New Hire Employment F older Checklist

Transcription

1 "*This Page is to be filled out by the Store Management Team and Admin Personnel only. New Hire Employment F older Checklist Year: 2017 EMPLOYEE NAME: Store Management Team Employee Application Complete and Verified New Hire Cover Page Completed Direct Deposit Page (if requesting it) 1-9 From Completed and Correct Copy of I -9 froms of ID used W-4 Form Completed and Correct Copy of Handbook Page Signed Employee Healthcare Policy Page Signed correctly) Employee Entered Into Radiant Employee Entered Into ADP Date: Verified By: Ufflce Aamm Healthcare forms sent to apprioprate Company Healthcare Deductions Started Direct Deposit Verified in Payroll E-Verify Completed Employee File Scanned and Filed After Em~loyment Terminated Separation Form Completed Any and All Documention Included (write-ups, notices, etc.) Employee Terminated from Radiant Employee Terminated from Payroll Healthcare Deductions Stopped Employee File scanned and filed in Separated Files Confidentallnformation Property 0/DB Florida Management LLC

2 New Hire Cover Page **ALL Grey Areas MUST be filled out by New Hire ** Name:1 I I First Middle Last Maiden Namel Social Security Number: ' Driver's License Number: ' ~ r_ ~ Expiration Date: Issuing State: 1-1_---'_--' Date of Birth: ' ' Home Phone: L..I ~ Cell Emerga ncy Contact: ~ :, r j Phone: 1,,-. --' Phone#:I~ ---, Relationship:. ~========~ ~ Address: I ~==================================~ Employee's Signature:1 Printed Name: ~------~ ~ Date: **To be filled out by hiring Manager ** Hire Date: Handbook Policy Form : ~ ~ ~ ~ Rate of Pay: ~ ~ Payroll Setup: f i Job Title: Store PC#: ~ ~ Healthcare Forms Completed: ' ~ Radiant Setup: ~ ~ Manage~ss~nature:I~ ~ Printed Name: ~ r_ ~ Date: L- J Confidentallnformation Property of D8 Florida Management He

3 **Only Fill Out This Page if you would like Direct Deposit **All Grey Areas MUST be filled out by New Hire ** Direct Deposit Form 1,1 I,do Authorize ADP Payroll Center to Electronically Deposit my payroll into the accounts listed below. Bank Name: ADD Account Number Change Delete I I I I J Routing Number Che ckin g Amount to be Deposited: 0, pe«eot,ge'b Savings Amount to be Deposited: Or Percentage:. Bank Name : --- ADD Account Number Change Delete Routin g Number Checking Amount to be Deposited: I I I I Or pe«en"ge'b Savings Amount to be Deposited: Or Percentage: For Direct deposit, please attach a voided check and/or a letter from your financial institution which includes ACH routing number and your accounting number on it. Note: By signing this form you agree to all condition s and fees imposed by the bank for the above actions. Deposit's can only be made into Checking and/or savin gs Accounts. I Please sign below agreeing to the following terms and conditions: If I change the banks or bank accounts, I am fully responsible for immediately notifing the store manager of the change. I hereby authorizle and agree that in the event that ADP funds are erroneously deposited into my account, I authorize ADP to debit my account for an amount not to exceed the orginial amount of erroneous deposit. Should the funds no longer be available and were not rightfully mine, I agree to return the amount of the erroneous deposit in full upon demand. I understand that any changes to my direct deposit, including stopping my direct deposit, must be sumbmitted by me to my store manager in writing at least (7) days prior to the my next deposited check date. Changes may require me to receive a live payroll check for up to (2) pay periods. Employee's Signature: Printed Name: Date: Confidental Information Property of DB Florida Management LLC

