Substitute New Hire Packet and Checklist by ajizai


									             Welcome to Boulder Valley School District (BVSD)!
Your new Substitute Teacher packet has a number of forms that must be filled out and brought
with you to the Substitute Teacher orientation. Please contact the Substitute Teacher office at
720-561-5033 if you have questions.

Please make sure that all required forms are completed, along with any supporting
documentation attached. We will be unable to process your payroll until all required forms
are turned in.

                 Form                                      Purpose

      2012-13 Statement of      Required for all BVSD substitute teachers.
      Reasonable Assurance

                                BVSD requires that all employees (including subs,
      Fingerprint Card          regardless of CDE licensure) provide a set of fingerprints
                                prints before reporting to work.
                                Most fingerprinting agencies will supply a blank fingerprint
                                card(agencies that will not supply a card are noted on the
                                list of authorized fingerprinting agencies).
                                A list of authorized fingerprinting agencies is included in this

      Fingerprint deduction     Required for all employees. The fingerprint processing
      form                      fee of $39.50 will be deducted from the employee’s first
                                two paychecks.
                                Direct deposit of pay is required for all employees. Please
                                contact the Payroll Office at 720-561-5921 if you do not
      Authorization Agreement   have a bank account.
      for Automated Payroll
      Deposit                   If we receive this form after the 20th of the month of your first
                                paycheck, you will be required to pick up your check in the
                                Payroll Office with a photo ID.
      Form W – 4                Form W-4 is required for all employees. Lets us know how
      Employees’ Withholding    to calculate your tax withholding.
                                Form I-9 is required for all employees and must be filled out
      Form I-9                  before you begin work. Verifies your eligibility to work in the
                                United States.
      Employment Eligibility
      Verification              You will need to bring original identification to Human
                                Resources and have Human Resources staff verify the
                                ID(s). A full list of allowable documents is listed on the back
                                of the form and some common documents are listed below:
                                     • Unexpired US Passport
                                     • Driver’s license and Social Security Card
                                     • Driver’s license and original or certified copy of birth
                              Required for all employees hired after January 1, 2007.
Affirmation of Legal Work
Status (complete only first   Affirms that employer has examined the legal work status of
two lines)                    newly-hired employees and has retained file copies of
                              appropriate document(s).
                              BVSD is a Colorado Public Employees’ Retirement
                              Association (PERA) Employer.
PERA member
information Form              All employees are required to complete the PERA
                              Membership form (with the exception of PERA retirees, see

                              If you are retired from PERA, please complete the PERA
                              Retiree form so that proper deductions will be made from
                              your pay.
                              Required for all employees hired after January 1, 2005.
Form SSA-1945                 Your earnings from this job are not covered under Social
Statement Concerning
Your Employment in a          Working for a government employer with a pension plan
Job Not Covered by            such as PERA may affect the Social Security benefit you
Social Security               receive. This form acknowledges that you have received
                              the information on form SSA-1945.
                              Required for all BVSD employees as a condition for their
Staff Acceptable Use          use of district technology resources.

                              For licensed employees only. State Law requires that all
Teacher’s Oath                Teachers sign the Teacher’s Oath.
                                                                                 Division of Human Resources
                                                                                              Substitute Office

        6500 Arapahoe, PO Box 9011
        Boulder, Colorado 80301
        Phone: 720-561-5033
        Fax: 720-561-5098

                                STATEMENT OF REASONABLE ASSURANCE
                                       2012-2013 SCHOOL YEAR

   Name (please print) _______________________________________ Employee #______________

