CITY OF SOUTHFIELD ELECTION INSPECTOR APPLICATION

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1 CTY OF SOUTHFELD ELECTON NSPECTOR APPLCATON (Must be co~npleted in your own handwriting in ink) Name in Full Date of Birth Social Security # Home Address Ho~iie Phone # Work Phone # Cell Phone # City Registered in Township of Precinct # Village County of Le~igth of Residence in Cou~ity Political Party Affiliation (to be eligible for appointment you MUST checl< one): Republican Party Democratic Party Other Party Have you ever been convicted of a felo~iy or election crime? Yes No Education Background (include highest grade co~npleted or degrees held) Employment Background (include current or last place of employment and type of work performed) Past experience as an election inspector, if any (include name ofjurisdiction) Do you have transportation? Yes No Will you work at any polling place? Yes No Are you e~nployed with the City of Southfield in any capacity or a ~ne~iiber of any Board or Commission? Yes f yes, where No CERTFY THAT am not a member or a known active advocate* of a political party other than the party identified above. FURTHER CERTFY THAT the foregoing statements are true to the best of my <nowledge and belief. Signature of Applicant Date * A "linown active advocate" of another political party is defined to mean a person who ) is a delegate to the convention or an officer of another party 2) is affiliated with another party through an elected 01. appointed governnient position or 3) has made docu~nented public statements specifically supporting by name another political party or its candidates in the same calendar year as the election at which the person will serve as an inspector. "Documented public statements" means statements reported by the news media or written statenients with a clear and unambiguous attribution to the applicant. ANY FALSE STATEMENTS MADE ON THS APPLCATON WLL DSQUALFY THE APPLCANT.

Form W-4 (2009) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

3, 4, and 7 and sign the form to validate it. Your exemption for 2009 expires February 16,2010. Sea Pub. 505, Tax Withholding and Estimated Tax. Note.

as a dependent on their tax retum. Basic instructions. f you are not exempt. complete the Personal Allowances Worksheet below.

.. - Complete all worksheets that apply. However, you may claim fewer (or zero) allowancas.

Generally, you may claim head of household filing status on your tax retum only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or

You can take projected tax crediis into account in figuring your allowable number of withholding allowances.

How Do Adjust My Tax Withholding, for information on converting your other credits into withholding allowances. Nonwage income.

Estimated Tax for ndividuals. Otherwise, you may owe additional tax. f you have pension or annuity income, see Pub. 919 to find out if you should adjust your withholding on Form W-4 or W-4P.

Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 919 for details.

919 to see how the amount you are having withheld compares to your projected total tax for 2009. See Pub. 919, especially if your earnings exceed $130.000 (Single) or $180,000 (Married). 1.