4 Employment Eligibility Verification USCIS Department of Homeland Security Form 1-9 U.S. Citizenship Immigration Expires 08/ OMB No, ~ 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 to discriminate work~authorized individuals, Employers CANNOT which document{s) an employee may to establish employment authorization and identity, The refusal to hire or oontinue to employ an individual because the documentation presented has a future expiration date may also constitute (E'n1JI OlfE~fts must ofform /-9 no! Middle Initial Other Last Names Used (ifany) IAddress (Street Number and Name) Apt Number City or Town ZIP Code Date of Birth (mm/ddlyyw) U.S. Social Security Number 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 of perjury, that I am (check one of the following A noncitizen national of the United States (See instructions).---~~...,-- 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mmjdd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to <.;UIIIUI""e: An Alien Registration Number/USCIS Number OR Form /-94 Admission Number OR Foreign Passport Number. QR Code - Section i Do Not Wnle In ThiS Space 1. Alien Registration NumberJUSCIS Number: OR 2. Form 1-94 Admission Number: OR 3, Foreign Passport Number: Country of Issuance: my Signature of Preparer or Translator Today's Date (mm/dd/yyw) Last Name (Family Name) First Name (Given Name). Address (Street Number and Name) i I City or Town I State IZIP Code Form 1-9 1li14i2016 N lof3

5 Employment Eligibility Verification Department of Homeland Security Form 1-9 U.S. and Immigration Services Expire.:> 08/3 U20 19 OMB No emnlo'vrrn'mlt, You as ffsted on the "Lists Last Name (Family Name) First Name (Given Name) IM,I. Citizenship/Immigration Status List A Identity and Employment Authorization Document Title OR Document Title List B Identity AND Document Title List C Employment Authorization Issuing Authority Issuing Authority Issuing Authority Document Number Document Number Document Number Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any)p,vv,jyyy) Document Title Issuing Authority Document Number Additional Information QR Code - Seclions 2 &3 Do Not Wlite In This Space Expiration Date (if any)(mmidd/yyyy) Document Title I Issuing Authority I Document Number Expiration Date (if any)(mmidd/yyyy) Certification: I attest, under 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 of employment (mmidd/yyyy): 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 Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) I attest, under penalty perjury, to my to the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Form J J2016N 2of3

6 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED nl(\'\i~f"~ may present one selection from List A or a combination of one selection from List B and one selection from List C, LIST A LIST 8 LIST C Documents that Establish Documents that Establish Documents that Establish 80th Identity and Identity Employment Authorization Employment Authorization AND 1. U,S, r-a.ssi:ioi1 or U,S, Passport Card 1. Driver's license or 10 card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of,2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, eye,3. Foreign passport that contains a color, and address VALID FOR WORK ONLY WITH temporary stamp or temporary INS AUTHORIZATION state or local ' '-_55_1_p_r_in_te_d_n_o_t_at_io_n_o_n_a_m_a_ch_i_ne_-----i (3) VALID FOR WORK ONLY WITH readable immigrant visa government or entities, DHS AUTHORIZATION 1 provided it contains a photograph or ' 4. Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State I 5. For a nonimmigrant alien authorized to work for a employer because of his or her status: a. and b. Form 1-94 or Form 1-94A that has the following: (1) The same name as the and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the nrnin()'~",n employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the of the Marshall Islands (RMI) with Form 1-94 or Form 1-94A indicating nonimmigrant admission under the of Free Association Between the United States and the FSM or RMI School 10 card with a photograph 4. Voter's registration card 5. U.S Military card or draft record Driver's license issued by a Canadian government authority For persons under age 18 who are unable to a document listed above: 10. School record or report card r hospital record 3. Certification of of Birth issued by the Department of State DS-1350) 4. or certified copy of birth I'.:>rtlt'''<ltc issued by a State, county, municipal authority, or territory of the United States an official seal 6. U,S. Citizen 10 Card (Form 7. Identification Card for Use of Resident Citizen in the United States (Form 1-179) 8. Employment authorization document issued by the Department of Homeland Security 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. FOIDl 1-9 J1114/2016 N 30[3

7 The exceptions don't apply to supplemental wages greater than $1, income. If you have a large amount of income, such as interest or dividends, making estimated tax payments using Form Estimated Tax for IndividualS. Otherwise. you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W"4 or W"4P. Note: If another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1.050 and includes more than $350 of unearned income (for example, interest and dividends). may witlhhcl,lliirlo even Head of household. Generally. you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% 01 the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub, 501. Exemptions. Standard Deduction, and Rling Information, for information. You're single and have only one job; or } B Enter "1" if: { You're married, have only one job, and your spouse doesn't work; or B Your wages from a second job or your wages (or the total of both) are $1,500 or less. 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 than your spouse or yourself) you will claim on your tax retum. D E Enter "1" if you will file as head of household on your tax retum (see conditions under Head of household above) E F Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G H Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $70,000 ($100,000 if married), enter "2" for each eligible child; then less "1" if you have two to four eligible children or less "2" if you have five or more eligible children... If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each child. G 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 $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 that apply_ ( to avoid having too little tax withheld... If neither of the above situations applies. sto 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. -""--"-""""""""---..."""""""""---", Employee's Withholding Allowance Certificate OMB No OAn~rtn'.ntof the TreaSlllY.., Whether you are entitled to claim a certain number of allowances or exemption from withholding is Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 17 Your first name and middle initial 2 Your social security number A Home address (number and street or rural route) City or town, state. and ZIP code 3 D Single Married D Married. but withhold a! higher Single rate. 4 If your last name differs from that shown on your social security card, box. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2017, 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 liab,.:.:ii"'itylt.'-- -'-- 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. For Privacy Act and Paperwork Reduction Act Notice, see page 2. Ca!. No Q Form