   Please read and initial each statement:
   _____    I understand that my substitute teacher status is on an on call as-needed basis.
   _____    I understand that substitute teachers are not guaranteed a set number of hours of work per
   _____    I understand that this Substitute Teacher Statement of Reasonable Assurance when
            completed and returned will assure my eligibility to substitute for Boulder Valley School
            District. If I do not receive this statement by July 1 each year, I will contact the Substitute
            Office to complete one.
   _____    I understand that substitute teachers are not called to work on days that students are not in
            attendance (i.e., teacher work days, in-service days and seasonal breaks). I understand that I
            am not eligible for unemployment insurance from the district during seasonal breaks and
            between school years.
   _____    I understand that I must register as a substitute teacher, obtaining a PIN number, for the
            system to call me for a teaching assignment.
   _____    I understand it is my responsibility to notify the Substitute Office, in writing, of any changes in
            my address or phone number.
   _____    I understand that it is my responsibility to maintain current licensure through the Colorado
            Department of Education. Failure to do so will be treated as a separation from employment
            with BVSD.
   _____    I understand that it is my responsibility to comply with all Boulder Valley School District
            policies, regulations and procedures.
   _____    I understand that I am a non-contract employee; that I am not eligible for tenure; and that I
            am not covered by any negotiated agreement.
   _____    I understand that my employment as a substitute teacher with Boulder Valley School District
            is at-will. There is no guarantee of employment for any specific duration, at any particular
            building, or for any particular assignment. The district has the right to terminate my
            employment at any time, for any reason.

   __________________________________________                  _________________________________
   Signature                                                   Date

This form must be signed and returned to the Substitute Office before teaching assignments will be made.
         Fingerprinting Requirements for Employment

Please read and sign below. These requirements apply only if
you are hired for a position. DO NOT provide fingerprints at time
of application.

Under Colorado law, all persons employed by a school district in
non-teacher certificated/licensed positions must submit a set of
fingerprints to the school district before reporting to work.* As a
condition of employment with Boulder Valley School District, any
individual being hired for a position, including certificated/licensed
positions, must complete a fingerprint card. Upon employment,
payment of $39.50 for processing the fingerprints is required of
the employee. This fee will be deducted from the employee’s first
two(2) paychecks.

*Students enrolled in Boulder Valley K-12 programs working for
the Boulder Valley School District are exempt.

All applicants please complete this section:

I understand that upon hire and before reporting to work, I must
supply a set of fingerprints to the Boulder Valley School District
and that I will be required to pay a processing fee of $39.50 which
will be deducted from my first two (2) paychecks. If I do not
receive two(2) paychecks from BVSD I agree to pay the balance
remaining upon separation of employment.

