RFQENED State of New York Department of iiServi Albany. NY 2239 i ELECT YS MPLOYEE BENEFITS DIVISION INSURANCE TRANSACTION FORM PS-404 (3/06) INSTRUCTIONS: READ AND calitPLETiiliiP I . PLEASE PRINT AND CHECK THE APPROPRM TE CHOICES. Enron: ATION (All employees must complete) 1. Last Name First Name MI 2. Social Security Number 3. Sex Male Female 4. Street Address City State Zip 5. Date of Birth 6. Telephone Numbers 7. Work location and address Home Work 8. Marital Status Married Divorced Marital Status Date Single El Widowed El Separated 9. Covered under Medicare? Self DYes No Spouse/Domestic Partner El No 10. ENTER BELOW A. Request Enrollment- Medical (t0) (Select Empire Plan or HMO) . . Individual DEmpire Plan Code: Name Dental (H) VlSlon (14) B. Request Enrollment- Medical (10) (Select Em ire Plan or HMO) . Family (Complete G) CIEmpire Plan Code Name I I Dental (N) (M) C. Elect Pre-Tax Status for El Yes No If yes, initial here to indicate that you have read the Premium deduction? Pre-Tax Contribution memorandum. D. Decline Coverage DMedical (i0) CI Dental (it) Vision (M) (Process WA transaction) E. El Voluntarily Cancel . Qualifying . Coverage DMedmal (10) Event: Dental (H) V1510n F. Change Coverage DMedical (M) Dental (it) Vision (14) Date of Event: El Change to FAMILY (Complete G) . El Change to INDIVIDUAL El Marriage I voluntarily cancel coverage for my dependents El Domestic Partner I voluntarily cancel coverage for my domestic permer First dependent child acquired Only dependent died Dependent returned to full-time student status? Only dependent married Request coverage for dependents not previously Only dependent graduated covered El Divorce Newborn Only dependent disquali?ed by age Previous coverage termmated (Complete Section 1 l) Termination of domestic partnership (Attach Completed Other Other G. Check One: A (Add), 1) (Delete) or (Change) DEPENDENT INFORMATION (use additional sheets if necessary) Check all that apply: (Medical), (Dental), and (Vision) Date 0f Event Last Name First Name MI Relationship Date of Birth Sex Address (if di?ereng sociiziliriig?completed HMOform must be attached. NYS Department of Civil Service Health Insurance Transaction-Form Albany, NY 12239 PS-404 (3/06) Page 2 10. Continued. ENTER BELOW . . H. Change Medical Bene?t Plan Change to. Empire Plan HMO Code] I HMO Name - A completed HMO form must be attached. . Processed only by the Employee Bene?ts Division during 1, Change Pre Tax Status Change to. El Pr Tax El Tax the Pro-Tax Contribution Selection Period (November) 11. PREVIOUS COVERAGE INFORMATION If you were previously covered under NYSHIP Previous ID Number Date Coverage or another health insurance plan (attach proof, Terminated i.e. insurance bill or letter stating former Enrollee?s Name Under Last First Middle Initial coverage), please complete this secrion. Which Previously Covered 12. LEAVE WITHOUT PAY AND RETIREMENT STATUS I: I wish to continue coverage while I am on authorized leave. I Medical Dental CI Vision LEAVE understand that I will be billed for this coverage. I do not wish to continue coverage while I am on authorized leave. Medical Dental ID Vision WITHOUT PAY El I wish to resume my coverage upon return to the payroll. I understand the requirements for continuing medical insurance coverage as a retiree and wish to continue my coverage. RETH JENIENT I understand the requirements for continuing medical insurance coverage as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.) 13. REQUEST FOR EMPIRE PLAN CARD ONLY For Health Maintenance Organization (HMO) cards, contact your HMO. DUPLICATE CARD non ENROLLEE (Previously issued card remains valid.) El ENROLLEE AND ALL DEPENDENTS CI REPLACEMENT CARD INDIVIDUAL DEPENDENT (Previously issued card(s), lost or stolen, become invalid.) Name Personal Privacy Protection Law Noti?cation This information you provide on this application is requested in accordance with Section ?53 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (I) of the Personal Privacy Protection Law. particularly subdivisions and Failure to provide the information requested may interfere with our ability to comply 'with your request. This information will be maintained by the Director of the Employee Bene?ts Division, NYS Department of Civil Service, Albany, NY [2239. For information concerning the Personal Protection Law, call (5 457-9375. For information related to the Health insurance Program, contact your Agency Health Bene?ts Administrator. If, after calling your Agency Health Bene?ts Administrator, you need more information, please call (5 l8) or 1-800-833-4344 between the hours of 9:00 em. and 3:00 pm. . AUTHORIZATION I have read the Pro-Tax Contribution Program memorandum and have made my selection on Page I of this document, if applicable. I understand that if I voluntarily decline or cancel my coverage, I may subject myself andfor my dependents to waiting periods if I decide to enroll at a later date, and I may be forfeiting the right to such coverage after leaving State service (vest, retirement, etc. I certify that the information I have supplied is true and correct. I understand that my failure to provide required prootIs) within 28 days (30 days for newborns) may delay the availability of bene?ts for me or any dependent for whom I fail to provide such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime, conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims. I hereby authorize deduction from my salon! or retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing. Employee's Signature (Required) Signature Date (Required) USE ONLY . Date of 1? Percentage Neg. Action/Reason Date of Event - Hire Date Eligibility (PE only) Working