2 Form W-4 (2009) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. f you are exempt, complete only lines 1, 2.3, 4, and 7 and sign the form to validate it. Your exemption for 2009 expires February 16,2010. Sea Pub. 505, Tax Withholding and Estimated Tax. Note. You cannot claim exemption from withholding if (a) your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends) and (b) another Person can claim vou * as a dependent on their tax retum. Basic instructions. f you are not exempt. complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-eamer/multipie job situations... - Complete all worksheets that apply. However, you may claim fewer (or zero) allowancas. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you may claim head of household filing status on your tax retum only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions. Standard Deduction, and Filing nformation, for infomation. Tax credits. You can take projected tax crediis into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit mav be claimed usina the Personal ~llowances Worksheet bilow. See Pub How Do Adjust My Tax Withholding, for information on converting your other credits into withholding allowances. Nonwage income. f you have a large amount of nonwage income, such as interest or Personal Allowances Worksheet (Keep for your records.) dividends, consider making estimated tax payments using Form 1040-ES. Estimated Tax for ndividuals. Otherwise, you may owe additional tax. f you have pension or annuity income, see Pub. 919 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. f you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 919 for details. Nonresident alien. f you are a nonresident alien, see the nstructions for Form , before cornoletina this Fom W-4. Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the amount you are having withheld compares to your projected total tax for See Pub. 919, especially if your earnings exceed $ (Single) or $180,000 (Married). 1.. You are single and have only one job; or B Enter '1" if: You are married, have only one job, and your spouse does not work; or B- Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. A Enter "1" for yourself if no one else can claim you as a dependent A- [ 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 $1.800 of child or dependent care expenses for which you plan to claim a credit.. F- (Note. Do not include child support payments. See Pub Child and Dependent Care Expenses. for details.) G Child Tax Credit (including additional child tax credit). See Pub Child Tax Credit, for more information. f your total income will be less than $61,000 ($90,000 if married), enter '2" for each eligible child; theniass '1" if you have three or more eligible children. f your total income will be between $ and $84,000 ($ and $1 19,000 if married), enter "1" for each eligible child plus '1" additional if you have six or more eligible children. G- H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you daim on your tax retum.) H - f you plan to itemize or claim adjustments to income and want to reduce your withholding. see the Deductions and Adjustments Worksheet on page 2. that apply. f you have more than one job or are married and you and your spouse both workand the combined earnings from all jobs exceed $40,000 ($25,000 if married), see thetwo-eamerslmultiple Jobs Worksheet on page 2 to avoid having too rile tax withheld. f neither of the above situations applies. stop here and enter the number from line H on line 5 of Form W-4 below.... Cut here and give Form W4 to your employer. Keep the top part for your records Form w-4 Depament of the T-, nternal Revenue Sarvice. 1 Type or print your first name and middle initial. Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowancei or exemption from withholding s subject to review by the RS. Your employer may be required to send a copy of this form to the RS. Home address (number and street or rural mute) 1 Single 17 Married Manied, but withhold at higher Single rate. City or town, state, and ZP code 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) Employee's signature (Form is not valid unless vou sian it.) b Last name OMB No Your social seoutity number Note. f married, but legally separated, or spouse is a nonresident alien, check the 'Single' box. 4 f your last name differs from that shown on your social security card. check hem. You must call for a aplacnment card. b n 6 Additional amount. if any, you want withheld from each paycheck claim exemption from withholding for 2009, and certify that meet both of the following conditions for exemption. Last year had a right to a refund of all federal income tax withheld because had no tax liability and This year expect a refund of all federal income tax withheld because expect to have no tax liability. f you meet both conditions, write "Exempt" here Under penalties of perjury. i declare that have examined this certificate and to the best of my knowledge and belief. il is true, correct, and complete. Date b 8, - $ L~*s;$r'p...,.,:.. 3p:<C&,i;2t;)>! $??,;,;:-%;!;??>:.,:= %&< <;.<>,::,:;:7:,.~a*.:.; <,<* > :>*~,.d:;.,.: :'. c.: Employer's name and address (Employer: Complete nnes 8 and 10 only if sending to the RS.) 19 Olficsmdsl@bd~ 10 Employ:r Mentiation number (EN) For Privacy Act and Papemork Reduction Act Notice, see page 2. Cat. No Form w-4 (2009)

~wm W-4 p009) Page 2 Deductions and Adjustments Worksheet Note.

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.

400 if married filing jointly or qualifying widow(er) 2 Enter. $ 8.350 if head of household........... 2 s $ 5.700 if single or married filing separately 3 Subtract line 2 from line 1. f zero or less.

$f zero or less. enter '-02... 7 $ 1 8 Divide the amount on line 7 by $3,500 and enter the result here. Drop any fraction... 8 1......... 9 1 9 Enter the number from the Personal Allowances Worksheet.$ line H. ~aae 10 Add lines 8 and 9 and enter the total here. f you plan to use the~wo-&m;rsl~ultiple Jobs Worksheet, also enter this total on line 1 below.

line H. ~aae 10 Add lines 8 and 9 and enter the total here. f you plan to use the~wo-&m;rsl~ultiple Jobs Worksheet, also enter this total on line 1 below.