Signature                                             Date

Print Name                                            Employee #
                      FINGERPRINT INFORMATION
Adams County SO       Arapahoe Community               Arapahoe County SO         Arvada PD                  Aurora PD
4201 E 72nd Ave       College-Police                   13101 E Broncos Pkwy       8101 Ralston Road          15001 E Alameda Pkwy
                      5900 S Santa Fe Dr               720.874.3600
720.322.1145                                                                      720.898.6920               303.739.6308
                      Littleton, CO                    Mon-Thurs
Wed 1pm-5pm           2nd Floor Main Bldg                                         Tues-Thurs 8am-            Tue/Thur 10am-
$5.00 1st card                                         12:30pm-4:30pm             4:30pm                     11:30am & 3pm-
                      M-Th 8am-5pm                     $10.00 pp/child related    $7.00 per card             5:30pm
$2.50 each addtl                                       $25.00 all others
Must reside/work in   Fri 8am-4pm                                                 Must reside/work in        $11.00 residents
county                Call for fees. Elect.transmit                               city                       $22.00 non-residents
                      Real Estate, Mortgage, Private
                      Inv. & Massage Only Otherwise
Black Hawk PD         Boulder County SO                Boulder PD                 Boulder PD                 Brighton PD
221 Church Street     5600 Flatiron Pkwy               1805 33rd Street           COMMUNITY POLICE
                                                                                                             3401 Bromley Lane
303.582.0503                                           303-441-3300               1500 Pearl Ste E           303.655.2300
                      Mon-Fri 11am-4:30pm
City residents ONLY   $10 per card county              Tue & Thur 8am-6pm         303-413-7324               Wed 1:30pm-4:30pm
Please call in        resident                         $11 per card               Mon-Thurs 10am-2pm         $10.00 per person
advance.              $15 per card non-resident        Must reside/work in city   $11 per card               CASH ONLY
                      CASH OR CHECK                                               Must reside/work in city
                      ONLY                                                        Call for availability
Broomfield PD         Castle Rock PD                   Cherry Hills Village PD    Clear Creek SO             Colorado Correctional
7 Descombes Drive     100 Perry Street                 2450 East Quincy Ave       405 Argentine St           Industries
                                                       303.761.8711               303.679.2452               4999 Oakland Street
303.464.5722          303.663.6104                                                                           303.370.2169
Mon/Tue 9am-4pm       Tue/Thur 8am-5pm                 Mon-Fri 8am-3:00pm         Mon-Fri
                                                                                                             Mon-Fri 8am-4pm
                                                       Call for fees              9am-11am
Tue 6pm-8pm           $10 1st two cards                                                                      $10.00 1st card
                                                       CHV residents ONLY         1pm-4pm                    $5.00 each additional
No Charge             $5 each additional                                          $10 pp (2cards)            CASH ONLY
Residents Only
University of         Commerce City PD                 Dacono PD                  Denver PD                  Douglas County SO
Colorado Boulder-PD   7887 E 60th Ave                  512 Cherry Street          1331 Cherokee Street       4000 Justice Way
1050 Regent Dr        303-287-2844                     303.833.3095               720.913.6756               303.660.7545
303-492-5115                                                                                                 Tues-Thur 9am-4pm
Tues-Fri 3pm-4pm
                      Tue 2pm-4pm                      Mon-Fri 8am-5pm            Wed/Thur 10am-8pm
                      $20.00 per card                  $10.00 per card            $10 1st card               $10 1-2 cards
$8.00 per card                                                                                               $3.00 each additional
CASH OR CHECK                                          General Public/Ink         $5 each additional
ONLY                                                                              Residence Only
Edgewater PD     Englewood PD                          Erie PD                    Federal Heights PD         Firestone PD
5901 W 25 Avenue 3615 S Elati Street                   645 Holbrook St            2380 W 90th Ave            151 Grant Avenue
303.235.0500     303.762.2489                          303.926.2800               303.412.3548               303.833.0811
Wed & Fri 11am-2pm Mon-Fri 8am-3:30pm                  Mon–Fri 9am-4 pm           Tue & Thursday             Mon/Thur 8am-
$10 per person        $15 per card                     No appt needed             9am-11am & 2pm-4pm         12pm
Must reside/work in   CASH ONLY                        $5.00 per card             $5.00 per card             Tues & Fri 1pm-
city                                                   CASH, CHECK OR             Must reside/work in city   5pm
                                                       CREDIT CARDS               Cash Only                  No charge residents
                                                                                                             $15 non-residents
Fort Lupton PD        Frederick PD                     Gilpin County SO           Glendale PD                Golden PD
130 S McKinley Ave    333 5th Street                   2960 Dory Hill Rd          950 S Birch                911 10th Street
303.857.4011          720.382.5700                     303.582.3576               303.759.1511               303.384.8045
Tue and Thur          Tues, Wed, Thur                  Mon-Fri 9am-5pm            Tue 9am-11am               Wed by appt ONLY
1pm-4:30pm            1pm-4pm                          Closed 12-1                $5 residents               $10 per card
$10 per person        Res $5 per card                  $12.00 per person          $20 non-resident           Must reside/work in
                      Non-res $15                      CASH OR CHECK              CASH ONLY                  city