8 Form W-4 (2017) Page 2 Deductions and Ad'ustments 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 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions your income is over $313,800 and you're married filing jointly aqualifying widow(er}; if you're head of household; $261,500 you're single, not head of household and not a wldow(er}; or $156,900 if you're married filing See Pub. 505 for details. 2 Enter: $12,700 If married filing jointly or qualifying widow(er) $9,350 if head of household { $6,350 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 2017 adjustments to income and any additional standard deduction (see Pub. 4 5 Add lines 3 and 4 and enter the total. any amount for credits from the Credits to Wil'hholdina Allowances for 2017 Form W-4 worksheet in Pub. 505.). 5 6 Enter an estimate of your 2017 nonwage income 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 $4,050 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 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 Two-Earners/Multi Ie Jobs Worksheet See Two earners or multi Ie 'obs on a e 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 job are 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 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 Find the amount in Table 2 below that applies to the HIGHEST 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 2017, For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 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 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are- Enteron line 2 above $0 $7,000 a 7,001 14, , ,001-55, ,001 65, , , , , , , , and over If wages from LOWEST Enter on paying job are- line 2 above $0 $8,000 a 8, , ,001 70, , , , , and over 10 Privacy Act and Paperwork Reduction Act Notice. We ask for Ihe informalion on this form to carry Olrt the Intemal Revenue laws of the United Stales. Internal Revenue Code sections 3402(Q(2) and 6109 and require you to your employer uses it to determine withholding. completed form will result being treated as allowances; providing information this information include giving it to the nanartn'anl slates, the District of Columbia, commonweatths and possessions for use in and to the Department of Health and Human Services for use in Hires. We also disclose this information to other countries under a tax treaty, stale nonlax criminal laws, or 10 federal law enforcement and intelligence agencies to combel terrorism. If wages from HIGHEST paying job are $0 $75,000 75, , , , , ,001 and over Enter on line 7 above $ ,420 1,600 If wages from HIGHEST paying job are $0 $38,000 38,001-85, , , ,001 and over Enter on ove $ , ,600 You are not on a form that is subject 10 Ihe Act unless the displays a valid OMS control number. or records to a form or its instructions must be retained as long as their contents material in the administration of Internal Revenue law. Generally, returns and retum informalion are IYlrlfirl,"oti,,1 as required by Code section The average lime and expenses required 10 complete and file this form will vary rl"r",n,,;nn on individual circumstances. For estimated averages. see the """;""'J"" for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

9 Employee Handbook Policy Review and Acceptance Form II (Insert your Name above.) have read and reviewed the mployee handbook provided to m for DB Florida Management LLC. This was handbook was read by me on (insert date read). By signing this document, I that I have and understand the company policies and guidelines as outlined in the Employee ndbook provided to me. You refer back to this employee handbook at any time by speaking with your Manager on Duty. They will then you access to the hard copy handbook stored in the Managers office at location. If you would like a hard copy ofthe handbook for your own records, notify the and they will provide with one. Signature Name Handbook Review Form: Version Property ofdb Florida Management Inc.