Agency Code Unit' Ret. System Sick Leave Information Date Entered on Retirement Tier Re istration Effect' te Hours Hourly Rate of Pay NYBEAS we a I: HBA Signature: Date: Paul E. Jonke 128 Joes Hill Road Brewster, NY 10509 845-222-3556 RECEIVED 8 TOWN OF CARMEL December 30, 2019 Michael Simone Superintendent Carmel Highway Department 55 McAlpin Avenue Mahopac, NY 10541 Dear Mr. Simone, Thank you for the opportunity to work full-time for the Town of Carmel Highway Department. Please accept this as written noti?cation of my retirement from the Town of Carmel effective close of business today, December 30, 2019, in accordance with the provisions of the New York State retirement system. Thank you, E. Jo Employee: TOer/ RECEIVED Start: 30' "Ci Classification: er Man DE: 3* J's SUPERVISORS OFFICE TOWN OF CARMEL NEW EMPLOYEE EET 1. Employee Completes: PUTNAM COUNTYAPPLICA TI ON - Original to Putnam County Personnel/cc Highway File Town Personnel Dept. TO WN APPLICA TI ON (Completed Before Hired?) cc Town Personnel Dept NEW EMPLOYEE INF SHEET -- cc Town Personnel Dept YS DMV LENS DRIVER cc Town Personnel Dept EMPLOYEE Insurance Form RETIREMENT MEMBERSHIP REGISTRA EMPLOYEES RETIREMENT TTON of BENEFICMR DIRECT DEPOSIT A TH ORIZA TI ON - Federal IT-2104 INCOME TAX WIT HH OLDING FORMS -- Current Year's Forms Online with appropriate 11) Originals to Town Personnel/cc Highway File 4. Employee completes NYS LENS INFO A UTHORIZA TION submits copy of Drivers? License Original in Highway file/copy to Town Personnel Enter LENS Info online see ?Insurance? NYS ?le in Chrono File Cabinet Fax Authorization Letter Drivers? License to Spain Obtain ?Abstract? from Spain 3. Highway completes Putnam County RPC FORM (0n Computer-?Employment Fomts?l?Putnam County Original to Putnam County Personnel/cc Highway File Town Personnel 5. GET FROM Town Personnel Notify sending employee over for: Town Handbook Code of Ethics ask for capies for acknowledgments of receipt. 6. PARTNERS IN has forms Give man Chain of Custody form send for testing 7. MIKE GIVES MAN DRIVER INFORMATION. Driver Information Certificate of Receipt?copy to Personnel 8. COMPUTE BENEFIT TIME Give Sick Time: 1.25 Days! 10 Hours per Month, starting ?'om the month hired Give 3-Personal Days, regardless of start-date! 9. CHANGE ALL FORMS, ADDING HIS NAME In ?Employee List? Folder?~ExceiSHEET STORM CALL-IN SHEET SOCIAL SECURITY NUMBERS EMPLOYEE BENEFIT TIME Worksheet EMPLOYEE IDENTIFICATION INFO for Spain Agency EMPLOYEE ADDRESSES MAN NUMBERS OF OVERTIME In ?Employee List? Folder??Word: 9) FUEL MANAGEMENT LIST to Donna Engineering Miscellaneous: 10) STORM REPORT Spreadsheet 11) PLOWING 10. GET CARDS FOR NEW I 1. AFTER SIX MONTHS PROBATION, complete another Putnam County date on calendar TOWN OF CARMEL HIGHWAY DEPARTMENT Carmel Highway Department 55 McAlpin Avenue Mahopac, NY 10541 1 MICHAEL SIMONE 845.628.7474 FAX 845.628.1471 SUPERVISOR MSimone@bestweb.net I I i Superintendent of Highways DEC 3 I 5-513 TOWN OF CARMEL I NYS DMV License Event Noti?cation Service Spain Insurance Agency Employee Authorization I hereby authorize the Town of Carmel Highway Department to submit my CDL information to New York State Department of Motor Vehicles License Event Noti?cation Service, LENS, for my initial motor vehicle driving record and any future status changes throughout my employment. Furthermore, I am also authorizing that a copy of my CDL may be faxed to Spain Insurance A ency for insurance purposes. 'Upalu twig: Print Date CDL Number LENS via website Spain via Fax 845.628.1804 NEW Department of Taxation and Finance Employee?s Withholding 2020 New York State - New York City - Yonkers lT-21 04 Allowance Certificate First name and middle initial Last name PM cow: Permanent home address {number and stream-main?) ?at Jars Am: ?Fame? "umber SingleorHead ofhousehold Married El Married. but withhold at higher single rate Clty. villageE or post office Sit;r I g?gd?y mark an Xin Are you a resident of New York City? Yes No Are you a resident of Yonkers? Yes No Complete the worksheet on page 4 before making any entries. 1 Total number of allowances you are claiming for New York State and Yonkers. if applicable (item tine 20) 1 2 Total number of allowances for New York City (from line 35) 2 Use lines 3. 4. and 5 below to have additional withholding per pay period under special agreement with your employer. 3 New York State amount 3 4 New York City amount '4 5 Yonkers amount 5 I certify that mined t3 the number of withholding allowances claimed on this certi?cate. Employee's sigrrture Date [3.13059 Penalty A 1@ alty 500 may be imposed for any false statement from your wags. You ay also be subject to criminal penalties. Employee: detach this page and give it to your employer; keep a you make that decreases the amount of money you have withheld copy for your records. Employer: Keep this certi?cate with your records. Mark an in box A andlor box toindicate why you are sending a copy of this form to New York State (see instructions): A Employee claimed more than 14 exemption allowances for NYS. AD Employee is a new hire or a rehire First date employee performed services for pay (see instr): Are dependent health insurance bene?ts available for this employee? Yes No If Yes. enter the date the employee quali?es I Employer's name and address (En-aprons complete this section ontyifyou are sending a copy orthis form to the NYS rax Department} Employer identification number Instructions Changes effective for 2020 Form lT-2104 has been revised for tax year 2020. The worksheet on page 4 and the charts beginning on page 5. used to compute withholding allowances or to enter an additional dollar amount on line(s) 3. 