Page 1 of 2      **CHARGES AND DAYS SUBJECT TO CHANGE PLEASE CALL AHEAD**                                            revised 5/1/12
Greenwood Village            Idaho Spring PD                  Jefferson County               Jeffco Mtn Precinct            Lafayette PD
PD                           1711 Miner Street                SO                             4990 Hwy 73                    451 N 111th Street
6060 S Quebec Street         303.567.4291                     200 Jefferson County           303.271.5686                   303.665.5571
303.773.2525                                                  Pkwy                           Jeffco South
                             Mon-Fri 8:30-4:30pm                                                                            Tue 8:30am-12pm
Tue & Thur                                                    303.271.5542                   Precinct
9am-12pm & 2pm-4pm           $20 per person                                                                                 $15 per card
                                                              Mon-Fri                        8100 Shaffer Pkwy #100
$5/card/live/work city                                        8am-5:15pm                                                    Must reside/work in
                                                                                             Mon-Fri 8am-4:30pm             city
$10 per card non-                                             $10 1st two cards              $10.00 1st 2 cards
resident                                                      $5 each additional             $5 each additional
Sell blank cards $.54                                         Must reside in Unincorp        Must reside in Unincorp
                                                              Jeffco                         Jeffco
Lakewood PD                  Larimer Cnty SO                  Littleton PD                   Longmont PD                    Louisville PD
445 S Allison Pkwy           2501 Midpoint Dr                 2255 W Berry Ave               225 Kimbark Street             992 Via Appia
303.987.7022                 970.498.5100                     303.795.3880                   303.651.8746                   303.666.6531
Mon 4:00pm-6:00pm                                                                            303.651.8555                   Tue 8am-3pm
                             Mon-Fri 8am-5pm                  Tue-Fri 1pm-4pm                Mon-Fri 8:30-5:30
Tue 8am-10am                                                                                                                By appointment ONLY
                             $20 per person                   $10 1st two cards              $10 - 1st card
Wed 11:30am-1:30pm                                                                                                          $10 resident
$10 residents/2 cards        CASH OR CHECK                    $10 each additional            $2 each additional             $15 non-resident
$25 non-residents/2 cards    ONLY                             Residents Only                 Must reside/work in city       More than 3 cards/double
$2.00 each additional card                                    $10 each card Non-                                            fee. Must provide your
                                                              Residents                                                     own card.
Loveland PD                  Nederland PD                     Northglenn PD                  Parker PD                      Red Rocks PD
810 E 10th Street            20 Lakeview Drive                11701 Community                19600 E Parker Sq Dr           13300 W 6th Ave
970.217.1209                 Mon – Fri 9am-4pm                Center Dr                      303.841.9800                   303.914.6394
Email                        Cash or Check                    303.450.8893                   Mon-Fri 9am-5pm                Mon-Thur 8am-
                             $10 card                         By Appointment ONLY            $10.00 1st 2 cards             6pm
By Appointment ONLY                                           $10 residents
$10.00 First card            Residents Only                                                  $3.00 each additional          Fri 9am-5pm
                                                              $15 non-residents
$3 each additional                                                                           Weekends 10-4                  $15 1st card
                                                                                                                            $2 each additional
                                                                                                                            $1 blank cards
Sheridan PD                  Thornton PD                      Westminster PD                 Weld County SO-                Wheat Ridge PD
3960 River Point             9551 Civic Center Dr             9110 Yates Street              Jail Complex                   7500 W 29th Ave
Pkwy                         720.977.5140                     303.658.4378                   2110 “O” Street                303.235.2995
303-761-8500                 Wed 12:30pm-4:30pm               303.658.4377                   Greeley                        Tue-Thur 10am-
Mon-Fri 10am-2pm             $10 per card                     Tue-Thur 1pm-6pm               970-356-4015 x 3893            5pm
                             Must reside/work in city         $20 per person
$10 residents                                                                                Mon-Fri 8am-5pm                $10 per person
                                                              Must reside/work in city
$18 non-residents                                                                            $10.00 per person              Reside/work in city
CALL FIRST                                                                                                                  Appt needed for court
                                                                                                                            ordered prints


(Q) How/where can you get applicant cards with CBI’s ORI on them?
(A) Blank cards with the CBI ORI are available for a charge plus shipping and handling cost through Colorado Correctional Industries @ 4999 Oakland
Street – 303.370.2165. Fingerprints may also be obtained at this location.

 (Q) Which people should provide their own applicant fingerprint cards (with CBI ORI on them)?
 (A) Use cards with CBI’s ORI for:
                  Licensed Day Care
                  Foster & Adoptions 303.32.4164
                  Public School 303.866.6628
                  Gaming 303.757.7555
                  Racing 303.894.2990
                  P.O.S.T 303.866.5385
(Q) Which people should provide their own applicant fingerprint cards?
(A) Use cards with Agency, City County or State ORI for:
                  Visa applicants (get cards from the country to which they are going)
                  Job in other City, State or County (get cards from place of employment)
                  Immigration 303.361.3841
                                                Boulder Valley School District
                                      Authorization agreement for direct deposit

Name                                                                           Employee Number or
                                                                                Social Security Number

Effective Date (Month/Year)

This request is to:                   START           (not currently on direct deposit)
(Please check only one)               CHANGE          of bank and/or account number
                                      STOP            (paper check will be issued)

                    If this is a START or CHANGE request, please attach either a voided check or
                                   a Direct Deposit information form in the box below.

• For START and CHANGE requests, the Payroll Office must receive this form no later than the 20th of the month.
    (DECEMBER ONLY—the deadline is the 10th of the month)
• The Payroll Office can STOP a direct deposit if this form is received at least five days before payday.
                                MAY RESULT IN A DELAY OF YOUR PAYCHECK!!
• Your bank information will also be used for any employee reimbursements paid through Accounts Payable.

I HEREBY AUTHORIZE and request to have my regular monthly pay deposited to my account on the last working day of the month.
 I also authorize any employee reimbursements paid by the Boulder Valley School District to be deposited to this same account as needed.
I understand and agree that if an erroneous credit is made to my account, the District is authorized to stop payment, reverse the entry, or
make any adjustment necessary to my account to correct the erroneous entry.

Signature                                                                                Today’s Date

Please check one:                          Checking Account                          Savings Account

♦    CHECKING account: attach a VOIDED CHECK in the box below.
♦    SAVINGS account: attach a DIRECT DEPOSIT INFORMATION FORM, available from your bank.

♦    IMPORTANT!! DO NOT ATTACH A DEPOSIT SLIP. Deposit slips do not always have the information we need
     to process your request. Attaching a deposit slip will delay processing of your direct deposit request.


Please attach                                                                                                           check or direct
deposit                                                                                                                 information
form here.

Form W-4 (2012)                                             Complete all worksheets that apply. However, you
                                                            may claim fewer (or zero) allowances. For regular
                                                            wages, withholding must be based on allowances
                                                                                                                             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
Purpose. Complete Form W-4 so that your                     you claimed and may not be a flat amount or                      working spouse or more than one job, figure the
employer can withhold the correct federal income            percentage of wages.                                             total number of allowances you are entitled to claim
tax from your pay. Consider completing a new Form           Head of household. Generally, you can claim head                 on all jobs using worksheets from only one Form
W-4 each year and when your personal or financial           of household filing status on your tax return only if            W-4. Your withholding usually will be most accurate
situation changes.                                          you are unmarried and pay more than 50% of the                   when all allowances are claimed on the Form W-4
Exemption from withholding. If you are exempt,              costs of keeping up a home for yourself and your                 for the highest paying job and zero allowances are
complete only lines 1, 2, 3, 4, and 7 and sign the          dependent(s) or other qualifying individuals. See                claimed on the others. See Pub. 505 for details.
form to validate it. Your exemption for 2012 expires        Pub. 501, Exemptions, Standard Deduction, and                    Nonresident alien. If you are a nonresident alien,
February 18, 2013. See Pub. 505, Tax Withholding            Filing Information, for information.                             see Notice 1392, Supplemental Form W-4
and Estimated Tax.                                          Tax credits. You can take projected tax credits into             Instructions for Nonresident Aliens, before
Note. If another person can claim you as a                  account in figuring your allowable number of                     completing this form.
dependent on his or her tax return, you cannot claim        withholding allowances. Credits for child or                     Check your withholding. After your Form W-4 takes
exemption from withholding if your income exceeds           dependent care expenses and the child tax credit                 effect, use Pub. 505 to see how the amount you are
$950 and includes more than $300 of unearned                may be claimed using the Personal Allowances                     having withheld compares to your projected total tax
income (for example, interest and dividends).               Worksheet below. See Pub. 505 for information on                 for 2012. See Pub. 505, especially if your earnings
                                                            converting your other credits into withholding                   exceed $130,000 (Single) or $180,000 (Married).
Basic instructions. If you are not exempt, complete         allowances.
the Personal Allowances Worksheet below. The                                                                                 Future developments. The IRS has created a page
worksheets on page 2 further adjust your                    Nonwage income. If you have a large amount of                    on for information about Form W-4, at
withholding allowances based on itemized                    nonwage income, such as interest or dividends,          Information about any future
deductions, certain credits, adjustments to income,         consider making estimated tax payments using Form                developments affecting Form W-4 (such as
or two-earners/multiple jobs situations.                    1040-ES, Estimated Tax for Individuals. Otherwise, you           legislation enacted after we release it) will be posted
                                                            may owe additional tax. If you have pension or annuity           on that page.
                                               Personal Allowances Worksheet (Keep for your records.)
A       Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .                               A