3 ~wm W-4 p009) Page 2 Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions, daim certain credits, adjustments to income, or an addiiional standard deduction 1 Enter an estimate of your 2009 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. (For 2009, you may have to reduce your itemized deductions if your income is over $166,800 ($ if married filing separately). See Worksheet 2 in Pub. 919 for details.).. 1 $ i $ if married filing jointly or qualifying widow(er) 2 Enter. $ if head of household s $ if single or married filing separately 3 Subtract line 2 from line 1. f zero or less. enter '-0-"... 3 $ 4 Enter an estie of your 2009 adjustments to income and any addiial standard deduction. (Pub. 919) $ 5 Add lines 3 and 4 and enter the total. (nclude any amount for credits from Worksheet 8 in Pub. 919.). 5 $ 6 Enter an estimate of your 2009 nonwage income (such as dividends or interest)... 6 $ 1 7 Subtract line 6 from line5. f zero or less. enter ' $ 1 8 Divide the amount on line 7 by $3,500 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet. line H. ~aae 10 Add lines 8 and 9 and enter the total here. f you plan to use the~wo-&m;rsl~ultiple 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-EamersJMuttiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use thii 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 yw wed the Deduction8 and Adjustmmts Work~h8@ 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are manied filing jointly and wages from the highest paying job are $ or less. do not enter more th~3.' f line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero. enter "-0-3 and on Form W-4. line 5, page 1. Do not use the rest of this worksheet... 3 Note. f line 1 is less than line 2. enter '-0-' on Form W-4, line 5. page 1. Complete lines 4-9 below to calculate the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HGHEST paying job and enter it here... 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the addiiional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 26 if you are paid every two weeks and you complete this fonn in December Enter the resutt here and on Form W-4. line 6, page 1. This is the additional amount to be withheld from each ~avcheck $. - Table 1 1 Table 2 Manied Filing Jointly! All Others Married Filing Jointly All Others bun LOWEST *gpb- Enter an line 2 shove wrsgsshanloms lob am- Enter on line 2 above $0 $4,500 0 SO S , , , ,001 50, , , , , ODO and over 10 65, , , , and over 15 1 Privacy Act and Papawork Reduction Act Notice. We ask for the information on this form to cany out the hrtemal Revenue laws of the Unitad States. The lntamal Rwenue Code requires this information under sections 3402(4(2)(A) and 6109 and their regulations. Failure to provide a properly completed fonn will lasun in your being treated as a sing* person who claims no withholding allowances; providmg fraudulent information may also subpcl you to penattii. Routine uses of this information indude giving t to me Department of Justice for civil and mminal l'iatii, to cities. state&, the D i m of Columbia. and U.S. commonwealths and passessions far we in administering their tax ~ WS. and using it m the National Directory of New Hires. We may also disdose this informstion to other cwntrias under a tax treaty, to federal and state agencies to enfme fedse) nontax ahinal laws. or to fedaral law mfommant and intelligence agencies to combat taroh. f wags fmm HlQHESt paying job are- SO - $ , , , and over line 7 above ,280 paying job lme 7 above so - s , You are not required to provide the information requested on a form that is subpct lo the Paperwork Reduction Act Unless the form d~plays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any nternal Revenue law. Generally, tax returns and return information are confdential. as required by Code section The average time and expenses required to complete and file thin form will vary depending on individual circumstances. For estimated averages, sea the instructions for your income tax return. f you have suggestions for making this form simpler. we would be happy to hear from you. See the instructions tor your income tax return.

