CONSUMER DISCLOSURE AND AUTHORIZATION FORM. Disclosure Regarding Background Investigation

Transcription

1 CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation Montgomery College (the Company ) may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as background reports ). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight can be contacted by phone at (800) Information about HireRight s privacy practices is available at Policy.aspx. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker s compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. 1 HireRight

2 ADDITIONAL STATE LAW NOTICES If you are a California, Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please also note: CALIFORNIA: Pursuant to section of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight s offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. HireRight has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. Proper identification includes documents such as a valid driver s license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, HireRight may require additional information concerning your employment and personal or family history to verify your identity. MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports. MASSACHUSETTS: If we request an investigative consumer report, you have the right, upon written request, to a copy of the report. NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If an investigative consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Attached below is additional information about New York law. WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. 2 HireRight

3 Authorization of Background Investigation I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, Inc., and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company. California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company. Applicant Last Name First Middle Applicant Signature Date address: 3 HireRight

4 Section 750. Definitions Applicability. NEW YORK CORRECTION LAW ARTICLE 23-A LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited Factors to be considered concerning a previous criminal conviction; presumption Written statement upon denial of license or employment Enforcement Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons. (3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency. 4 HireRight

5 751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. 5 HireRight

6 (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. 6 HireRight

7 Para informacion en español, visite o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave., N.W., Washington, DC A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, DC You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer 7 HireRight

8 reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to. You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are: TYPE OF BUSINESS Consumer reporting agencies, creditors and others not listed below National banks, federal branches/agencies of foreign banks (word National of initials N.A. appear in or after bank s name) PLEASE CONTACT Federal Trade Commission: Consumer Response Center FCRA Washington, DC Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC HireRight

9 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Savings associations and federal chartered savings banks (word Federal or initials F.S.B. appear in federal institution s name) Federal credit unions (words Federal Credit Union appear in institution s name) State-chartered banks that are not members of the Federal Reserve System Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Activities subject to the Packers and Stockyards Act, 1921 Federal Reserve Board Division of Consumer & Community Affairs Washington, DC Office of Thrift Supervision Consumer Complaints Washington DC National Credit Union Administration 1775 Duke Street Alexandria, VA Federal Deposit Insurance Corporation Consumer Response Center 2345 Grant Avenue, Suite 100 Kansas City, MO Department of Transportation, Office of Financial Management Washington, DC Department of Agriculture Office of Deputy Administrator GIPSA Washington, DC HireRight

10 Employee Personal Data Form MC ID# (Current Employees Only) PART 1 NEW EMPLOYEE REHIRE UPDATE DATA Social Security Number (New Employee or Rehire Only) Employee s Name ( Last Name, First, MI) (as it appears on your Social Security Card) Were you ever a Student/Employee of Montgomery College? Name under which you were employed or enrolled Yes No Prefix Mr. Mrs. Ms. Dr. Other Suffix Jr. II III Sr. PhD Other PART 2 EMPLOYEE ADDRESS & PHONE INFORMATION Street APT/FL/SUITE Home Phone Cell Phone City State Zip Code County PART 3 Gender Female Male Marital Status Single Married DEMOGRAPHIC INFORMATION Divorced Widowed Birth Date (mm/dd/yyyy) Birth Country Ethnicity Hispanic or Latino Yes No American Indian or Alaskan Native African American/Black Asian Native Hawaiian or Other Pacific Islander White Military Status (Check one if appropriate) Citizenship Status US Citizen Birth ( Native) Permanent Resident Disability ( optional) US Citizen Naturalized Non-Resident Alien- Visa type: Exp. Date: No Military Service Vietnam Veteran Only Both Vietnam and Other Eligible Veteran Other Protected Veteran Are you a disabled veteran? YES NO PART 4 EDUCATION None Mobility Speech Learning Blind Hearing No Academic Credentials High School Diploma Trade Certification Some College Associate Degree Major: Year Confirmed Bachelor s Degree Major: Year Confirmed Master s Degree Major: Year Confirmed Doctorate Major: Year Confirmed Professional Certification : Certification: Year Confirmed PART 5 EMERGENCY CONTACT Contact Name ( Last, First) Phone Number Relationship to Employee (Optional) Contact Name ( Last, First) Phone Number Relationship to Employee (Optional) PART 6 CERTIFICATION I certify the information, which I have provided, is complete and accurate to the best of my knowledge. Employee Signature Date Revised 10/07 Please Forward to the Office of Human Resources for processing.