4. or 5. have been revised. If you previously ?led a Form IT-2104 and used the worksheet or charts. you should complete a new 2020 Form lT-2104 and give it to your employer. Who should ?le this form This certi?cate. Form is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee's pay. The more allowances claimed. the lower the amount of tax withheld. If the federal Form you most recently submitted to your employer was for tax year 2019 or earlier. and you do not ?le Form lT-2104. your employer may use the same number of allowances you claimed on your federal Form Due to differences in tax law. this may result in the wrong amount of tax withheld for New York State. New York City. and Yonkers. For tax years 2020 or later. withholding allowances are no longer reported on federal Form Therefore. if you submit a federal Form W-4 to your employer for tax year 2020 or later. and you do not ?le Form lT-2104. your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State. New York City. and Yonkers. Complete Form IT-2104 each year and ?le it with your employer if the number of allowances you may claim is different fro has changed. Common reasons for completing a year include the following: - You started a new iob. - You are no longer a dependent. - Your individual circumstances may have chang were married-or have an additional child). - You moved into or out of NYC or Yonkers. Form IT-2104 each - You owed tax or received a large refund when 1 income tax return for the past year. - Your wages have increased and you expect to $107.650 or more during the tax year. Page 2 of la rr-21o4 (2020) - The total'income of you and your spouse has increased to $107,650 or lnore for the tax year. - You have signi?cantly more or less income from other sources or from another job. - You no longer qualify for exemption from withholding. - You have been advised by the Intemat Revenue Service that you are entitled to fewer allowances than claimed on your original federal Form (submitted to your employer for tax year 2019 or earlier), and the disallowed allowances were claimed on your original Form lT-2104. You are a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program. - You made contributions to a New York Charitable Gifts Trust Fund (the Health Charitable Account or the Elementary and Secondary Education Account). Exemption from withholding You cannot use Form lT-2104 to claim exemption from withholding. To claim exemption from income tax withholding. you must ?le Form IT-2104-E, Certi?cate of Exemption from Withholding. with your employer. You must ?le a new certi?cate each year that you qualify for exemption. This exemption from withholding is allowable only if you had no New York income tax liability in the prior year. you expect none in the current year. and you are over 65 years of age. under 18. or a full-time student under 25. You may also claim exemption from withholding if you are a military spouse and meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency ReliefAct and the Veterans Bene?ts and Transition Act. If you are a dependent who is under 16 or a full-time student. you may owe tax if your income is more than $3,100. Withholding allowances You may not claim a withholding allowance for yourself or. if married your spouse. Claim the number of withholding allowances you compute in Part 1 and Part 5 of the worksheet on page 4. If you want more tax withheld, you may claim fewer allowances. If you claim more than 14 allowances, your employer must send a copy of your Form "-2104 to the New York State Tax Department. You may .then be asked to verify your allowances. If you arrive at negative allowances (less than zero) on lines 1 or 2 and your employer cannot accommodate negative allowances. enter 0 and see Additional dollar amount(s) below. Income from sources other than wages ?'If you have more than $1,000 of income from sources other than wages (such as interest. dividends, or alimony received). reduce the number of allowances claimed on line 1 and line 2 (if applicable) of the IT-2104 certi?cate by one for each $1,000 of nonwage income. If you arrive at negative allowances (less than zero), see Withholding allowances above. You may also consider making estimated tax payments. especially if you have signi?cant amounts of nonwage income. Estimated tax requires that payments be made by the employee directly to the Tax Department on a quarterly basis. For more infomation. see the instructions for Form lT-2105, Estimated Tax Payment Voucher for individuals. or see Need help? on page 7. Other credits (Worksheet line 14) If you will be eligible to claim any credits other than the credits listed in the worksheet. such as an investment tax credit, you may claim additional allowances. Find your ?ling status and your New York adjusted gross income (NYAGI) in the chart below. and divide the amount of the expected credit by the number indicated. Enter the result (rounded to the nearest whole number) on line 14. Single and Head of household Married Divide amount of is: and is: and NYAGI is: expected credit by: Less than Less than Less than 65 $215,400 $269,300 $323,200 Between Between Between $215,400 and $269,300 and $323,200 and 68 $1,077,550 $1,616,450 $2,155,350 Over Over Over 88 $1,077,550 $1,616,450 $2,155,350 Example: You are married and expect your New York actiusted gross income to be less than $323, 200. ln addition, you expect to receive a ?ow-through of an investment tax credit from the corporation of which you are a shareholder. The investment tax credit will be 6 60. Divide the expected credit by 65. 