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pumpkinthehead on 12/07/11


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HTML I9


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An html version of US form I-9.

  1. <p>&nbsp;</p>
  2. <div style="width: 780px; padding-top: 8px; padding-bottom: 8px; font-family: 'Times New Roman', Times, serif;">
  3. <div style="width: 100%; clear: both; height: 62px; padding-bottom: 8px; border-bottom: 9px solid black;">
  4. <div style="float: left; padding-top: 30px;">
  5. <div style="clear: both; font-weight: bold; font-size: 9pt;">Department of Homeland Security</div>
  6. <div style="clear: both; font-size: 9pt;">U.S. Citezenship and Immigration Services</div>
  7. </div>
  8. <div style="float: right; text-align: right; padding-top: 4px;">
  9. <div style="clear: both; font-size: 9pt;">OMB No. 1615-0047; Expires 08/31/12</div>
  10. <div style="clear: both; font-size: 13pt; font-weight: bold;">Form I-9, Employment</div>
  11. <div style="clear: both; font-size: 13pt; font-weight: bold;">Eligibility Verification</div>
  12. </div>
  13. </div>
  14. <div style="width: 100%; border-top: 1px solid black; border-bottom: 1px solid black; text-align: center; font-weight: bold; font-size: 10pt; margin-top: 4px; padding-top: 11px; padding-bottom: 13px;">Instructions <br /> Read all instructions carefully before completing this form.</div>
  15. <div style="clear: both; width: 100%; font-size: 10pt;">
  16. <div style="float: left; width: 362px;">
  17. <div style="margin-top: 18px; border: 1px solid black; padding: 5px 6px 8px;"><strong>Anti-Discrimination Notice.</strong> It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers <strong>CANNOT</strong> specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.</div>
  18. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">What Is the Purpose of This Form?</div>
  19. <div style="padding-top: 9px;">The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.</div>
  20. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">When Should Form I-9 Be Used?</div>
  21. <div style="padding-top: 9px;">All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9.</div>
  22. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">Filling Out Form I-9</div>
  23. <div style="padding-top: 9px;">
  24. <p style="margin-top: 0px; margin-bottom: 0px;"><strong>Section 1, Employee</strong></p>
  25. <p style="margin-top: 8px; margin-bottom: 0px;">This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). <strong>The employee is responsible for ensuring that Section 1 is timely and properly completed.</strong></p>
  26. <p style="margin-top: 14px; margin-bottom: 0px;"><strong>Noncitizen nationals of the United States</strong> are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.</p>
  27. <p style="margin-top: 14px; margin-bottom: 20px;"><strong>Employers should note</strong> the work authorization expiration date (if any) shown in <strong>Section 1</strong>. For employees who indicate an employment authorization expiration date in <strong>Section 1</strong>, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of Marshall Islands). For such employees, reverification does not apply unless they choose to present</p>
  28. </div>
  29. </div>
  30. <div style="float: left; width: 362px; margin-left: 56px;">
  31. <p style="margin-top: 18px; margin-bottom: 0px;">in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).</p>
  32. <p style="font-weight: bold; margin-top: 14px; margin-bottom: 0px;">Preparer/Translator Certification</p>
  33. <p style="margin-top: 14px; margin-bottom: 0px;">The Preparer/Translator Certification must be completed if <strong>Section 1</strong> is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete <strong>Section 1</strong> on his or her own. However, the employee must still sign <strong>Section 1</strong> personally.</p>
  34. <p style="font-weight: bold; margin-top: 14px; margin-bottom: 0px;">Section 2, Employer</p>
  35. <p style="margin-top: 14px; margin-bottom: 0px;">For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete <strong>Section 2</strong> by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, <strong>Section 2</strong> must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document <strong>OR</strong> a combination of a List B and a List C document.</p>
  36. <p style="margin-top: 14px; margin-bottom: 0px;">If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.</p>
  37. <p style="font-weight: bold; margin-top: 14px; margin-bottom: 0px;">Employers must record in Section 2:</p>
  38. <ol style="font-weight: bold; padding-top: 5px; padding-bottom: 5px;">
  39. <li><span style="font-weight: normal;">Document title;</span></li>
  40. <li><span style="font-weight: normal;">Issuing authority;</span></li>