4 $'. Ml=W4.- EMPLOYEFS MCHGAN W~THHOLDNG EXEMPTON CERTFCATE m- 7~9) STATE OF MCHGAN - DEPARTMENT.OF TREASURY -. ' : ' i Hrme~(Nq~P.O.BmorRunl~) UywTawn muctons TO EMPLOYEE b BAssyou.nav~? kn 6. Enter the number of parxnml and dependency ed(bmpths yw are daiming P Additionalam#rn1ywwrantdedudedfr#neachpay Cf ~ployw 8. dabn exemption fran Mi became (see b6udbm): a. 0 AMichiganb#netaxHeMlityisnatexpecWthisyaar. b. Wages are enapt fmm withhdcling. Explaii c. Pennanenthome(domi)kbcatedhthefollawingRenaissance~: - EUPLOYEE: tf you fen a mfuw m knn. pr empbyar mat w m a franyplrumlle6wlthout-fw.ny -. ' -. Q axanpbans. Kmp e capydthiskrmfaywl UsmumnmTO agrees) * ".-~ * dmcmaa.-awalm6~m =='SF-=", a mius agmpling the smpbya mm -g fonnwlththemi~oftnragny. You must suknit a MidJgw wilhhdding ga#nption cerwicats (fam M-W4) to your employw on or bafoce the date that emp@mmt bcgim. f you fail or rshrse to uubmit this certificate, ywr employer must withhold tex from your annpersath without al&wanz fw any exempfkm. Your employer is required to natify the Michigen Deqammt of Treasury f yw ham daimed more than nine dependency exemptions or claimed a status which ewempts you from withholding. Yw MUST fre a new MLW4 wlthh'10 days ff ywr residency aeatus changes or if yrwn exemptions demase because: a) : Your swou?e, for whom yw have bean daiming an exemption, isdircedor~liy~fromywotdaknshislher~ exempti~(s) on a separate csrtificate. or b) a dependent must i be droppad for federal purposes. 5: f YOU chedc M,' enter ywr date of hire (mdday/year). Unc 6: Personal and deptndency exemptions. The total number of exemptions yw daim on the MLW4 may not exceed the number of exsmptions yw are entitled to daim when yw file your Michigen indiil inme tax return. f you are married and yw and ywr spouse.are bath employed.ywbothmaynotdabnthesarneexemptkns~ each of your empkyers. 7. $.00 ~ l k d w ~ d ~, ~ a r d l ) r ~ ~ & d ~ a h n p d b n t ~ d l h r n r n b n b ~ ~ r n a ~ d Y n C l O u a n p l i o n ~ ~, ~ ~. n l i e S r*mlheu.lldripn~mx~wiydr~. b m bnpbyw:~rmpk(s~l~wdllbefors~bthsmiehieandsparbmnt~~~ l o - ~ m ~ m a h n d ~ d ~ ~ City of Southf ield '26000 Evergreen Rd. b11. h d. n 3 1 ~ Southf ield, M Georgians Smi th (248) lfywhddmarethsnonejob,~maynotefebnthessme e x e m ~ w i t h m o n ~ o n ~ ~. ~ y same sxsmptions at more than one job, ywr tax will be under withhdd. Lhm 7: Youmaydes$nate edditbnalwithhdding if you expect to M mom than the amount withheld. ~8:YwmaydaimexamPtialfmmMich~incametax nathhddmg ONLY if yw do not ankifmb a Michigan income! taxliawlityfortheansntyearbecauseallofthefdlawing exkt a) ywr employment is less than M time, b) ywr personal and dependency exem- all~lrarmx! exa&s ywr annual capensation, c) yw d a i exemption from fsderal withholding, d) ybu di not incur a Michigan income tax liability fortheprsviwsyear.ywrmayelsodeianex#nptionffyow permanent home (domiale) is kcsted in a Renaiissance Zone. For more infomation on Renaissance ZOMS call the Midugan TebHclp System, , end &en to topic 293. Full-time sklents cannot daim exempt stalus. w* site V i the Treasury Web slte at wwnumi-ury