11 Government of the District of Columbia Year D-4 Employee Withholding Allowance Certificate Your first name M.I. Last name Home address (number and street) Apartment number Social security number City State Zip code +4-1 Tax filing status Fill in only one: Single Married/domestic partners filing jointly Married filing separately Head of household 2 Total number of withholding allowances from worksheet below 3 Additional amount, if any, you want withheld from each paycheck Married/domestic partners filing separately on same return 4 If claiming exemption from withholding, read below and, if qualified, write EXEMPT in this box. I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and this year I do not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt status on federal Form W-4. If claiming withholding exemption, are you a full-time student? Yes No $ Signature Under penalties of law, I declare that I have completed this certificate and, to the best of my knowledge, it is correct. Employee s signature Date Employer Keep this certificate with your records. If 10 or more exemptions are claimed or if you suspect this certificate contains false information please send a copy to: Office of Tax and Revenue, 941 North Capitol St., NE, Washington, DC Attn: Compliance Administration # Detach and give the top portion to your employer. Keep the bottom portion for your records. Government of the District of Columbia D-4 Employee Withholding Allowance Worksheet Section A Number of withholding allowances a Enter 1 for yourself and b Enter 1 if you are filing as a head of household and c Enter 1 if you are 65 or over and d Enter 1 if you are blind e Enter number of dependents a b c d e f Enter 1 for your spouse/registered domestic partner if filing jointly f g Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is 65 or over and h Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is blind g h i Number of allowances Add Lines a through h and enter on Line 2 of the certificate. If you want to claim additional withholding i allowances, complete section B below. Section B Additional withholding allowances j Enter estimate of your itemized deductions j k Enter $2,000 if married/registered domestic partners filing separately; all others enter $4,000 k l Subtract k from j l m Multiply $1,675 by the number of allowances on Line i m n Divide l by m. Round to the nearest whole number. o Add Lines n and i and enter on Line 2 above. n o D-4 P1 Employee Withholding Allowance Certificate Revised 08/08

12 # Detach and give the top portion to your employer. Keep the bottom portion for your records. Who must file a Form D-4? Every new employee who resides in DC and is required to have DC taxes withheld, must fill out Form D-4 and file it with his/her employer. If you are not liable for DC taxes because you are a nonresident you must file Form D-4A. Certificate of Nonresidence in the District of Columbia, with your employer. When should you file? File Form D-4 whenever you start new employment. Once filed with your employer, it will remain in effect until you file an amended certificate. You may file a new withholding allowance certificate any time the number of withholding allowances you are entitled to increases. You must file a new certificate within 10 days if the number of withholding allowances you claimed decreases. How many withholding allowances should you claim? Use the worksheet on the front of this form to figure the number of withholding allowances you should claim. If you want less money withheld from your paycheck, you may claim additional allowances by completing Section B of the worksheet, Lines j through o. However, if you claim too many allowances, you may owe additional taxes at the end of the year. Should I have an additional amount deducted from my paycheck? In some instances, even if you claim zero withholding allowances, you may not have enough tax withheld. You may, upon agreement with your employer, have more tax withheld by entering on Line 3, a dollar amount of your choosing. What to file After completing Form D-4, detach the top portion and file it with your employer. Keep the bottom portion for your records.