160/65 2.4615. The additional withholding allowancefs) would be 2. Enter 2 on line 14. Married couples with both spouses working If you and your spouse both work. you should each ?le a separate IT-2104 certi?cate with your respective employers. Your withholding will better match your total tax if the higher wage-eaming spouse claims all of the couple's allowances and the lower wage-eaming spouse claims zero allowances. Do not claim more total allowances than you are entitled to. if your combined wages are: - less than $107,650, you should each mark an in the box Married. but withhold at higher single rate on the certi?cate front, and divide the total number of allowances that you compute on line 20 and line 35 (if applicable) between you and your working spouse. $107,650 or more. use the chart(s) in Part 6 and enter the additional withholding dollar amount on line 3. Taxpayers with more than one job If you have more than one job. ?le a separate lT-2104 certi?cate with each of your employers. Be sure to claim only the total number of allowances that you are entitled to. Your withholding will better match your total tax if you claim all of your allowances at your higher-paying job and zero allowances at the lower-paying job. In addition, to make sure that you have enough tax withheld. if you are a single taxpayer or head of household with two or more jobs, and your combined wages from all jobs are under $107,650. reduce the number of allowances by seven on line 1 and line 2 (if applicable) on the certi?cate you ?le with your higher-paying job employer. If you arrive at negative allowances (less than zero). see Withholding allowances above. If you are a single or a head of household taxpayer. and your combined wages from all of yourjobs are between $107,650 and $2,263,265. use the chart(s) in Part 7 and enter the additional withholding dollar amount from the chart on line 3. If you are a married taxpayer. and your combined wages from all of yourjobs are $107,650 or more. use the chart(s) in Part 6 and enter the additional withholding dollar amount from the chart on line 3 (Substitute the words Higher-paying job for Higher eamer's wages within the chart). Dependents If you are a dependent of another taxpayer and expect your income to exceed $3.100, you should reduce your withholding allowances by one for each $1.000 of income over $2,500. This will ensure that your employer withholds enough tax. Following the above instructions will help to ensure that you will not owe additional tax when you ?le your return. Heads of households with only one job If you will use the head-of-household ?ling status on your state income tax return, mark the Single or Head of household box on the front of the certi?cate. If you have only one job. you may also wish to claim two additional withholding allowances on line 15. Additional dollar amount(s) You may ask your employer to withhold an additional dollar amount each pay period by completing lines 3, 4. and 5 on Form lT-2104. In most instances. it you compute a negative number of allowances and your employer cannot accommodate a negative number. for each negative allowance claimed you should have an additional $1.85 of tax withheld per week for New York State withholding on line 3, and an additional $0.80 of tax withheld per week for New York City withholding on line 4. Yonkers residents should use 16.75% (.1675) of the New York State amount for additional withholding for Yonkers on line 5. Note: if you are requesting your employer to withhold an additional dollar amount on lines 3, 4, or 5 of this allowance certi?cate. the additional dollar amount. as determined by these instructions or by using the chart(s) in Part 6 or Part 7. is accurate for a weekly payroll. Therefore. if you are not paid on a weekly basis, you will need to adjust the dollar amount(s) that you compute. For example, if you are paid biweekly, you must double the dollar amount(s) computed. Avoid underwithholding Form lT-2104. together with your employer?s withholding tables. is designed to ensure that the correct amount of tax is withheld from your pay. If you fail to have enough tax withheld during the entire year. you may owe a large tax liability when you ?le your return. The Tax Department must assess interest and may impose penalties in certain situations in addition to the tax liability. Even if you do not ?le a retum, we may determine that you owe personal income tax. and we may assess interest and penalties on the amount of tax that you should have paid during the year. Employers Box A If you are required to submit a copy of an employee?s Form lT-2104 to the Tax Department because the employee claimed more than 14 allowances, mark an in box A and send a copy of Form lT-2104 to: NYS Tax Department. Income Tax Audit Administrator, Withholding Certi?cate Coordinator, A Harriman Campus, Albany NY 12227-0865. If the employee is also a new hire or rehire. see Box instructions. See Publication 55. Designated Private Delivery Services, if not using U.S. Mail. Due dates for sending certi?cates received from employees claiming more than 14 allowances are: Quarter Due date Quarter Due date January March April 30 July September October 31 April June July 31 October December January 31 Box If you are submitting a copy of this form to comply with New York State's New Hire Reporting Program. mark an in box 8. Enter the ?rst day any services are performed for which the employee will be paid wages. commissions. tips and any other type of compensation. For services based solely on commissions. this is the ?rst day an employee working for commissions is eligible to earn commissions. Also, mark an in the Yes or No box indicating if dependent health insurance bene?ts are available to this employee. If Yes. enter the date the employee qualities for coverage. Mail the completed form. within 20 days of hiring. to: NYS Tax Department. New Hire Noti?cation, PO Box 15119. Albany NY 12212-5119. To report newly-hired or rehired employees online instead of submitting this form. go to (contin ued) lT-2104 (2020) Page 3 of 3' Page 4 bf i3 lT-2104 (2020) Worksheet See the instructions before completing this worksheet. Part 1 - Complete this part to compute your withholding allowances for New York State and Yonkers (line 1). 