Bernardino *City of Costa Mesa (Safety employees only)Fresno San Diego City of Fresno (Miscellaneous andImperial San Joaquin Safety Retirement Systems)Kern San Mateo City of Los Angeles (non-Safety only)Los Angeles Santa Barbara City of Oakland (non-Safety Marin Sonoma employees only)Mendocino Stanislaus City of Pasadena (Fire and PoliceMerced Tulare Retirement System)Orange Ventura *City of Sacramento

*City of San Clemente (non-Safety employees only)

Non-Reciprocal & UCRS Retirement Systems City of San Diego*City and County of San Francisco

Non-reciprocal systems are not covered by City of San Josereciprocity retirement laws, but participate Contra Costa Water Districtin retirement agreements with other systems. County of San Luis Obispo

East Bay Municipal Utility DistrictState Teachers’ Retirement System East Bay Regional Park DistrictLegislators’ Retirement System (Safety employees only)Judges’ Retirement System Los Angeles County MetropolitanJudges’ Retirement System II Transportation AuthorityUniversity of California Retirement System (Non-Contract Employees’ Retirement

Income Plan, formerly SouthernCalifornia Rapid Transit District)

*Also CalPERS-covered agency

AUTHORITY FOR RELEASE OF INFORMATION Human Resources

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710 Authority for Release of Information_5.13.16

I authorize any hiring official from Travis Unified School District to obtain any information relating to

my employment with past employers listed on my application.

This information may include, but is not limited to, achievement, performance, attendance, personal

history, or disciplinary action.

I direct you to release such information upon request of any designated hiring official from Travis

Unified School District regardless of any agreement I may have made with you previously to the

contrary.

I release the Travis Unified School District and any employee of the district, including records

custodians, from any and all liability for damages that may result to me on account of compliance or

attempts to comply with this authorization.

An electronically transmitted copy or a facsimile of this document constitutes the same as possession

of the original document and signature.

Employee Name (Please Print) Employee Signature Date

HEALTHY WORKPLACES, HEALTHY FAMILIES ACT OF 2014 PAID SICK LEAVE Human Resources

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710 Healthy Workplaces, Healthy Families Act of 2014_6.21.16

NOTICE TO TEMPORARY/SUBSTITUTE EMPLOYEE Employee Name: ______________________________________________________________________ Start Date: ___________________________ Position/Assignment: ___________________________ Entitlement:

• An employee of the Travis Unified School District (“District”) who, on or after July 1 of the current school year, works for 30 or more days within a year from the beginning of employment is entitled to paid sick leave.

• Paid sick leave accrues at the rate of 1 hour per every 30 hours worked, paid at the employee’s regular hourly wage rate. Accrual shall begin on the first day of employment or July 1 of the current school year, whichever is later.

Usage: The Travis Unified School District (TUSD) shall annually provide three (3) days of paid leave for all substitute employees who satisfy the following requirements:

• Been employed as a sub for TUSD in good standing for at least ninety (90) days. • Have worked at least thirty (30) days for TUSD in the current school year.

The three days of paid leave will be paid on the employee’s next paycheck after they meet the qualifications. The employee does not need to report the sick days in order to receive the paid leave. They will automatically receive the paid leave as long as they meet the requirements above. The leave will not accrue or carry over from year to year. Each year the employee will need to fulfill the 30-day requirement again in order to qualify for the payment. Every year the employee meets the requirements they will be paid for three days of leave regardless of whether they take sick days or not. There is no need to report the sick days in Aesop. If the employee is sick they simply take the day off. For the purposes of this provision a “day” will be equal to the employee’s normal work day. A 6.5-hour substitute teacher would earn three 6.5-hour days. A two-hour noon aide would earn three two-hour days. The rate of pay will be equal to the employee’s normal rate of pay. If an employee works different positions with different hours or rates of pay, the earned rate of pay and hours shall be the average of all assignments worked during the school year. Retaliation or discrimination against an employee who requests paid sick days or uses paid sick days or both is prohibited. An employee can file a complaint with the Labor Commissioner against an employer who retaliates or discriminates against the employee. ACKNOWLEDGEMENT OF RECEIPT Employee Signature _____________________________________ Date: _____________________

Form W-4 (2018) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4. 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 2018 if both of the following apply. • For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and • For 2018 you expect a refund of all 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 2018 expires February 15, 2019. 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 2018 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 www.irs.gov/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 nonwage income 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 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form 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 file your tax return, 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 and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. 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 might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.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 can 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 return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. 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, during the year. Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. 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 income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4 Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate ▶ Whether you’re 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.