B       Enter “1” if:    { • You are single and have only one job; or
                           • 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.
                                                                                                                                  . . .      B       }
C       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
D       Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .                    D
E       Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .                E
F       Enter “1” if you have at least $1,900 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.)
G       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 $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three to
        seven eligible children or less “2” if you have eight or more eligible children.
        • If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child . . .   G
H       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

                              • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
        For accuracy,           and Adjustments Worksheet on page 2.
        complete all          • If you are single and have more than one job or are married and you and your spouse both work and the combined
        worksheets            earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
        that apply.           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
                                         Employee's Withholding Allowance Certificate
                                 ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
                                                                                                                                                                OMB No. 1545-0074

Internal Revenue Service           subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
    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, 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     Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)           5
    6     Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .                          6 $
    7     I claim exemption from withholding for 2012, 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 lines 8 and 10 only if sending to the IRS.)         9 Office code (optional)    10    Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                                Cat. No. 10220Q                                       Form W-4 (2012)
Form W-4 (2011)                                                                                                                                                                   Page 2

                                                                Deductions and Adjustments Worksheet
 Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

   1      Enter an estimate of your 2011 itemized deductions. These include qualifying home mortgage interest,
          charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
          miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . .                                                                        1     $

   2      Enter:     {$11,600 if married filing jointly or qualifying widow(er)
                      $8,500 if head of household
                      $5,800 if single or married filing separately
                                                                                   . . . . . . . . . . .                                                    2     $

   3      Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .                                                         3     $
   4      Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)                                         4     $
   5      Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
          Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)         . . . . . . . . . . .                                                    5     $
  6       Enter an estimate of your 2011 nonwage income (such as dividends or interest) . . . . . . . .                                                     6     $
  7       Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .                                                         7     $
  8       Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction . . . . . . .                                                  8
  9       Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .                                                         9
 10       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                                     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.
  1    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” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                 2
   3      If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
          “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .                 3
 Note. If line 1 is 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      Enter the number from line 2 of this worksheet . . . . . . . . . .                      4
   5      Enter the number from line 1 of this worksheet . . . . . . . . . .                      5
   6      Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     6
   7      Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .                                                 7     $
   8      Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .                                         8     $
   9      Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid
          every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
          line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . .                                                   9     $
                                         Table 1                                                                                        Table 2
         Married Filing Jointly                                  All Others                              Married Filing Jointly                             All Others
 If wages from LOWEST          Enter on          If wages from LOWEST          Enter on            If wages from HIGHEST     Enter on        If wages from HIGHEST       Enter on
 paying job are—               line 2 above      paying job are—               line 2 above        paying job are—           line 7 above    paying job are—             line 7 above
           $0 - $5,000 -                 0                 $0 - $8,000 -                    0             $0   - $65,000         $560               $0   - $35,000           $560
       5,001 - 12,000 -                  1             8,001 - 15,000 -                     1         65,001   - 125,000          930           35,001   - 90,000              930
     12,001 - 22,000 -                   2            15,001 - 25,000 -                     2        125,001   - 185,000        1,040           90,001   - 165,000           1,040
     22,001 - 25,000 -                   3            25,001 - 30,000 -                     3        185,001   - 335,000        1,220          165,001   - 370,000           1,220
     25,001 - 30,000 -                   4            30,001 - 40,000 -                     4        335,001   and over         1,300          370,001   and over            1,300
     30,001 - 40,000 -                   5            40,001 - 50,000 -                     5
     40,001 - 48,000 -                   6            50,001 - 65,000 -                     6
     48,001 - 55,000 -                   7            65,001 - 80,000 -                     7
     55,001 - 65,000 -                   8            80,001 - 95,000 -                     8
     65,001 - 72,000 -                   9            95,001 -120,000 -                     9
     72,001 - 85,000 -                 10            120,001 and over                     10
     85,001 - 97,000 -                 11
     97,001 -110,000 -                 12
    110,001 -120,000 -                 13
    120,001 -135,000 -                 14
   135,001 and over                    15
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to               You are not required to provide the information requested on a form that is
carry out the Internal Revenue laws of the United States. Internal Revenue Code sections               subject to the Paperwork Reduction Act unless the form displays a valid OMB
3402(f)(2) and 6109 and their regulations require you to provide this information; your employer       control number. Books or records relating to a form or its instructions must be
uses it to determine your federal income tax withholding. Failure to provide a properly                retained as long as their contents may become material in the administration of
completed form will result in your being treated as a single person who claims no withholding          any Internal Revenue law. Generally, tax returns and return information are
allowances; providing fraudulent information may subject you to penalties. Routine uses of this        confidential, as required by Code section 6103.
information include giving it to the Department of Justice for civil and criminal litigation, to         The average time and expenses required to complete and file this form will vary
cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in            depending on individual circumstances. For estimated averages, see the
administering their tax laws; and to the Department of Health and Human Services for use in            instructions for your income tax return.
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          If you have suggestions for making this form simpler, we would be happy to hear
federal law enforcement and intelligence agencies to combat terrorism.                                 from you. See the instructions for your income tax return.
                                       AFFIRMATION OF LEGAL WORK STATUS
                                              Pursuant to Colorado Revised Statute *8-2-122