6 Enter the number of dependents that you will claim on your state return (do not include yourself or. if married. your spouse} 6 For lines 7, 8. and 9. enter 1 for each credit you expect to claim on your state return. 7 College tuition credit 7 8 New York State household credit 8 9 Real property tax credit 9 For lines 10. 11. and 12, enter 3 for each credit you expect to claim on your state return. 10 Child and dependent care credit .. 10 11 Earned income credit 11 12 Empire State child credit 12 13 New York City school tax credit: If you expect to be a resident of New York City for any part of the tax year enter 2 13 14 Other credits (see instructions} 14 15 Head of household status and only one job {enter Zil the situation applies) 15 16 Enter an estimate of your federal adjustments to income. such as deductible IRA contributions you will make for the tax year. Total estimate Divide this estimate by $1,000. Drop any fraction and enter the number 16 17 If you expect to be a covered employee of an employer who elected to pay the employer compensation expense tax in 2020. complete Part 3 below and enter the number from line 29 1? 18 If you made contributions in 2019 to a New York Charitable Gifts Trust Fund (the Health Charitable Account or the Elementary and Secondary Education Account). complete Part 4 below and enter the amount from line 32 18 19 If you expect to itemize deductions on your state tax return. complete Part 2 below and enter the number from line 24. All others enter 0 19 20 Add lines 6 through 19. Enter the result here and on line 1. if you have more than one job. or if you and your spouse both work. see instructions for Taxpayers with more than one job or Married couples with both spouses working. 20 Part 2 -- Complete this part only if you expect to itemize deductions on your state return. 21 Enter your estimated NY itemized deductions for the tax year (see Form 111196 and its instructions: enter the amount from line 49) 21 22 Based on your federal ?ling status. enter the applicable amount from the table below 22 Standard deduction table Single (cannot be claimed as a dependent) 8.000 Qualifying widow(er) $16.050 Single (can be claimed as a dependent) 3.100 Married ?ling jointly $16,050 Head of household $11,200 Married ?ling separate returns 8.000 23 Subtract line 22 from line 21 22 is larger than line 21. enter!) here and on line 19 above) 23 24 Divide line 23 by $1.000. Drop any fraction and enter the result here and on line 19 above 24 Part 3 Complete this part if you expect to be a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program (line 17). 25 Expected annual wages and compensation from electing employer in 2020 25 26 Line 25 minus $40.000 (if zero or less. stop) 26 27 Line 26 multiplied by .03 .. 27 28 Line 27 multiplied by .935 2 8 29 Divide line 28 by 65. Drop any fraction and enter the result here and on line 17 above 29 Part 4 - Complete this part if you made contributions in 2019 to the Health Charitable Account or the Elementary and Secondary Education Account (line 13). 30 Contributions to these funds in 2019 .. 30 31 Multiply line 30 by 85% (.85) . 31 32 Divide line 31 by 60. Drop any fraction and enter the result here and on line 18 above 32 Part 5 - Complete this part to compute your withholding allowances for New York City (line 2). 33 Enter the amount from line 6 above 33 34 Add lines 15 through 19 above and enter total here 34 35 Add lines 33 and 34. Enter the result here and on line 2 35 17-2194 (2020) Page 5 of 9 ?Part 6 These charts are only for married couples with both spouses working or married couples with one spouse working more than one job. and whose combined wages are between $107,650 and $2,263.265. Enter the additional withholding dollar amount on line 3. The additional dollar amount. as shown below. is accurate for a weekly payroll. If you are not paid on a weekly basis. you will need to adjust these dollar amount(s). For example. if you are paid biweekly. you must double the dollar amount(s) computed. $197. 959 9129. 259 5159. 759 9172. 399 ?1905' 5 ?1995 $129. 249 3159. 749 9172.299 .5193, 949 between. an 5133. 350 -. 30'? -. 5484. 900 $538. 749 $539. 759 9592.959 $949. 599 9799 499 "'9h?'?ame'5wa995 5592.949 9949? 499 $799 399 9754. 299 131. 500 51.5135. 399 awaiaamages 9mmyas*9rn,axsms .. ..9 99: 5754. 300 5000. 200 5362. 050 5915. 950 5569. 000 51. 023. 750 51. 077 .550 51.131.500 5808.199 52. 049 5915. 9 5959. 393 51'. 023 .749 51. 031' .9 51Lr131.499p51.1.85 99 Page 6-of?8 lT-2104 (2020) . .. Twa'i. is 91m 334:9 3939297299 .. H. 91. 195 499 91. 239. 259 293. 299 347. 959 51. 499. 959 454. 959 91. 599.799 51. 552 559 91. 519.459 91. 979. 499 9" earners ?"3995 239. 249 91293.199 51.347.949 51.499 949 91454949 91. 599.999 91.992949 91,919,449 919 79399 51724299 ?-19.19- . Qo?lA. . . JP. - ill-:- . ?cam ?HE-mm? eqm?lns?d?smem 99.9 - - - . 91. 724 .399 91.779.159 932. 959 995. 959 939. 999 993. 799 947. 999 191. 599 155. 359 52,299,399 HigheTS earner' 5 91.; 779. 149 51. 932. 949 995. 949 $1939. 799 31.179391152347599 92.101399 $155,349 32.209.299 52.263355 Bb' m?mm- mam-mm-? {r 4'31: . 1.791 .--..- -mm-mm-m 209. 300 263. 