OMB No. 1545-0074

2018 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married filing separately, check “Married, but withhold at higher Single rate.”

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 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5

6 $ 7 I claim exemption from withholding for 2018, 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.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

http://www.irs.gov/FormW4

http://www.irs.gov/W4App

http://www.irs.gov/


Form W-4 (2018)

your wages and other income, including income earned by a spouse, during the year. Line G. Other credits. You might be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as the earned income tax credit and tax credits for education and child care expenses. 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.

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, 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.irs.gov/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 owe 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 all 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 $60,000 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-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.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.acf.hhs.gov/programs/css/ employers.

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).



http://www.acf.hhs.gov/programs/css/

Form W-4 (2018)

Personal Allowances Worksheet (Keep for your records.) A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A B Enter “1” 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 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 will be less than $69,801 ($101,401 if married filing jointly), enter “4” for each eligible child. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “2” for each eligible child. • If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter “1” for each eligible child. • If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . E

F Credit for other dependents. • If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “1” for each eligible dependent. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 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 $175,550 ($339,000 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 . . G H Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . ▶ H

{ • 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 and want to increase your withholding, see the Deductions,

For accuracy, Adjustments, and Additional Income Worksheet below. complete all • If you have more than one job at a time or are married filing jointly and you and your spouse both worksheets work, and the combined earnings from all jobs exceed $52,000 ($24,000 if married filing jointly), see the that apply. 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 line 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.

1 Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $

{ $24,000 if you’re married filing jointly or qualifying widow(er) } 2 Enter: $18,000 if you’re head of household . . . . . . . . . . . 2 $

$12,000 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 2018 adjustments to income and any additional standard deduction for age 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 2018 nonwage income (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 $4,150 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 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, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 .................................................................................................................................... 10

EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

1. Number of allowances for Regular Withholding Allowances, Worksheet A

Number of allowances from the Estimated Deductions, Worksheet BTotal Number of Allowances (A + B) when using the CaliforniaWithholding Schedules for 2017

OR2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C

OR3. 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. (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.

Signature Date

Employer’s Name and Address California Employer Account Number

cut here

Give the top portion of this page to your employer and keep the remainder for your records.

YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.

IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.

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.

You should complete this form if either:

(1) You claim a different marital status, number of regular allowances, or different additional dollar amount to be withheld for California PIT withholding than you claim for federal income tax withholding or,

(2) You claim additional allowances for estimated deductions.

THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES.

The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, and/or the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance

DE 4 Rev. 45 (1-17) (INTERNET) Page 1 of 4 CU

City, State, and ZIP Code

Home Address (Number and Street or Rural Route)

Type or Print Your Full Name Your Social Security Number

Filing Status Withholding Allowances

SINGLE or MARRIED (with two or more incomes)

MARRIED (one income)

HEAD OF HOUSEHOLD

certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source.

CHECK YOUR WITHHOLDING: After your Form W-4 and/or 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. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption is good for one year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted by February 15 each year to continue your exemption. If you are not having federal income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new Form W-4 by December 1.

This form can be used to manually compute your withholding allowances, or you can electronically

compute them at www.taxes.ca.gov/de4.pdf.

EXEMPTION FROM WITHHOLDING (continued): Under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act, 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 3. You may be required to provide proof of exemption upon request.

IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB).

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES 800-852-5711 (voice)800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free) 916-845-6500

The California Employer’s Guide, DE 44, provides the income tax withholding tables. This publication may be found on the Employment Development Department (EDD) website at www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To assist you in calculating your tax liability, please visit the FTB website at www.ftb.ca.gov/individuals/index.shtml.

NOTIFICATION: If the IRS instructs your employer to withhold federal income tax based on a certain withholding status, your employer is required to use the same withholding status for state income tax withholding.

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 California Revenue and Taxation Code.

DE 4 Rev. 45 (1-17) (INTERNET) Page 2 of 4

http://leginfo.legislature.ca.gov/faces/codes.xhtml

http://www.edd.ca.gov/pdf_pub_ctr/de44.pdf



https://govt.westlaw.com/calregs/Search/Index

https://govt.westlaw.com/calregs/Search/Index

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, underwithholding 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 or Form W-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.

(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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (F)

INSTRUCTIONS — 2 — 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

WORKSHEET A REGULAR WITHHOLDING ALLOWANCES

1. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in theschedules in the FTB Form 540 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. __________________________

2. Enter $8,258 if married filing joint with two or more allowances, unmarried head of household, orqualifying widow(er) with dependent(s) or $4,129 if single or married filing separately, dual incomemarried, 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);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. __________________________Enter this number on line 1 of the DE 4. Complete Worksheet C, if needed.