10 Employee Healthcare Information I, have read and (Insert your Name above.) reviewed the employee healthcare information provided to me for DB Florida Management LLC. This information is provided on their website at There you will find enrollment/change forms, descriptions of all available plans, and the 2017 Rate sheet for each plan provided. I understand that at any time, if I have any questions, regarding the available healthcare options that I may reference this web page. Healthcare Eligibility Requirements; 1.) You will be eligible for insurance after (90) days of employment. 2.) You must be a Full-Time employee (to be considered full time you must work an average of (30) hours a week for the (6) weeks prior to your 90-day anniversary). 3.) If you are interested in accepting any insurance plan, you will start being deducted the stated premium amount (30) days prior to starting the insurance to make sure your premiums are paid. 4.) At any time during your initial (90) probationary period you may change your mind on any healthcare decision you have made. You must fill out a new Healthcare Enrollment/Change form and turn it in prior to the (90) point. 5.) After the (90) day point you will only be allowed to make changes to your healthcare decisions based on life change events. This applies to loss of job, change of jobs, and change to spousal job or insurance status only; By signing this document, I agree that I have read and understand the company policies and guidelines in regards to Healthcare Plans as outlined above to me. ***You may refer back to back to any healthcare plans at any time on our webpage at Signature Printed Name Date Healthcare Acknowledgment Form: Version Property of DB Florida Management Inc.

11 .'CBABlue p ENROLLMENT I CHANGE FORM UAddition U Change U Termination Reason: If change or termination, complete only Employee's Name, Social Security Number, and the Change details. Termination date includes last day of coverage. EMPLOYEE INFORMATION Effective Date EmQlo,!ee Name Sex Date of Birth Social Security Number Last First MI EmQlo,!ee Home Address StreeUApt. City State Zip + Four County Mailing Address (ifdifferent From Home Address) J M ~ F I I - - Home Telephone ( ) - Business Telephone ( ) - Status Marital :status Covera~e Coveraae: Check the box to select your Medical and Dental clans U Active o Single U Employee Only M~~i~5l1:0Premium OQuality OValue HSA OMEC ONONE U COBRA o Married o Employee + One o Retired o Family Dental: OPremium OQuality ONONE Relation To If other insurance, Please Employee If he I she is List Name of Other Insurance List Full Name of Your Eligible 1-Spouse Date Social jjandicapped or Carrier & Type ofcoverage Dependents 2-Child <26 Gender of Security Qisabled (Medical, Qental) for each years of age (M orf) Birth Number indicate H or D dependent with effective 3-Stepchild with effective dates 4-0ther date 1 I I I I - - I I - - I I I I - - I I - - Will this plan replace existing coverage? 0 Yes 0 No If yes, please provide a Certificate of Prior Health Insurance Coverage (HIPAA certificate) to your employer as soon as you receive it from your prior insurer. I verify that this information is true to the best of my knowledge. I authorize my employer to deduct from my pay any required contributions and understand that my enrollment will continue until the Plan renews or I experience a qualifying event. Please see Human Resources for additional information. Is employee eligible for Medicare? o YON Effective Date_ Is spouse/dependent eligible for Medicare? Employee Signature Date o YON Effective Date THIS SECTION TO BE COMPLETED BY EMPLOYER: EMPLOYER (OR PLAN SPONSOR)STATEMENT: Employer Name: Hire Date leffective Date National DCP, LLC. / / I / Pc# (Required) Employee Title Employer Authorized Signature: Print Name: ~~~ate: ~~lephone Mail to: CBA Blue P.O. Box2365 South Burlington VT I ICBA Blue FAX ILiMBER t-ax to: CSA Blue Eli gyp ibilit Ue artment

12 D WAIVER OF COVERAGE FORM EMPLOYEE NAME (Please Print): [WAIVER OF GROUP MEDICAL COVERAGE (Please Check One): 0 I waive my employer's group health insurance coverage for myself and dependents (if any). 0 I am enrolling in my employer's group health insurance coverage but I am waiving coverage for my dependents (if any). WAIVER OF GROUP DENTAL COVERAGE (Please CheckOne): 0 I waive my employer's group dental insurance coverage for myself and dependents (if any). 0 I am enrolling in my employer's group dental insurance coverage but I am waiving coverage for my dependents (if any). REASON FOR WAIVER OF GROUP COVERAGE (Please CheckOne): 0 Coverage through spouse's employer: Employer Name: Insurance Company: 0 Other reason (please explain) EMPLOYEE STATEMENT: As a result. I waive my, and/or my dependents' (if any) eligibility to enroll in my employer's group health plan(s) at this time. I understand that I and/or my dependents may enroll under these plans in the future only within 30 days from loss of other group coverage or at the time of my employer's annual open enrollment. EMPLOYEE SIGNATURE DATE