265 $14 Note: These charts do not account for additional withholding in the following instances: - a married couple with both spouses working. where one spouse's wages are more than $1 .131.632 but less than 32.263265. and the other spouse's wages are also more than $1,131,632 but less than $2.263.265: - married taxpayers with only one spouse working. and that spouse works more than one job. with wages from each job under 32.263265. but combined wages from all jobs is over $2,263,265these situations and you would like to request an additional dollar amount of withholding from your wages. please contact the Tax Department for assistance (see Need help? on page 7). lT-2104 (2020) Page 7 of 8 ?Pad 7 ?.These charts are only for single taxpayers and head of household taxpayers with more than one job. and whose combined wages are between $107,650 and $2,263,265. Enter the additional withholding dollar amount on line 3. The additional dollar amount. as shown below. is accurate for a weekly payroll. If you are not paid on a weekly basis. you will need to adjust these dollar amount(s). For example. if you are paid biweekly. you must double the dollar amount(s) computed. Combwged - e's' ?51911? H. 9107. 950 $129. 250 $150. 750 3172. 300 5193 950 $235. 950 5290.100 5323. 200 9377100 $430. 950 5494. 900 '9 9":329 $129. 249 5150. 749 9172. 299 5193. 949 5235. 949 $290. 099 5323.199 5377 .099 $430. 949 #9494. 999 .5539. 749 $484. 900 55:38:89 749 mamas?! - 5592.550 $949. 500 $700 400 $754. 300 $909. 200 $952.8 050 5592 949 9949. 499? 5700. 399 $754. 299 5909199 9992 049? 5915 949 9999 999 31 023.749 91 077 711549 91131499 3' 1- . -.4$700 400 W54 299 F?ng Eli-31.131.500 $1.185. 399J (Part 7 continued on page 8) Privacy noti?cation See our website or Publication 54, Privacy Noti?cation. Need help? Visit our website at . - get information and manage your taxes online - check for new online services and features Telephone assistance Automated income tax refund status: 518-457-5149 Personal Income Tax Information Center: 518-457-5181 To order forms and publications: 518-457-5431 Text Telephone (TTY) or TDD Dial 7-1-1 for the equipment users New York Relay Service Page 8 of 8 45 IT-2104 (2020) . 55351355115953.4535513355?3 11335.35 . gogo 3.115395723131299 33 333.33: 33333 333 33333333 33 333333 33 333333 3343 33333333 33 333333 33 333333 33. 33333 5.32355 a555552.59_9 {Es-Ly? - ..- g, '52; -. I $846,500 $700, 399 .5. Lo}, .2993 Higher wage $2,101,499 5754 300 $505,199 $475 $495 $522 $545 $559 3333355 35335 55.5% ??wm . $475 $495 $522 $593 $553 $557 $959 900 $1,023,749 $493 $495 $522 $545 $559 $593 $515 $540 $553 $557 3.. .3159. -. 955555 555.55% 555% 53525 5.555% 5555555 1333355 355555355 555% 077 550 131.499 $255 $254 $312 $515 $541 $355 $355 $412 $435 $459 155, 400 239. 249 $92 $120 $125 $149 $175 $195 $220 3-.-. .9. .1.- .993 mm 9 .- I51. 293, 200 .357: 049 $42 $74 $92 $120 $125 $149 $175 400. 950 $1,454,549 $92 $120 I I 9.6.9.- . . $1,505,700 $1,552,549 - ?4.5514353 - $1,515,450 $1.570.399 3.529.. .. 2. .- 5mm ?23135 :1 724. 300 532, 550 555.990 51. 939, 500 993. 750 $2,047,500 $2,101,500 155, 350 92.155. :49 $2,209,299 _.253 255 52.209.300 535% $1,170,149 $1 832,049 91 I885.9119 I52 347,599 -- $710 ?'r-a3r -- 283, 265 $14 TOWN OF CARMEL HIGHWAY DEPARTMENT NEW EMPLOYEE INFORMA TI ON SHEET Employee Complete PLEASE PRINT LEGIBLY. Name (First. Middle, Last) Driver's License NumberIClass EM. 6- do? HOME PHONE ADDITIONAL CONTACT NUMBERS Address Social Security Number 498 Ma. 12/) City State Zip Date of 7377? AJ 7? 955E- SINGL SPOUCE NAME EMERGENCY CONTACT INFO: Address Cell Phone Employee Signature: Date: 1' HIRE DATE MAN NUMBER Employment Eligibility Veri?cation USCIS Department of Homeland Security 0M: 32.1116590947- UUS Citizenship and [migration Services Expires 0313112019 START HERE: Read instructions carefully before. completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation opresented has a future expiration date may also constitute illegal discriminationLast Name (Famiiy Name) First Name (Given Name) Middle Initial Other Last Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State ZIP Code [ca-8: grief/MC Rb WW ?7 ram? U.S. Social Securi Number Employee?s Email Address Employee's Telephone Number I am aware that federal law provides for imprisonment andior ?nes for false statements or use of false documents in connection with the completion of this form. I attes . under penalty of perjury, that I am (check one of the following boxes): A citizen of the United States 2. A noncitizen national of the United States {See instructions) 3. A lawful permanent resident (Alien Registration NumberiUSClS Number): 4. An alien authorized to work until (expiration date. if applicable. Some aliens may write "NiA'jn the expiration date field. {See instructions) QR Code - Section 1 Aiiens authorized to work must provide oniy one of the foiiowing dooument numbers to complete Form i-9: Do Not Write In This space An Atien Registration Number OR Form i?94 Admission Number OR Foreign Passport Number. 