             Employee name: ________________________________________________                                           _______
                                Last,              First             Middle                                            DOB

             Social Security Number: _____ - ____ - ________ Date of Employment ____________


             ____ I have examined the legal work status of the above named employee.

             ____ I have retained file copies of the documents required by 8 U.S.C. SEC. 1324a used
                        to verify this employee’s legal work status.

             ____ I have neither altered or falsified the employee’s identification documents.

             ____ I have not knowingly hired an unauthorized alien.

             Employer Name: _________________________________________________________

             I, ____________________________________________, hereby declare under the
                                  Print name

             penalty of perjury (C.R.S. 18-8-503) that I personally affirm the above is true and correct

             to the best of my knowledge and belief.


             Official title

             *(2) On and after January 1, 2007, within twenty days after hiring a new employee, each employer in Colorado shall
             affirm that the employer has examined the legal work status of such newly-hired employee and has retained file copies
             of the documents required by 8 U.S.C. sec. 1324a; that the employer has not altered or falsified the employee's
             identification documents; and that the employer has not knowingly hired an unauthorized alien. The employer shall
             keep a written or electronic copy of the affirmation, and of the documents required by 8 U.S.C. sec. 1324a, for the term
             of employment of each employee.

             NOTE: This information is confidential and should be attached with supporting documents to
                   the Federal I-9 form.

CDLE:ICE/Affirmation Form/CRS 8-2-122/Employers/Affirmation Form 12.20.06 v.001
                           Statement Concerning Your Employment in a Job
                                   Not Covered by Social Security

Employee Name                                              Employee ID#

Employer Name                                              Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you
may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social
Security based on either your own work or the work of your husband or wife, or former husband or wife, your
pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will
not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be

Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”

Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government
Pension Offset.”

For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.

Signature of Employee                                                                   Date

Form SSA-1945 (12-2004)
                   Information about Social Security Form SSA-1945
     Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State
and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not
covered under Social Security. The statement explains how a pension from that job could affect future Social
Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the
document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential
effects of two provisions in the Social Security law for workers who also receive a pension based on their work in
a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s
Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social
Security benefit received as a spouse or an ex-spouse.

Employers must:
  • Give the statement to the employee prior to the start of employment;
  • Get the employee’s signature on the form; and
  • Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website,
Paper copies can be requested by email at or by fax at 410-965-2037. The
request must include the name, complete address and telephone number of the employer. Forms will not be sent to
a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The
forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (12-2004)

PRINT NAME___________________________________________________________

State of Colorado

County of Boulder

“I solemnly swear or affirm that I will support the Constitution of the State of Colorado
and of the United States of America and the laws of the State of Colorado and of the
United States.”



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