5 U.S. Department of Justice OMB No mmigration and Naturalization Service Employment Eligibility Verification Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANT-DSCRMNATON NOTCE: t is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future exdration date mav also constitute illegal discrimination. Section 1. Employee lnforrnation and Verification. TO be completed and signed by employee at the time employment begins. Print Name: Last First Middle nitial Maiden Name Address (Street Name and Number) Apt. # Date of Birth (month/day/year) City State Zip Code Social Security # 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. Employee's Signawe attest, under penalty of pwjwy. that am (check one of the following): A citizen or MUOM of the United States A Lawful Permanent Resident (Alien # A An alien authorized to work until 1 1 (Alien # or Admnsion #) Date (month/day/year) Preparer and/or Translator Certification. no be completed andsigned if %&on is prepared by a person other than the employee.) attest, under penahy of pyrjirry, that hive assisted best of my knowledge the infonnstlbn is true and EMKt. Preparw'slTranslator's Signature Print Name Address (Street Name and Number. City, State, Zip Code) the awn@tion of this form end that to Ohe Date (montn&y/') Section 2. Employer Review and Verification. TO k canpkted ad'sgned by employer. Examine one document from List A OR examine om document from List B and one fmm List C, as listed on the reverse of this fonn, and record the Wk, number and expiration date, if my, of the document(s) List A OR ListB AND List C Document title: *n-,... Driver s License Social Securitv # ssuing authority: 5. - k;? 1.: Document #: i" Expiration Date (if any): Document #: 2 - t-- Expiration Date (if any): 1.-?.- -3 CERTFCATON - attest, under penalty of pe jury, that have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named. that the employee began employment on (month/day/year) and that to the best of my knowledge the employee is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.) S~gnature of Employer or Authorized Representative Print Name Title Business or Organization Name City o f Southfield Address (Street Name and Number, City, State, Zip Code) Evergreen Road Date (month/day/year) Section 3. Updating and Reverification. To be completed and signed by employer. A. New Name /if applicable) B. Date of rehire (month&ay/year) (if applicable) C. f employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility. Document Title: Document #: Expiration Date (if any): attest, under penalty of perjwy, chat to the best of my knowkdge, this employee is eligible to wak in thc United States, md if the employee pmented docummt(s), the doannent(s) have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (montndey/year) Form 1-9 (Rev l)n Page 2

6 LSTS OF ACCEPTABLE DOCUMENTS LST A LST B LST C Documents that Establish Both Documents that Establish Documents that Establish dentity and Employment dentity Employment Eligibility Eligibility AND 1. U.S. Passport (unexpired or expired) 2. Certificate of U.S. Citizenship (NS F o N-560 ~ or N-56 ) 1. Driver's license or D card 1. U.S. social security card issued issued by a state or outlying by the Social Security possession of the United States Administration (other then a card brovided it contains a stating it is not valid for photograph or information such as employment) name, date of birth, gender, height, eye color and address 3. Certificate of 'Naturalization (NS Fonn N-550 or N-570) 4. Unexpired foreign passport, with stamp or attached NS Form 1-94 indicating unexpired employment authorization 5. Permanent Resident Card or Alien Registration Receipt Card with photograph (NS Form or 1-551) 6. Unexpired Temporary Resident Card (NS Form 1-688) 7. Unexpired Employment Authorization Card (NS Form -688A) 8. Unexpired Reentry Permit (NS Form 1-327) 9. Unexpired Refugee Travel Document (NS Form ) 10. Unexpired Employment Authorization Document issued by the NS which contains a photograph (NS Form D card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address 3. School D card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's D card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor or hospital record 12. Day-care or nursery school record 2. Certification of Birth Abroad issued by the Department of State (Form FS-545 or Form DS Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen D Card (NS b rm 1-797) 6. D Card for use of Resident Citizen in the United States (NS Form 1-179) 7. Unexpired employment authorization document issued by the NS (other than those listed under List A) lllustmtions of many of these documents appear in Part 8 of the Handbook for Employers (M-274) Fonn C9 (Rev. 1 W4/00)Y Page 3

EMPLOYEE INFORMATION SHEET

EMPLOYEE INFORMATION SHEET PLEASE PRINT CLEARLY COMPANY: EMPLOYEE #: SOCIAL SECURITY NUMBER: - - NAME: First MI LAST STREET: CITY: AS APPEARS ON SOCIAL SECURITY CARD STATE: ZIP CODE: TELEPHONE NUMBER: