CITY OF SOUTHFIELD ELECTION INSPECTOR APPLICATION

Transcription

1 CTY OF SOUTHFELD ELECTON NSPECTOR APPLCATON (MUST BE COMPLETED N YOUR OWN HANDWRTNG N NK) Name in Full Date of Birth Home Address Telephone Number ( ) Registered in Precinct No. Social Security Number Length of Residence in County Political Party Affiliation (to be eligible for appointment you MUST check one) Republican Party Democratic Party Minor Party Have you ever been convicted of a felony or election crime? Yes No - (name) Educational Background - (include highest grade completed 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 of jurisdiction) Do you have transportation? Y e s No- Will you work at any polling place? Y e s No- Are you employed with the City of Southfield in any capacity, or a member of any Boards or Commissions? 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 knowledge and belief. Signature of Applicant Date 1 *A "known active advocate" of another political party is defined to mean a person who 1) is a delegate to the convention or an officer of another party 2) is affiliated with another party through and elected or appointed government position or 3) has made documented 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 election inspector. "Documented public statements" means statements reported by the news media or written statements with a clear and unambiguous attribution to the applicant. ANY FALSE STATEMENTS ON THS APPLCATON WLL DSQUALFY THE APPLCANT

2 Form W-4 (2008) adjustments to income, or two-eamer/multiple payments using Form 1040-ES, Estimated Tax job situations. Complete all worksheets that for ndividuals. Otherwise, you may owe apply. However, you may claim fewer (or zero) additional tax. f you have pension or annuity Purpose. Complete Form W-4 so that your allowances. income, see Pub. 919 to find out if you should employer can withhold the correct federal income Head of household. Generally, you may claim adjust Your withholding On Form W-4 or W-4P. tax from Your Pay. Consider completing a new head of household filing status on your tax Two earners or multiple jobs. f you have a Form W-4 each year and when Your personal or retum only if you are unmarried and pay more working spouse or more than one job, figure financial situation changes. than 50% of the costs of keeping up a home the total number of allowances you are entitled Exemption from withholding. f you are for yourself and your dependent(s) or other to claim on all jobs using worksheets from only exempt, complete only lines 1,2, 3, 4, and 7 qualifying individuals. See Pub. 501, one Form W-4. Your withholding usually will and sign the form to validate it. Your exemption Exemptions, Standard Deduction, and Filing be most accurate when all allowances are for 2008 expires February 16, See nformation, for information. claimed on the Form W-4 for the highest Pub. 505, Tax Withholding and Estimated Tax. Tax credits. You can take projected tax paying job and zero allowances are claimed on Note. You cannot claim exemption from credits into account in figuring your allowable the Others. See Pub. gq9 for details. if (a) your income exceeds $900 number of withholding allowances. Credits for Nonresident alien. f you are a nonresident and includes more than $300 of unearned child or dependent care expenses and the alien, see the nstructions for Form 8233 income (for example, interest and dividends) child tax credit may be claimed using the before completing this Form W-4. and (b) another person can claim you as a Personal Allowances Worksheet below. See Check your withholding. After your Form W-4 dependent on their tax return. Pub How Do Adjust My Tax takes effect, use Pub. 919 to see how the Basic instructions. f you are not exempt, Withholding, for information on converting dollar amount you are having withheld complete the Personal Allowances your other credits into withholding allowances. compares to your projected total tax for Worksheet below. The worksheets on page 2 Nonwage income. f you have a large amount See Pub. 919, especially if your earnings adjust your withholding allowances based on of nonwage income, such as interest or exceed $1 30,000 (Single) or $1 80,000 itemized deductions, certain credits, dividends, consider making estimated tax (Married). Personal Allowances Worksheet (Keep for your records.) 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- A Enter "1" for yourself if no one else can claim you as a dependent ,..... A- Your wages from a second job or your spouse's 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 (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 retum (see conditions under Head of household above). E - F Enter "1" if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit.. F- (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses. for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. f your total income will be less than $58,000 ($86,000 if married), enter "2" for each eligible child. f your total income will be between $58,000 and $84,000 ($86,000 and $1 19,000 if married), enter "1" for each eligible child plus "1" additional if you have 4 or more eligible children. G- H Add lines A through G and enter total This may be different from the number of exemptions you claim on your tax retum.) b H For accuracy, f you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions complete all and Adjustments Worksheet on page 2. worksheets f you have more than one job or are married and you and your spouse both workand the combined eamings from all jobs exceed that apply. $40,000 ($25,000 if married), see thetwo-eamers/mukiple Jobs Worksheet on page 2 to avoid having too little 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 Form w-4 Deparrmen, of the Treasury nternal Revenue Service Cut here and give Form W-4 to your employer. Keep the top part for your records Employee's Withholding Allowance Certificate b Whether you are entitled to claim a certain number of allowances or exemptlon from withholding is subject to review by the RS. Your employer may be required to send a copy of this form to the RS. 1 Type or print your first name and middle initial. Last name 8 0 Home address (number and street or rural route) 1 Single Married Manied, but withhold at higher Single rate. Note. f married, but legaly separated, or spouse is a nonresident alien, check the 'Singlem box. City or town, state, and ZP code 1 f your last name diiers from that shown on your social security card. check here. You must call for a replacement card. b 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 1 5 OMB No Your social security number 6 Additional amount, if any, you want withheld from each paycheck claim exemption from withholding for 2008, 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 b , 8, $..-.'. '.,,. 1. /1. ~- ~.,..., <..',--'..-,.%'.. cj..-..+,. ". ;... ~.'i. ;,,.?. <-yl,.... >. Under penalties of perjuw, declare that have examined this certificate and to the best of my knowledge and belief, it is true. correct, and complete. Employee's signature (Form is not valid unless you sign it.) Date b 8 Employer's name and address (Employer Complete lines 8 and 10 only if sending to the RS.) 9 Ofticemde(opticral) 10 Employer identification number (EN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form w-4 (2008)

3 . M-W4.. EMPLOYEE'S MCHGAN W~THHOLDNG EXEMPTON CERTFCATE w. 743) STATE OF MCHGAN - DEPARTMENT. OF TREASURY - Thh CM~~C&J br hrmme tar Whdding purposes wjy. You must file a mvft& ~bm, 10 d,gys /fp exgnptbm decn%sa oryourden~ &a& hnl mmwdent b3 ms~ent. Reed hrrbuctions belowbek cw&3nng thk Rxm. b 1. Social Seruri(y Number b 2. Date of Birth lssuad under PA 281 of FMWJ is mandatory. b 3. Type or Plht Your Fhat Name. Middle nitial and Last Name 1 4. h r License Number Home Address (No.. SbeeS P.O. Box or Rural Rwte) Cily or Town 1 State (ZP 6. Enter the number of personal and dependency exemptions you are daiming... b6. 7. Additional amount you want deducted from each pay (if em~io~w agrees)... _... m $.oo 8. 1 claim exemption from withholding because (see instructions) a. A Michigan income tax liability is not expected this year. b. Wages are exempt from withholding. Explain c. 0 Permanent home (domicile) is located in the following Renaissance Zone EMPLOYEE.. f yw fail w refuse to file this fwm, ywr employer must withhold Michigan income tax from your wages without allowance for any exemptions. Keep a copy of this form for your records. NSTRUCTONS TO EMPLOYER Employers must report all new hires to the State of Michigan. Keep a copy of this certificate with your records. f the employee daims more than nine personal and dependency exemptions or claims a status exempting the employee from withholding, you must file their original M-W4 form with the Michioan Deaarbnent af Tmasu~. G not rot hcur ~ichm inanw, 9. Empbw's Sinature You must submit a Michigan withholding exemption certificate (form M-W4) to your employer on or before the date that employment if yw fail or refuse to submit this certificate, your employer must withhold tax from your compensation without allowance for any exemptions. Your employer is required to notify the Michigan Department of Treesury if you have claimed more than nine dependency ' exemptions or claimed a status which exempts you from l l l l l l b 5.hywenewmpkyBB? Y@ ly.*lrd..d hh iab111ty ~br this her. 1 1 Employer Complete lines 10 and 11 before sending to the Michigan Department of Treasury. 10. Empb@s Name, Addram. Phone No. end Name of Contect Psnon City of Southfield '26000 Evergreen Rd. b 11. ~ederal ~mpbpr#en~icetion Number Southfield, M Ceorgiana Smith (248) NSTRUCTONS TO EMPLOYEE b b 1 l l6 lo l3 1' l8 f you hold mare than one job, you may not daim the same exemptions with more than one employer. f yw claim the same exemptions at more than one job, your tax will be under withheld. Line 7 You may designate additional withholding if you expect to owe more than the amount withheld. i withholding. Line s You may claim exemption fmm Michigan income tax You MUST file a new M-W4 within'l0 days if your residency status changes or if your exemptions decrease because a) your spouse, for whom you have been claiming an exemption. is divorced or legally separated from you or claims hiiher own exemption@) on a separate certificate, or b) a dependent must i be dropped for federal purposes. Line 5 f you check 'yes,' (moldaylyear). enter your date of hire Line 6 Personal and dependency exemptions. The total number of exemptions you claim on the M-W4 may not exceed the number of exemptions you are entitled to daim when you file your Michigan individual income tax return. f you are married and you and your spouse.are both employed, you both may not claim the same exemptions with each of your employers. withholding ONLY if you do not anticipate a Michigan income tax liability for the current year because all of the following exist a) your employment is less than full time, b) your personal and dependency exemption allowance exceeds your annual compensation, c) you claimed exemption from federal withholding, d) you did not inwr a Michigan income tax liability for the previous year. You may also claim exemption if your permanent home (domicile) is located in a Renaissance Zone. For more information on Renaissance Zones call the Michigan TeleHelp System , and listen to topic 293. Full-time students cannot claim exempt status. Web Site Visit the Treasury Web site at ww&.michigan.gov/treasury

4 U.S. Department of Justice mmigration and Naturalization Service OMB NO 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 expiration date may also constitute illegal discrimination. Section 1. Employee information 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 Signature 1 attest, under penalty of perjury, that am (check one of the following) A citizen or national of the United States A Lawful Permanent Resident (Alien # AA n - An alien authorized to work until 1 1 (Alien # or Admission #) Date (month/day/year) Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) attest, under penalty of pegury, that have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator's Signature Print Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s) List A OR List B AND List C T A-- Document title Driver'sLicense Social Security # ssuing authority i -,. Document #. i Expiration Date (if any). -/--, Document # Expirat~on Date (lf any),, CERTFCATON - attest, under penalty of perjury, 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) 1 and that to the best of my knowledge the employee is el~gible to work in the United States. (State employment agencies may omit the date the employee began employment.) Signature of Employer or Authorized Representative Print Name l~itle Business or Organization Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) City of Southfield Evergreen Road Southfield. M Section 3. Updating and Reverification. To be completed and signed by employer. A. New Name (if applicable) B. Date of rehire (month/day/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 perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (month/day/year) Form 1-9 (Rev l)n Page 2

5 LSTS OF ACCEPTABLE DOCUMENTS LST A LST B LST C Documents that Establish Both Documents that Establish Documents that Establish dentity and Employment OR. dentity AND Employment Eligibility Eligibility 1. Driver's license or D card 1. U.S. social security card issued 1. U.S. Passport (unexpired or issued by a state or outlying by ttre Social Security expired) possession of the United States Administration' (other than a provided it contains a card stat~ng it is not valid for 2 Certificate of U.S. Citizenship photograph or informatibn such employment) (NS Fom N-560 or N-561) as name. date of birth, sex, height, eye color, and address 2 Certification of Birth Abroad 3.. Certificate of Naturalization 2 D card issued by federal. state, issued by the Department of (NS Form N-550 or N-570) w local government agencies or State (Fom FS-545 or Form entities provided it contains a DS- 1350) photograph or information such 4. Unexpired foreign passport. as name. date of birth, sex, with stamp or attached NS Form 1-94 indicating height. eye color, and address 3. Original or cettified copy of a unexpired employment birth certificate issued by a authorization 3. School D card with a state. county, municipal photogaph authority or outlying possession of the United States bearing an 5. Alien Registration Receipt Card 4. Voter's registration card official Seal with photograph (NS Form or 1-551) 5. U.S. Military card or draft record 6. Unexpired Temporary Resident Card (NS Form 1-688) 7. Unexpired Employment Authorization Card (NS Form -688A) 8. Unexpired Reentry Permit (NS F o 1-327) ~. 6. Military dependent's D card 4. Native American tribal document 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 5. U.S. Citizen D Card (NS Form - 197) 9. Driver's license issued by a ' Canadian govemment authority 6. D Card for use of Resident Citizen in the United States For pemons under age 18 who (NS Form - 179) are unable to present a document ilsted above 9. Unexpired Refugee Travel Document (NS Form 1-571) 7. Unexpired employment 10. Unexpired Employment 10. School record or report card authorization document issued by the NS (other than those Authorization Document issued by the NS which contains a 11. Clinic. doctor, or hospital record listed under bst A) photograph (NS Form ) 12 Day-care or nursery school record lluswauons of many of these documents appear n Part 8 of the Handbook for Employers (M-274)