1. Alien Registration Numb?eriUSClS Number: OR 2. Form l-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: attest, under penalty of perjury, that i have assisted in the completion of Section1 of form and thatto the best of my knowledge the information is true and correct of3 Signature of Preparer or Translator Today's Date Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or State ZIP Code OFFICE 31 i I Form Gift TOWN OF CARMEL Page Employment Eligibility Veri?eation Department of Homeland Security Form OMB No. [615-0047 US. Citizenship and Immigration Services Expm 0331,9019 a: g7 sit? Employee Info from Section 1 . List A 0R List AND List 0 Identity and Employment Authorization identity Employment Authorization Document Title Document Title Document Title Issuing Authority Issuing Authority issuing Authority Document Number -. Document Number Document Number Expiration Date {if Expiration Date (ifanmem/dd/WW) Expiration Date Document Title GR Code -Seclions 2 8- 3- Issuing Authority Additional information Do No, mm In W, space Document Number Expiration Date {if Document Title Issuing Authority Document Number Expiration Date (if Certi?cation: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and to the best of my knowledge the employee is authorized to work in the United States. The employee's ?rst day of employment {See instructions for exemptions) Signature of Employer or Authorized Representative Today's Date Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code .. 95.4 - . Ar?Nst?i?ameifian?lgabtesmarts i Last Name (Family Name} First Name (Given Name) Middle Initial Date 1 mpiaymentaum tonintisspaceprowded below - .- . Document Title Document Number Expiration Date (if any) (mandfm/y) 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. Signature of Employer or Authorized Representative Today's Date Name of Employer or Authorized Representative Form 07117?? Page 2 of 3 LISTS 0F ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List and one selection from List C. LIST A Documents that Establish Both identity and Employment Authorization LIST Documents that Establish identity AND LIST 0 Documents that Establish Employment Authorization 1. U.S. Passport or U.S. PaSsport Card 2. Permanent Resident Card or Alien 3. Foreign passport that contains a temporary l-551 stamp or temporary [-551 printed notation on a machine- readable immigrant visa 4. Employment Authorization Document that contains a photograph (Form l-766) 5. For a nonimmigrant alien authorized to work for a speci?c employer because of his or her status: a. Foreign passport: and b. Form l-94 or Form l-94A that has the following: and An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in con?ict with any restrictions or limitations identi?ed on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form or Form indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI Registration Receipt Card (Form 1?551) State or outlying possession of the United States provided it contains a photograph or information such as name. date of birth. gender. height. color. and address 2. ID card issued by federal. state or local government agencies or entities. provided it contains a photograph or . Driver's license or ID card issued by a 1. A Social Security Account Number card. unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION gender. height. color. and address information such as name. date of birth. 2- Certificalion of report of birth issued by the Department of State (Forms DS-1350. FS-240) . School ID card with a photograph IE 4. Voter's registration card . U.S. Military card or draft record 6. Military dependent?s ID card Original or certi?ed copy of birth certi?cate issued by a State. county. municipal authority. or territory of the United States bearing an official seal The same name as the'passport; 1 7. US Coast Guard Merchant Mariner 4- Native American tribal document Card 5 . U.S. Citizen ID Card (Form l-197) Native American tribal document I 9. Driver's license issued by a Canadian government authority Identi?cation Card for Use of Resident Citizen in the United States (Form l-179) 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 For persons under age 18 Who are 7- Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form Page 3 of 3 Silace oi the New York State Comptroller New York State and Local Reii nt ITI 110 State Sireei. Albany. New York 12244-0001 Fax Number: (518) 486-4382 For questions concerning Member Enrollment call: (518) 474-3081 ID Received Date Employees? Retirement System Membership Registration RS 5420 [329. 10/131 Plan Tier Rate Date of Membership Registration Number Part 1: Employee Read information provided on page 2. Complete part 1 and sign at the bottom of the form. Employee's Last Name: First Name: Pride. Middle Initial: .pmr Employee's Address: Apt City State Zip Code (as 4.955 Hm. 25 NY #559 Former Name: (if applicable) - Data. of Birth Gender Teachers'. NYC Employees') If yes. please indicate name of system: Are you inactive or withdrawn from a New York State or New York City public retirement system? If yes. please Indicate name of system: (NYS Teachers'. NYS Empioyees'. NYS Police and FireI NYC Police Pension FundiYC Fire Pension Fund, NYC Board of Education. NYC Are you receiving or about to receive a pension from a New York State or New York City public retirement system? We Female E?Yes No DYes No Part 2: Employer See page 2 for additional information and instructions regarding the completion of this form. Employer's Name: Employer?s Telephone: Employer's Address: Employer's Fax Numben" Job Code 1 Em io ea Cl I Regular Full Time U12 Month El 10 Month U12 Provisional Den Call El Seasonal Substitute Per Diem Temporary Part Time Date of Full-Time Permanent Standard For State Agency Use Only - Hm ?at? [3?1 Ap oointment [3b] ?can? code Workday 90?? Month Day Year Month Day Year For a substituteII seasonal, on call or per diem employee. lease check if heishe is working on the day the application is being submitted. Yes Frequency. of Payment DWeekly Dal-Weekly. DSemi - Dauarteriy DSeml- Annually EIAnnually DOther- Please Specify Projected Annualized Wage 'l'lerB requires employers to determine the Annualized Wage for individuals who work part-time. seasonal. or on an hourly. daily. or unit of work basis. We ask that you use this calculation for all other tiers as well. See page 2 for examples. Important: If your employment is on a