13 DIRECT DEPOSIT FORM NOTE: I hereby authorize Montgomery College, Payroll Office to deposit my net pay automatically to the account at the financial institution listed below. I understand that I may select another bank for direct deposit at any time by submitting a new authorization form and allowing a reasonable amount of time to act on same. I am aware that it will always take two full pay cycles from the process date for the first direct deposit, and that I will receive a regular pay check by mail in the interim. This form will remain in effect until I request it be stopped, in writing, or I submit a new form, even after a break in service. Return completed form to the Payroll Office Hungerford Dr., Rm 225 Rockville, MD NOTE: PLEASE ATTACH ONE OF YOUR VOIDED CHECKS WHICH CLEARLY SHOWS YOUR ACCOUNT NUMBER AND THE TRANSIT NUMBER OF YOUR BANK FOR VERIFICATION. DO NOT ATTACH A DEPOSIT TICKET PART I: EMPLOYEE INFORMATION: (MANDATORY) Employee Name: College ID #: M (Required) (Required) ACTION TO BE TAKEN (Check all that apply) a. Start Direct Deposit b. Change of Financial Inst. c. Change of Account Number d. Stop PART II: BANK INFORMATION Financial Institution Name Deposit to Account # (Required) (Required) Type of Account: (check one) Savings Checking Routing Number (ABA) # (Required) TO BE COMPLETED ONLY FOR ADDITIONAL ACCOUNT(S) OR TO CHANGE $ AMOUNTS BANK NAME ROUTING # SAVING OR CHECKING ACCOUNT # AMOUNT OF DEPOSIT Employee Signature: Date: Revised 1/10/14

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18 FORM MW 507 Purpose. Complete Form MW507 so that your employer can withhold the correct Maryland income tax from your pay. Consider completing a new Form MW507 each year and when your personal or financial situation changes. Basic Instructions. Enter on line 1 below, the number of personal exemptions that you will be claiming on your tax return; however, if you wish to claim more exemptions, or if your adjusted gross income will be more than $100,000 if you are filing single or married filing separately ($150,000, if you are filing jointly or as head of household), you must complete the Personal Exemption Worksheet on page 2. Complete the Personal Exemption Worksheet on page 2 to further adjust your Maryland withholding based upon itemized deductions, and certain other expenses that exceed your standard deduction and are not being claimed at another job or by your spouse. However, you may claim fewer (or zero) exemptions. Additional withholding per pay period under agreement with employer. If you are not having enough tax withheld, you may ask your employer to withhold more by entering an additional amount on line 2. Exemption from withholding. You may be entitled to claim an exemption from the withholding of Maryland income tax if: a. last year you did not owe any Maryland Income tax and had a right to a full refund of any tax withheld; AND b. this year you do not expect to owe any Maryland income tax and expect to have a right to a full refund of all income tax withheld. If you are eligible to claim this exemption, complete Line 3 and your employer will not withhold Maryland income tax from your wages. FORM MW 507 Print full name Students and Seasonal Employees whose annual income will be below the minimum filing requirements should claim exemption from withholding. This provides more income throughout the year and avoids the necessity of filing a Maryland income tax return. Certification of nonresidence in the State of Maryland. Complete Line 4. This line is to be completed by residents of the District of Columbia, Pennsylvania, Virginia or West Virginia who are employed in Maryland and who do not maintain a place of abode in Maryland for 183 days or more. Line 4 is NOT to be used by residents of other states who are working in Maryland, because such persons are liable for Maryland income tax and withholding from their wages is required. If you are domiciled in the District of Columbia, Pennsylvania or Virginia and maintain a place of abode in Maryland for 183 days or more, you become a statutory resident of Maryland and you are required to file a resident return with Maryland reporting your total income. You must apply to your domicile state for any tax credit to which you may be entitled under the reciprocal provisions of the law. If you are domiciled in West Virginia, you are not required to pay Maryland income tax on wage or salary income, regardless of the length of time you may have spent in Maryland. Under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act, you may be exempt from Maryland income tax on your wages if (i) your spouse is a member of the armed forces present in Maryland in compliance with military orders; (ii) you are present in Maryland solely to be with your spouse; and (iii) you maintain your domicile in another state. If you claim exemption under the SCRA enter your state of domicile (legal residence) on Line 5; enter EXEMPT in the box to the right on Line 5; and attach a copy of your spousal military identification card to Form MW507. Employee s Maryland Withholding Exemption Certificate Social Security number Duties and responsibilities of employer. Retain this certificate with your records. You are required to submit a copy of this certificate and accompanying attachments to the Compliance Division, Compliance Programs Section, 301 West Preston Street, Baltimore, MD 21201, when received if: 1. you have any reason to believe this certificate is incorrect; 2. the employee claims more than 10 exemptions; 3. the employee claims an exemption from withholding because he/she had no tax liability for the preceding tax year, expects to incur no tax liability this year and the wages are expected to exceed $200 a week; 4. the employee claims an exemption from withholding on the basis of nonresidence; or 5. the employee claims an exemption from withholding under the Military Spouses Residency Relief Act. Upon receipt of any exemption certificate (Form MW 507), the Compliance Division will make a determination and notify you if a change is required. Once a certificate is revoked by the Comptroller, the employer must send any new certificate from the employee to the Comptroller for approval before implementing the new certificate. If an employee claims exemption under 3, 4 or 5 above, a new exemption certificate must be filed by February 15th of the following year. Duties and responsibilities of employee. If, on any day during the calendar year, the number of withholding exemptions that the employee is entitled to claim is less than the number of exemptions claimed on the withholding exemption certificate in effect, the employee shall file a new withholding exemption certificate with the employer within 10 days after the change occurs. Street Address City, State, ZIp County of residence (or Baltimore City) Single Married (surviving spouse or unmarried Head of Household) Rate Married, but withhold at Single Rate 1. Total number of exemptions you are claiming not to exceed line f in Personal Exemption Worksheet on page Additional withholding per pay period under agreement with employer $ 3. I claim exemption from withholding because I do not expect to owe Maryland tax. See instructions above and check boxes that apply. a. Last year I did not owe any Maryland Income tax and had a right to a full refund of all Income tax withheld and b. This year I do not expect to owe any Maryland income tax and expect to have the right to a full refund of all income tax withheld. (This includes seasonal and student employees whose annual income will be below the minimum filing requirements). If both a and b apply, enter year applicable (year effective) Enter EXEMPT here I claim exemption from withholding because I am domiciled in one of the following states. Check state that applies. District of Columbia Pennsylvania Virginia West Virginia I further certify that I do not maintain a place of abode in Maryland as described in the instructions above. Enter EXEMPT here I certify that I am a legal resident of the state of and am not subject to Maryland withholding because l meet the requirements set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Enter EXEMPT here Under the penalty of perjury, I further certify that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption from withholding, that I am entitled to claim the exempt status on line 3, 4 or 5, whichever applies. Employee s signature Date Employer s Name and address including zip code (For employer use only) Federal employer identification number COM/RAD

19 FORM MW 507 PAGE 2 Personal Exemptions Worksheet Line 1 a. Multiply the number of your personal exemptions by the value of each exemption from the table below. (Generally the value of your exemption will be $3,200; however, if your federal adjusted gross income is expected to be over $100,000, the value of your exemption may be reduced. Do not claim any personal exemptions that you are currently claiming at another job, or any exemptions being claimed by your spouse. To qualify as your dependent, you must be entitled to an exemption for the dependent on your federal income tax return for the corresponding tax year. NOTE: Dependent taxpayers may not claim themselves as an exemption... b. Multiply the number of additional exemptions you are claiming for dependents who are 65 years of age or older by the value of each exemption from the table below... c. Enter the estimated amount of your itemized deductions (excluding state and local income taxes) that exceed the amount of your standard deduction, alimony payments, allowable childcare expenses, qualified retirement contributions, business losses and employee business expenses for the year. Do not claim any additional amounts you are currently claiming at another job; or any amounts being claimed by your spouse. NOTE: Standard deduction allowance is 15% of Maryland adjusted gross income with a minimum of $1,500 and a maximum of $2, d. Enter $1,000 for additional exemptions for taxpayer and/or spouse at least 65 years of age and/or blind... e. Add total of lines a through d... f. Divide the amount on line e by $3,200. Drop any fraction. Do not round up. This is the maximum number of exemptions you may claim for withholding tax purposes.... a. b. c. d. e. f. If Your federal AGI is Single or Married Filing Separately Your Exemption is If you will file your tax return Joint, Head of Household or Qualifying Widow(er) Your Exemption is $100,000 or less $3,200 $3,200 Over But not over $100,000 $125,000 $2,400 $3,200 $125,000 $150,000 $1,800 $3,200 $150,000 $175,000 $1,200 $2,400 $175,000 $200,000 $1,200 $1,800 $200,000 $250,000 $600 $1,200 In excess of $250,000 $600 $600 FEDERAL PRIVACY ACT INFORMATION Social Security numbers must be included The mandatory disclosure of your Social Security number is authorized by the provisions set forth in the Tax-General Article of the Annotated Code of Maryland. Such numbers are used primarily to administer and enforce the individual income tax laws and to exchange income tax information with the Internal Revenue Service, other states and other tax officials of this state. Information furnished to other agencies or persons shall be used solely for the purpose of administering tax laws or the specific laws administered by the person having statutory right to obtain it. Revised COM/RAD

20 FORM VA-4 COMMONWEALTH OF VIRGINIA DEPARTMENT OF TAXATION PERSONAL EXEMPTION WORKSHEET 1. If no one else can claim you as a dependent, and you wish to claim yourself, write "1" If you are married and your spouse is not claimed on his/her own certificate, write "1" Exemptions for age... (a) If you will be 65 or older on December 31, write "1"... (b) If you claimed an exemption on line 2 and your spouse will be 65 or older on December 31, write "1" Exemptions for blindness.... (a) If you are legally blind, write "1"... (b) If you claimed an exemption on line 2 and your spouse is legally blind, write "1" Write the number of dependents you will be allowed to claim on your income tax return (do not include your spouse) Total exemptions (add lines 1 through 5) Detach here and give the certificate to your employer. Keep the top portion for your records FORM VA-4 EMPLOYEE'S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE Your social security number Name Street address City State ZIP code COMPLETE THE APPLICABLE LINES BELOW 1. If subject to withholding, enter the number of exemptions claimed on line 6 of the Personal Exemption Worksheet Enter the amount of additional withholding requested (see instructions) I certify that I am not subject to Virginia withholding. l meet the conditions set forth in the instructions (check here).... Signature EMPLOYER: Keep exemption certificates with your records. If you believe the employee has claimed too many exemptions, notify the Department of Taxation, P.O. Box 1880, Richmond, Virginia , telephone (804) VA DEPT OF TAXATION REV 6/93 Date

21 FORM VA-4 INSTRUCTIONS Use this form to notify your employer whether you are subject to Virginia income tax withholding and how many exemptions you are allowed to claim. You must file this form with your employer when your employment begins. If you do not file this form, your employer must withhold Virginia income tax as if you had no exemptions. PERSONAL EXEMPTION WORKSHEET You may not claim more personal exemptions on form VA-4 than you are allowed to claim on your income tax return unless you have received written permission to do so from the Department of Taxation. Line 1. You may claim an exemption for yourself if no one else claims you as a dependent on their income tax return. Line 2. You may claim an exemption for your spouse if he or she is not already claimed on his or her own certificate. Line 3. If you will be 65 or older at the end of this year, you may claim an additional exemption. The additional exemption for a spouse may be claimed only if you were entitled to an exemption on line 2. Line 4. If you are considered legally blind for federal income tax purposes, you may claim an additional exemption. The additional exemption for a spouse may be claimed only if you were entitled to an exemption on line 2. Line 5. Enter the number of dependents you are allowed to claim on your income tax return. NOTE: A spouse is not a dependent. FORM VA-4 Be sure to enter your social security number, name and address in the spaces provided. Line 1. If you are subject to withholding, enter the number of exemptions from line 6 of the Personal Exemption Worksheet. Line 2. If you wish to have additional tax withheld, and your employer has agreed to do so, enter the amount of additional tax on this line. Line 3. If you are not subject to Virginia withholding, check the box on this line. You are not subject to withholding if you meet any one of the conditions listed below. Form VA-4 must be filed with your employer for each calendar year for which you claim exemption from Virginia withholding. (a) You had no liability for Virginia income tax last year and you do not expect to have any liability for this year. (b) You expect your Virginia adjusted gross income to be less than $5,000 (single), $8,000 (married, filing a joint or combined return) or $4,000 (married, filing a separate return). (c) You live in Kentucky or the District of Columbia and commute on a daily basis to your place of employment in Virginia. (d) You are a domiciliary or legal resident of Maryland, Pennsylvania or West Virginia whose only Virginia source income is from salaries and wages and such salaries and wages are subject to income taxation by your state of domicile. VA DEPT OF TAXATION REV 6/93 (back)