  41. <li><span style="font-weight: normal;">Document number;</span></li>
  42. <li><span style="font-weight: normal;">Expiration date, if any; and</span></li>
  43. <li><span style="font-weight: normal;">The date employment begins.</span></li>
  44. </ol>
  45. <p style="margin-top: 14px; margin-bottom: 20px;">Employers must sign and date the certification in <strong>Section 2</strong>. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. <strong>Employers are still responsible for completing and retaining Form I-9.</strong></p>
  46. </div>
  47. </div>
  48. <!-- Page 2 -->
  49. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; padding-top: 4px; padding-bottom: 4px; border-top: 2px solid black; border-bottom: 10px solid black;">Page 2</div>
  50. <div style="clear: both; width: 100%; font-size: 10pt; border-top: 1px solid black; margin-top: 5px; padding-top: 16px;">
  51. <div style="float: left; width: 362px;">
  52. <p style="margin: 0px; font-weight: bold;">For more detailed information, you may refer to the <em>USCIS Handbook for Employers</em> (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."</p>
  53. <p style="margin-top: 14px; margin-bottom: 0px;">Employers must sign and date the certification in <strong>Section 2</strong>. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. <strong>Employers are still responsible for completing and retaining Form I-9.</strong></p>
  54. <p style="margin-top: 14px; margin-bottom: 0px; font-weight: bold;">Section 3, Updating and Reverification</p>
  55. <p style="margin-top: 14px; margin-bottom: 0px;">Employers must complete <strong>Section 3</strong> when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in <strong>Section 1</strong> (if any). Employers <strong>CANNOT</strong> specify which document(s) they will accept from an employee.</p>
  56. <ol style="padding-left: 22px; list-style: upper-alpha; font-weight: bold;">
  57. <li style="padding-bottom: 14px;"><span style="font-weight: normal; position: relative; right: 4px;"> If an employee's name has changed at the time this form is being updated/reverified, complete Block A. </span></li>
  58. <li style="padding-bottom: 14px;"><span style="font-weight: normal; position: relative; right: 4px;"> If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block. </span></li>
  59. <li><span style="font-weight: normal; position: relative; right: 4px;"> If an employee is rehired within three years of the date this form was originally completed and the employee's work authorization has expired <strong>or</strong> if a current employee's work authorization is about to expire (reverifcation), complete Block B; and: </span><ol style="font-weight: bold;">
  60. <li style="padding-top: 12px;"><span style="font-weight: normal;"> Examine any document that reflects the employee is authorized to work in the United States (see List A <strong>or</strong> C); </span></li>
  61. <li style="padding-top: 8px;"><span style="font-weight: normal;"> Record the document title, document number, and expiration date (if any) in Block C; and </span></li>
  62. <li style="padding-top: 8px;"><span style="font-weight: normal;"> Complete the signature block. </span></li>
  63. </ol></li>
  64. </ol>
  65. <p style="margin-top: 14px; margin-bottom: 0px;">Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing <strong>Section 3</strong></p>
  66. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">What Is the Filing Fee?</div>
  67. <p style="margin-top: 9px; margin-bottom: 20px;">There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.</p>
  68. </div>
  69. <div style="float: left; width: 362px; margin-left: 56px;">
  70. <div style="margin-top: 0px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">USCIS Forms and Information</div>
  71. <p style="margin-top: 9px; margin-bottom: 0px;">To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.</p>
  72. <p style="margin-top: 14px; margin-bottom: 0px;">Information about E-Verify, a free voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website ate www.uscis.gov/e-verify or by calling 1-888-464-4218.</p>
  73. <p style="margin-top: 14px; margin-bottom: 0px;">General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.</p>
  74. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">Photocopying and Retaining Form I-9</div>
  75. <p style="margin-top: 9px; margin-bottom: 0px;">A blank Form I-9 may be reproduced, provided both sides are copied. The instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.</p>
  76. <p style="margin-top: 14px; margin-bottom: 0px;">Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.</p>
  77. <div style="margin-top: 14px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">Privacy Act Notice</div>
  78. <p style="margin-top: 9px; margin-bottom: 0px;">The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).</p>
  79. <p style="margin-top: 14px; margin-bottom: 0px;">This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a few, of aliens who are not authorized to work in the United States.</p>
  80. <p style="margin-top: 14px; margin-bottom: 0px;">This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.</p>
  81. <p style="margin-top: 14px; margin-bottom: 20px;">Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.</p>
  82. </div>
  83. </div>
  84. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; font-weight: bold; padding-bottom: 20px; border-top: 2px solid black;">EMPLOYERS MUST RETAIN COMPLETED FORM I-9 <br /> DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS</div>
  85. <!-- Page 3 -->
  86. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; padding-top: 4px; padding-bottom: 4px; border-top: 2px solid black; border-bottom: 10px solid black;">Page 3</div>
  87. <div style="clear: both; width: 100%; font-size: 10pt; border-top: 1px solid black; margin-top: 5px; padding-top: 16px;">
  88. <div style="float: left; width: 362px;">
  89. <div style="margin-top: 0px; background-color: #c0c0c0; width: 355px; height: 37px; border: 1px solid black; line-height: 37px; font-size: 11pt; font-weight: bold; padding-left: 5px;">Paperwork Reduction Act</div>
  90. <p style="margin-top: 9px; margin-bottom: 20px;">An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. <strong>Do not mail your completed Form I-9 to this address.</strong></p>
  91. </div>
  92. </div>
  93. <!-- Page 4 -->
  94. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; padding-top: 4px; padding-bottom: 4px; border-top: 2px solid black; border-bottom: 10px solid black;">Page 4</div>
  95. <div style="width: 100%; clear: both; height: 62px; padding-top: 16px; padding-bottom: 8px; border-bottom: 9px solid black;">
  96. <div style="float: left; padding-top: 30px;">
  97. <div style="clear: both; font-weight: bold; font-size: 9pt;">Department of Homeland Security</div>
  98. <div style="clear: both; font-size: 9pt;">U.S. Citizenship and Immigration Services</div>
  99. </div>
  100. <div style="float: right; text-align: right; padding-top: 4px;">
  101. <div style="clear: both; font-size: 9pt;">OMB No. 1615-0047; Expires 08/31/12</div>
  102. <div style="clear: both; font-size: 13pt; font-weight: bold;">Form I-9, Employment</div>
  103. <div style="clear: both; font-size: 13pt; font-weight: bold;">Eligibility Verification</div>
  104. </div>
  105. </div>
  106. <div style="width: 100%; font-weight: bold; font-size: 10pt; margin-top: 2px; border-top: 1px solid black;">Read instructions carefully before completing this form. The instructions must be available during completion of this form.</div>
  107. <div style="width: 100%; font-weight: bold; font-size: 10pt; padding-top: 11px;">ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.</div>
  108. <div style="width: 100%; border-top: 4px solid black; border-bottom: 1px solid black; font-size: 10pt; padding-bottom: 1px; margin-top: 3px;"><strong>Section 1. Employee Information and Verification</strong> <em>(To be completed and signed by employee at the time employment begins.)</em></div>
  109. <div style="width: 100%; clear: both;">
  110. <div style="width: 100%; clear: both; height: 43px; border-bottom: 1px solid black;">
  111. <div style="float: left; width: 543px; height: 43px; border-right: 1px solid black; font-size: 9pt;">
  112. <div style="float: left;">Print Name:</div>
  113. <div style="float: left; padding-left: 12px; width: 162px;">
  114. <div style="clear: both;">Last</div>
  115. <div style="clear: both;">{%Last%}</div>
  116. </div>
  117. <div style="float: left; width: 162px;">
  118. <div style="clear: both;">First</div>
  119. <div style="clear: both;">{%First%}</div>
  120. </div>
  121. <div style="float: right; text-align: right; padding-right: 4px;">
  122. <div style="clear: both;">Middle Initial</div>
  123. <div style="clear: both;">{%MI%}</div>
  124. </div>
  125. </div>
  126. <div style="float: left; width: 236px; height: 43px; font-size: 9pt;">
  127. <div style="padding-left: 6px;">
  128. <div style="clear: both;">Maiden Name</div>
  129. <div style="clear: both;">{%Maiden%}</div>
  130. </div>
  131. </div>
  132. </div>
  133. <div style="width: 100%; clear: both; height: 43px; border-bottom: 1px solid black;">
  134. <div style="float: left; width: 543px; height: 43px; border-right: 1px solid black; font-size: 9pt;">
  135. <div style="float: left; width: 380px;">
  136. <div style="clear: both;">Address <em>Street Name and Number</em></div>
  137. <div style="clear: both;">{%Address%}</div>
  138. </div>
  139. <div style="float: left;">
  140. <div style="clear: both;">Apt. #</div>
  141. <div style="clear: both;">{%Apt%}</div>
  142. </div>
  143. </div>
  144. <div style="float: left; width: 236px; height: 43px; font-size: 9pt;">
  145. <div style="padding-left: 6px;">
  146. <div style="clear: both;">Date of Birth <em>(month/day/year)</em></div>
  147. <div style="clear: both;">{%Birthdate%}</div>
  148. </div>
  149. </div>
  150. </div>
  151. </div>
  152. <div style="width: 100%; clear: both; height: 43px; border-bottom: 1px solid black;">
  153. <div style="float: left; width: 543px; height: 43px; border-right: 1px solid black; font-size: 9pt;">
  154. <div style="float: left; width: 180px;">
  155. <div style="clear: both;">City</div>
  156. <div style="clear: both;">{%City%}</div>
  157. </div>
  158. <div style="float: left; width: 180px;">
  159. <div style="clear: both;">State</div>
  160. <div style="clear: both;">{%State%}</div>
  161. </div>
  162. <div style="float: left;">
  163. <div style="clear: both;">Zip Code</div>
  164. <div style="clear: both;">{%Zipcode%}</div>
  165. </div>
  166. </div>
  167. <div style="float: left; width: 236px; height: 43px; font-size: 9pt;">
  168. <div style="padding-left: 6px;">
  169. <div style="clear: both;">Social Security #</div>
  170. <div style="clear: both;">{%SSN%}</div>
  171. </div>
  172. </div>
  173. </div>
  174. <div style="clear: both; width: 100%; border-bottom: 1px solid black; height: 121px;">
  175. <div style="float: left; width: 389px; height: 121px; border-right: 1px solid black; font-weight: bold; font-size: 10pt;">
  176. <div style="padding-top: 11px;">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.</div>
  177. </div>
  178. <div style="float: left; width: 390px; height: 121px; font-size: 9pt;">
  179. <div style="clear: both; padding-left: 11px;">I attest, under penalty of perjury, that I am (check one of the following):</div>
  180. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  181. <div style="float: left;"><span style="font-size: xx-small;">{#C#}</span></div>
  182. <div style="float: left; padding-left: 6px;">A citizen of the United States</div>
  183. </div>
  184. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  185. <div style="float: left;"><span style="font-size: xx-small;">{#N#}</span></div>
  186. <div style="float: left; padding-left: 6px;">A noncitizen national of the United States (see instructions)</div>
  187. </div>
  188. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  189. <div style="float: left;"><span style="font-size: xx-small;">{#L#}</span></div>
  190. <div style="float: left; padding-left: 6px;">A lawful permanent resident (Alien #) {%LawAlien%}</div>
  191. </div>
  192. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  193. <div style="float: left;"><span style="font-size: xx-small;">{#Aa#}</span></div>
  194. <div style="float: left;">
  195. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  196. <div style="float: left;">An alien authorized to work (Alien # or Admission #)&nbsp;</div>
  197. <div style="float: left; max-width: 90px; overflow-x: hidden;">{%AuthAlien%}</div>
  198. </div>
  199. <div style="clear: both; padding-left: 6px; height: 22px; line-height: 22px;">
  200. <div style="float: left;">until (expiration date, if applicable - <em>month/day/year</em>)&nbsp;</div>
  201. <div style="float: left; max-width: 90px; overflow-x: hidden;">{%AlienDate%}</div>
  202. </div>
  203. </div>
  204. </div>
  205. </div>
  206. </div>
  207. <div style="clear: both; width: 100%; height: 29px; border-bottom: 5px solid black; font-size: 9pt;">
  208. <div style="width: 390px; float: left; height: 29px; line-height: 29px;">Employee's Signature {%Signature%}</div>
  209. <div style="width: 390px; height: 29px; float: left;">
  210. <div style="padding-left: 22px; height: 29px; line-height: 29px;">Date <em>(month/day/year)</em> {$CurrentDate$}</div>
  211. </div>
  212. </div>
  213. <div style="clear: both; width: 100%;"><span style="font-size: 10pt; font-weight: bold;">Preparer and/or Translator Certification</span> <span style="font-size: 9pt; font-style: italic;">(To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.</span></div>
  214. <div style="clear: both; width: 100%; height: 88px; border-bottom: 4px solid black; margin-top: 5px;">
  215. <div style="clear: both; width: 716px; height: 43px; margin-left: 32px; margin-right: 32px; border-top: 1px solid black;">
  216. <div style="float: left; width: 382px; height: 43px; border-right: 1px solid black;">
  217. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Preparer's/Translator's Signature</div>
  218. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%PrepSiganture%}</div>
  219. </div>
  220. <div style="float: left;">
  221. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Print Name</div>
  222. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%PrepName%}</div>
  223. </div>
  224. </div>
  225. <div style="clear: both; width: 716px; height: 43px; margin-left: 32px; margin-right: 32px; border-top: 1px solid black;">
  226. <div style="float: left; width: 537px; height: 43px; border-right: 1px solid black;">
  227. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Address <em>(Street Name and Number, City, State, Zip Code)</em></div>
  228. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%PrepAddress%}</div>
  229. </div>
  230. <div style="float: left;">
  231. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Date <em>(month/day/year)</em></div>
  232. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%PrepDate%}</div>
  233. </div>
  234. </div>
  235. </div>
  236. <div style="clear: both; width: 100%;"><span style="font-size: 10pt; font-weight: bold;">Section 2. Employer Review and Verification</span> <span style="font-size: 10pt; font-style: italic;">(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).)</span></div>
  237. <div style="clear: both; width: 100%; border-top: 1px solid black; margin-top: 4px;">
  238. <div style="float: left; width: 288px;">
  239. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; font-weight: bold;">List A</div>
  240. <div style="clear: both; width: 100%; padding-top: 8px;">
  241. <div style="float: left; font-size: 9pt;">Document title:</div>
  242. <div style="float: right;">{%DocA1%}</div>
  243. </div>
  244. <div style="clear: both; width: 100%; padding-top: 8px;">
  245. <div style="float: left; font-size: 9pt;">Issuing authority:</div>
  246. <div style="float: right;">{%DocA2%}</div>
  247. </div>
  248. <div style="clear: both; width: 100%; padding-top: 8px;">
  249. <div style="float: left; font-size: 9pt;">Document #:</div>
  250. <div style="float: right;">{%DocA3%}</div>
  251. </div>
  252. <div style="clear: both; width: 100%; padding-top: 8px;">
  253. <div style="float: left; font-size: 9pt; padding-left: 12px;">Expiration Date <em>(if any):</em></div>
  254. <div style="float: right;">{%DocA4%}</div>
  255. </div>
  256. <div style="clear: both; width: 100%; padding-top: 8px;">
  257. <div style="float: left; font-size: 9pt;">Document #:</div>
  258. <div style="float: right;">{%DocA5%}</div>
  259. </div>
  260. <div style="clear: both; width: 100%; padding-top: 8px;">
  261. <div style="float: left; font-size: 9pt; padding-left: 12px;">Expiration Date <em>(if any):</em></div>
  262. <div style="float: right;">{%DocA6%}</div>
  263. </div>
  264. </div>
  265. <div style="float: left; padding-left: 28px;">
  266. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; font-weight: bold;">OR</div>
  267. <div style="clear: both; width: 17px; height: 170px; background-color: #b7b7b7; margin-top: 2px; margin-left: 1px;">&nbsp;</div>
  268. </div>
  269. <div style="float: left; padding-left: 25px;">
  270. <div style="clear: both; width: 142px; text-align: center; font-size: 10pt; font-weight: bold;">List B</div>
  271. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocB1%}</div>
  272. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocB2%}</div>
  273. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocB3%}</div>
  274. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocB4%}</div>
  275. </div>
  276. <div style="float: left; padding-left: 25px;">
  277. <div style="clear: both; font-size: 10pt; font-weight: bold; text-decoration: underline;">AND</div>
  278. </div>
  279. <div style="float: left; padding-left: 25px;">
  280. <div style="clear: both; width: 142px; text-align: center; font-size: 10pt; font-weight: bold;">List C</div>
  281. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocC1%}</div>
  282. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocC2%}</div>
  283. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocC3%}</div>
  284. <div style="clear: both; padding-top: 8px; text-align: center;">{%DocC4%}</div>
  285. </div>
  286. </div>
  287. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 3px;"><strong>CERTIFICATION: I attest, under penalty of perjury, that I 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</strong> <em>(month/day/year)</em> {%CertDate%} <strong>and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.)</strong></div>
  288. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 5px;">
  289. <div style="float: left; width: 314px; height: 40px; border-right: 1px solid black;">
  290. <div style="clear: both; font-size: 9pt;">Signature of Employer or Authorized Representative</div>
  291. <div style="clear: both; font-size: 9pt;">{%EmpSign%}</div>
  292. </div>
  293. <div style="float: left; width: 235px; height: 40px; border-right: 1px solid black;">
  294. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Print Name</div>
  295. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%EmpName%}</div>
  296. </div>
  297. <div style="float: left; width: 227px; height: 40px;">
  298. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Title</div>
  299. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%EmpTitle%}</div>
  300. </div>
  301. </div>
  302. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 5px;">
  303. <div style="float: left; width: 550px; height: 40px; border-right: 1px solid black;">
  304. <div style="clear: both; font-size: 9pt;">Business or Organization Name and Address <em>(Street Name and Number, City, State, Zip Code)</em></div>
  305. <div style="clear: both; font-size: 9pt;">{%EmpAdd%}</div>
  306. </div>
  307. <div style="float: left; height: 40px;">
  308. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Date <em>(month/day/year)</em></div>
  309. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%EmpDate%}</div>
  310. </div>
  311. </div>
  312. <div style="clear: both; width: 100%; border-top: 3px solid black; font-size: 10pt;"><strong>Section 3. Updating and Reverification</strong> <em>(To be completed and signed by employer.)</em></div>
  313. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 5px;">
  314. <div style="float: left; width: 490px; height: 40px; border-right: 1px solid black;">
  315. <div style="clear: both; font-size: 9pt;">A. New Name <em>(if applicable)</em></div>
  316. <div style="clear: both; font-size: 9pt;">{%ReName%}</div>
  317. </div>
  318. <div style="float: left; height: 40px;">
  319. <div style="clear: both; padding-left: 9px; font-size: 9pt;">B. Date of Rehire <em>(month/day/year) (if applicable)</em></div>
  320. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%ReDate%}</div>
  321. </div>
  322. </div>
  323. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 5px;">C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.</div>
  324. <div style="clear: both; font-size: 9pt; padding-top: 8px; padding-left: 27px;">
  325. <div style="float: left;">Document Title:</div>
  326. <div style="float: left; padding-left: 8px;">{%EDoctitle%}</div>
  327. <div style="float: left; padding-left: 8px;">Document #:</div>
  328. <div style="float: left; padding-left: 8px;">{%EDocNumber%}</div>
  329. <div style="float: left; padding-left: 8px;">Expiration Date <em>(if any)</em>:</div>
  330. <div style="float: left; padding-left: 8px;">{%EDocDate%}</div>
  331. </div>
  332. <div style="clear: both; width: 100%; border-top: 1px solid black; margin-top: 1px; font-size: 9pt; font-weight: bold;">I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.</div>
  333. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt; margin-top: 5px;">
  334. <div style="float: left; width: 550px; height: 40px; border-right: 1px solid black;">
  335. <div style="clear: both; font-size: 9pt;">Signature of Employer or Authorized Representative</div>
  336. <div style="clear: both; font-size: 9pt;">{%EmpSign2%}</div>
  337. </div>
  338. <div style="float: left; height: 40px;">
  339. <div style="clear: both; padding-left: 9px; font-size: 9pt;">Date <em>(month/day/year)</em></div>
  340. <div style="clear: both; padding-left: 9px; font-size: 9pt;">{%EmpDate2%}</div>
  341. </div>
  342. </div>
  343. <!-- Page 5 -->
  344. <div style="clear: both; width: 100%; text-align: center; font-size: 10pt; padding-top: 4px; padding-bottom: 4px; border-top: 2px solid black; border-bottom: 10px solid black;">Page 5</div>
  345. <div style="width: 100%; font-size: 12pt; font-weight: bold; text-align: center; margin-top: 15px;">LISTS OF ACCEPTABLE DOCUMENTS <br /> <span style="font-size: 10pt;">All documents must be unexpired</span></div>
  346. <div style="clear: both; font-size: 10pt; font-weight: bold; margin-top: 10px;">
  347. <div style="float: left; text-align: center; width: 235px;">
  348. <div style="clear: both;">LIST A</div>
  349. <div style="clear: both; margin-top: 11px;">Documents that Establish Both <br /> Identity and Employment <br /> Authorization</div>
  350. </div>
  351. <div style="float: left; padding-top: 59px; padding-left: 15px;">OR</div>
  352. <div style="float: left; text-align: center; width: 235px;">
  353. <div style="clear: both;">LIST B</div>
  354. <div style="clear: both; margin-top: 11px;">Documents that Establish <br /> Identity</div>
  355. </div>
  356. <div style="float: left; padding-top: 59px;">AND</div>
  357. <div style="float: left; text-align: center; width: 230px;">
  358. <div style="clear: both;">LIST C</div>
  359. <div style="clear: both; margin-top: 11px;">Documents that Establish <br /> Employment Authorization</div>
  360. </div>
  361. </div>
  362. <div style="clear: both; width: 100%; border-top: 1px solid black; font-size: 10pt;">
  363. <div style="float: left; width: 258px; border-left: 1px solid black; border-right: 1px solid black;">
  364. <div style="clear: both; width: 100%; height: 65px; border-bottom: 1px solid black;">
  365. <div style="padding-left: 12px; padding-top: 14px;">
  366. <div style="float: left;">1.</div>
  367. <div style="padding-left: 12px; float: left; width: 224px;">U.S. Passport or U.S. Passport Card</div>
  368. </div>
  369. </div>
  370. <div style="clear: both; width: 100%; height: 90px; border-bottom: 1px solid black;">
  371. <div style="padding-left: 12px; padding-top: 28px;">
  372. <div style="float: left;">2.</div>
  373. <div style="padding-left: 12px; float: left; width: 224px;">Permanent Resident Card or Alien Registration Receipt Card (Form I-551)</div>
  374. </div>
  375. </div>
  376. <div style="clear: both; width: 100%; height: 130px; border-bottom: 1px solid black;">
  377. <div style="padding-left: 12px; padding-top: 25px;">
  378. <div style="float: left;">3.</div>
  379. <div style="padding-left: 12px; float: left; width: 224px;">Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa</div>
  380. </div>
  381. </div>
  382. <div style="clear: both; width: 100%; height: 85px; border-bottom: 1px solid black;">
  383. <div style="padding-left: 12px; padding-top: 10px;">
  384. <div style="float: left;">4.</div>
  385. <div style="padding-left: 12px; float: left; width: 224px;">Employment Authorization Document that contains a photograph (Form I-766)</div>
  386. </div>
  387. </div>
  388. <div style="clear: both; width: 100%; height: 276px; border-bottom: 1px solid black;">
  389. <div style="padding-left: 12px; padding-top: 14px;">
  390. <div style="float: left;">5.</div>
  391. <div style="padding-left: 12px; float: left; width: 224px;">In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form</div>
  392. </div>
  393. </div>
  394. <div style="clear: both; width: 100%; height: 195px; border-bottom: 1px solid black;">
  395. <div style="padding-left: 12px; padding-top: 18px;">
  396. <div style="float: left;">6.</div>
  397. <div style="padding-left: 12px; float: left; width: 224px;">Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI</div>
  398. </div>
  399. </div>
  400. </div>
  401. <div style="float: left; width: 259px; border-right: 1px solid black;">
  402. <div style="clear: both; width: 100%; height: 156px; border-bottom: 1px solid black;">
  403. <div style="padding-left: 12px; padding-top: 14px;">
  404. <div style="float: left;">1.</div>
  405. <div style="padding-left: 12px; float: left; width: 224px;">Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address</div>
  406. </div>
  407. </div>
  408. <div style="clear: both; width: 100%; height: 130px; border-bottom: 1px solid black;">
  409. <div style="padding-left: 12px; padding-top: 10px;">
  410. <div style="float: left;">2.</div>
  411. <div style="padding-left: 12px; float: left; width: 224px;">ID 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</div>
  412. </div>
  413. </div>
  414. <div style="clear: both; width: 100%; height: 43px; border-bottom: 1px solid black;">
  415. <div style="padding-left: 12px; padding-top: 11px;">
  416. <div style="float: left;">3.</div>
  417. <div style="padding-left: 12px; float: left; width: 224px;">School ID card with a photograph</div>
  418. </div>
  419. </div>
  420. <div style="clear: both; width: 100%; height: 41px; border-bottom: 1px solid black;">
  421. <div style="padding-left: 12px; padding-top: 10px;">
  422. <div style="float: left;">4.</div>
  423. <div style="padding-left: 12px; float: left; width: 224px;">Voter's registration card</div>
  424. </div>
  425. </div>
  426. <div style="clear: both; width: 100%; height: 42px; border-bottom: 1px solid black;">
  427. <div style="padding-left: 12px; padding-top: 13px;">
  428. <div style="float: left;">5.</div>
  429. <div style="padding-left: 12px; float: left; width: 224px;">U.S. Military card or draft record</div>
  430. </div>
  431. </div>
  432. <div style="clear: both; width: 100%; height: 42px; border-bottom: 1px solid black;">
  433. <div style="padding-left: 12px; padding-top: 12px;">
  434. <div style="float: left;">6.</div>
  435. <div style="padding-left: 12px; float: left; width: 224px;">Military dependent's ID card</div>
  436. </div>
  437. </div>
  438. <div style="clear: both; width: 100%; height: 55px; border-bottom: 1px solid black;">
  439. <div style="padding-left: 12px; padding-top: 11px;">
  440. <div style="float: left;">7.</div>
  441. <div style="padding-left: 12px; float: left; width: 224px;">U.S. Coast Guard Merchant Mariner Card</div>
  442. </div>
  443. </div>
  444. <div style="clear: both; width: 100%; height: 36px; border-bottom: 1px solid black;">
  445. <div style="padding-left: 12px; padding-top: 10px;">
  446. <div style="float: left;">8.</div>
  447. <div style="padding-left: 12px; float: left; width: 224px;">Native American tribal document</div>
  448. </div>
  449. </div>
  450. <div style="clear: both; width: 100%; height: 55px; border-bottom: 1px solid black;">
  451. <div style="padding-left: 12px; padding-top: 10px;">
  452. <div style="float: left;">9.</div>
  453. <div style="padding-left: 12px; float: left; width: 224px;">Driver's license issued by a Canadian government authority</div>
  454. </div>
  455. </div>
  456. <div style="clear: both; width: 100%; height: 79px; border-bottom: 1px solid black; text-align: center;">
  457. <div style="padding-top: 11px;"><strong>For persons under age 18 who <br /> are unable to present a <br /> document listed above:</strong></div>
  458. </div>
  459. <div style="clear: both; width: 100%; height: 43px; border-bottom: 1px solid black;">
  460. <div style="padding-left: 12px; padding-top: 12px;">
  461. <div style="float: left;">10.</div>
  462. <div style="padding-left: 12px; float: left; width: 210px;">School record or report card</div>
  463. </div>
  464. </div>
  465. <div style="clear: both; width: 100%; height: 44px; border-bottom: 1px solid black;">
  466. <div style="padding-left: 12px; padding-top: 12px;">
  467. <div style="float: left;">11.</div>
  468. <div style="padding-left: 12px; float: left; width: 210px;">Clinic, doctor, or hospital record</div>
  469. </div>
  470. </div>
  471. <div style="clear: both; width: 100%; height: 68px; border-bottom: 1px solid black;">
  472. <div style="padding-left: 12px; padding-top: 11px;">
  473. <div style="float: left;">12.</div>
  474. <div style="padding-left: 12px; float: left; width: 210px;">Day-care or nursery school record</div>
  475. </div>
  476. </div>
  477. </div>
  478. <div style="float: left; width: 259px; border-right: 1px solid black;">
  479. <div style="clear: both; width: 100%; height: 127px; border-bottom: 1px solid black;">
  480. <div style="padding-left: 12px; padding-top: 29px;">
  481. <div style="float: left;">1.</div>
  482. <div style="padding-left: 12px; float: left; width: 224px;">Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States</div>
  483. </div>
  484. </div>
  485. <div style="clear: both; width: 100%; height: 101px; border-bottom: 1px solid black;">
  486. <div style="padding-left: 12px; padding-top: 21px;">
  487. <div style="float: left;">2.</div>
  488. <div style="padding-left: 12px; float: left; width: 224px;">Certification of Birth Abroad issued by the Department of State (Form FS-545)</div>
  489. </div>
  490. </div>
  491. <div style="clear: both; width: 100%; height: 101px; border-bottom: 1px solid black;">
  492. <div style="padding-left: 12px; padding-top: 23px;">
  493. <div style="float: left;">3.</div>
  494. <div style="padding-left: 12px; float: left; width: 224px;">Certification of Report of Birth issued by the Department of State (Form DS-1350)</div>
  495. </div>
  496. </div>
  497. <div style="clear: both; width: 100%; height: 127px; border-bottom: 1px solid black;">
  498. <div style="padding-left: 12px; padding-top: 17px;">
  499. <div style="float: left;">4.</div>
  500. <div style="padding-left: 12px; float: left; width: 224px;">Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal</div>
  501. </div>
  502. </div>
  503. <div style="clear: both; width: 100%; height: 55px; border-bottom: 1px solid black;">
  504. <div style="padding-left: 12px; padding-top: 19px;">
  505. <div style="float: left;">5.</div>
  506. <div style="padding-left: 12px; float: left; width: 224px;">Native American tribal document</div>
  507. </div>
  508. </div>
  509. <div style="clear: both; width: 100%; height: 92px; border-bottom: 1px solid black;">
  510. <div style="padding-left: 12px; padding-top: 38px;">
  511. <div style="float: left;">6.</div>
  512. <div style="padding-left: 12px; float: left; width: 224px;">U.S. Citizen ID Card (form I-197)</div>
  513. </div>
  514. </div>
  515. <div style="clear: both; width: 100%; height: 79px; border-bottom: 1px solid black;">
  516. <div style="padding-left: 12px; padding-top: 10px;">
  517. <div style="float: left;">7.</div>
  518. <div style="padding-left: 12px; float: left; width: 224px;">Identification Card for Use of Resident Citizen in the United States (Form I-179)</div>
  519. </div>
  520. </div>
  521. <div style="clear: both; width: 100%; height: 157px; border-bottom: 1px solid black;">
  522. <div style="padding-left: 12px; padding-top: 14px;">
  523. <div style="float: left;">8.</div>
  524. <div style="padding-left: 12px; float: left; width: 224px;">Employment authorization document issued by the Department of Homeland Security</div>
  525. </div>
  526. </div>
  527. </div>
  528. </div>
  529. <div style="width: 100%; text-align: center; font-size: 12pt; font-weight: bold; position: relative; top: 4px;">Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)</div>
  530. </div>

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