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 withholdingand 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 888-745-3886.




WORKSHEET C TAX WITHHOLDING AND ESTIMATED TAX

1. Enter estimate of total wages for tax year 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 2017 tax rate schedules below . . . . . . . . . 8.

9. Enter personal exemptions (line F of Worksheet A x $122.10) . . . . . . . . . . . . . . . . . . . . . . . . . 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 2017. Contact your employer torequest the amount that will be withheld on your wages based on the marital status and number ofwithholding allowances you will claim for 2017. Multiply the estimated amount to be withheld bythe number of pay periods left in the year. Add the total to the amount already withheld for 2017 . . . . . . . 13.

14. Subtract line 13 from line 12. Enter difference. If this is less than zero, you do not need to have additionaltaxes 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 2017 ONLY

IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FTB:

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES 800-852-5711 (voice)800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES(Not Toll Free) 916-845-6500

*marginal tax

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.

MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS

IF THE TAXABLE INCOME IS COMPUTED TAX IS

OVER BUT NOTOVER

OF AMOUNT PLUS*OVER . . .

$0 $16,030 ...$16,030 $38,002 ...$38,002 $59,978 ...$59,978 $83,258 ...$83,258 $105,224 ...

$105,224 $537,500 ...$537,500 $644,998 ...

$644,998 $1,000,000 ... $1,000,000 $1,074,996 ... $1,074,996 and over

1.100% $0 $0.00 2.200% $16,030 $176.33 4.400% $38,002 $659.71 6.600% $59,978 $1,626.65 8.800% $83,258 $3,163.13 10.230% $105,224 $5,096.14 11.330% $537,500 $49,317.97 12.430% $644,998 $61,497.49 13.530% $1,000,000 $105,624.24 14.630% $1,074,996 $115,771.20

SINGLE PERSONS, DUAL INCOME MARRIED WITH MULTIPLE EMPLOYERS


OVER BUT NOTOVER


$0 $8,015 ...$8,015 $19,001 ...

$19,001 $29,989 ...$29,989 $41,629 ...$41,629 $52,612 ...$52,612 $268,750 ...

$268,750 $322,499 ...$322,499 $537,498 ...$537,498 $1,000,000 ...

$1,000,000 and over...

1.100% $0 $0.00 2.200% $8,015 $88.17 4.400% $19,001 $329.86 6.600% $29,989 $813.33 8.800% $41,629 $1,581.57 10.230% $52,612 $2,548.07 11.330% $268,750 $24,658.99

12.430% $322,499 $30,748.75 13.530% $537,498 $57,473.13

14.630% $1,000,000 $120,049.65

UNMARRIED HEAD OF HOUSEHOLD


OVER BUT NOTOVER


$0 $16,040 ...$16,040 $38,003 ...$38,003 $48,990 ...$48,990 $60,630 ...$60,630 $71,615 ...$71,615 $365,499 ...

$365,499 $438,599 ...$438,599 $730,997 ...$730,997 $1,000,000 ...

$1,000,000 and over

1.100% $0 $0.00 2.200% $16,040 $176.44 4.400% $38,003 $659.63 6.600% $48,990 $1,143.06 8.800% $60,630 $1,911.30 10.230% $71,615 $2,877.98 11.330% $365,499 $32,942.31 12.430% $438,599 $41,224.54 13.530% $730,997 $77,569.61

14.630% $1,000,000 $113,965.72


BS:07/01/2014

Last Name: ______________________________ First Name: ______________________________ Last 4 Digits of Social Security Number: ________ Telephone Number: _____________________ I hereby authorize Travis Unified School District, hereinafter called TUSD to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my: ACCOUNT INFORMATION Indicate what kind of account, along with amount to be deposited, if less than your net paycheck. Establish a new electronic deposit Change an existing electronic deposit

1. Bank Name/City/State: __________________________________________________

Routing/Transit #: _____________________Account #:________________________

Checking/Savings (circle one) I wish to deposit $__________ or ____ Entire Net Amount


Routing/Transit #: _____________________Account#:_________________________



Routing/Transit #: _____________________Account#: _________________________


This authorization is to remain in effect until TUSD has received written notification from me of its termination. Signature: ____________________________ Date: __________________________________

Direct Deposit Agreement Form

Please attach a voided check here.

(Checking account only)

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►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

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


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)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (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.

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

LISTS OF ACCEPTABLE DOCUMENTSAll 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

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable 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:

Documents that Establish Both Identity and

Employment Authorization

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

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.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

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

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

8. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

6. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 11/14/2016 N

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.