part-time. temporary or provisional basis. or less than 12 months a year. membership is optional. If your membership is optional. you must sign and date below to affirm Retirement System Membership. I acknowledge that my membership in the New York state and Local Retirement System is governed titled to all bene?ts thereof. I understand that. as required by law; a deduction will be made from my salary or Social Security Law and that I am compensation for retirement con Employee's Signature: by provisions of Article 15 of the Retirement and one: Egg [r51 Employee's Telephone Numb Employee's Email Address: For important information and instructions See Back Page Part 1 - Employee Instructions important: if your employment is on a part-time. temporary or provisional basis. or less than 12 months a year. membership is optional. If your membership is optional and you do not wish to join the Retirement System. do not complete this application; Warning: If you are receiving or'are about to receive a pension from another New York State or New York City public contact us directly before enrolling in Enrollment may result in suspension of your pension-bene?t. retirees should contact us directly before enrollment to discuss working after retirement and possible restoration of membership. Membership Information: If you are currently an active or vested member of any other public retirement system in New York State. you should contact that system concerning the advantages of transferring your membership to this System. Failure to contact that system could cause loss of the privilege of transferring membership and may affect contribution cessation dates. If you were previously a member of any public retirement system in New York State. and your membership was terminated or withdrawn. you may be eligible for a reinstatement of that membership. it' Is highly recommended that if you have a prior Tier 1 or 2 membership in any New York public retirement system that you complete the Tier Reinstatement application. and. include it with your membership registration application. You may also be eligible to receive credit for public service earned with a participating employer before your current date of membership. This additional service may impact your future bene?ts. You are covered by the Death Bene?t allowed by law. for your 'tier and plan status. If you have'not already done so. complete an Designation of Bene?ciary with Contingent Bene?ciaries form to designate beneficiary?es) to receive an Ordinary Death Bene?t-If there is no DesignatiOn of Bene?ciary with Contingent Bene?ciaries on tile with this System. your Ordinary. Death Bene?t will become payable to your estate. Part 2 - Employer Instructions -IField'_Epranation and information: Job Code? As the employer. you will need to reference our job code list todetermine which job code is applicable to the job title. if the title is accountant. auditor. physician. attorney. engineer or architect. please submit documentation as indicated at reporting vs employeephp. Regular' :5 the same as Permanent or Probationary. Temporary is anything other than" regular. [3a] Hire Date is the ?rst time the employee was hired for the job criteria entered. [3b] Full-Time permanent appointment box must only be completed if at anytime the employee is appointed to a (permanent or probationary) 12 month. full-time pesitIOn earning no less than current state minimum wage Standard Workday? Standard workday applies to all tiers. The minimum number cf hours that can be established for a standard workday' Is ..,six while the maximum is eight. A standard Workday' Is the denominator to be Used for the days worked calculation: it' Is not necessarily the number of hours the person actually werks. For example. if a bus driver works four hours a day. you must still establish a standard workday between six and eight hours as the denominator for their days worked calculation. When entering the information on the Employer Retirement OnlineI you will need to select "Daily" for Work Period and then enter the standard work day' In the standard day ?eld. Projected Annualized Wage? Examples of Tier 6 annual wage for individuals paid at an Hourly. Daily or Unit of Work basis of compensation: Hourly Employees I Daily Employees 12 month Employee: I I 260 12 month Employee: 35 260 HoUrly Standard Days AnnUal I I . Daily .- Days Annual Rate Workday Worked Wage I . Rate Worked Wage 10 month Employee: 3 130 10 month Employee: 5 - res Hourly Standard Days Annual - IDaily Days Annual . Rate Workday Worked Wage Rate Worked Wage Unit of-Work Employees Unit of Work Employee Example: Paid $50 per Meeting .5 X- . 5L matings wig-- Unit Rate of Events? Annual Wage Unit Rate of Events? - Annual Wage ?Estimated'or Actual . .-- . . - estimate of the number of events is acceptable Note: Any questions regarding annualized wage. please contact the Retirement System. *Social Security Disclosure Requirement In accordance with the Federal Privacy Act or 1974, you are hereby advised that disclosure of your Social Security account number is mandatory pursuant to Sections 11 and 34 of the Retirement and Social Security Law. The number will be used in identifying - retirement records and in the administration of the Retirement System. Personal Privacy Protection Law The Retirement System is required by law to maintain records to determine eligibility for and caicr'rlate bene?ts. Failure to provide" information may interfere with the timely payment of- bene?ts. The System may be required to provide certain information to participating employers. The of?cial responsible far record maintenance is the Director of Member and Employer Services. NYS and Local Retirement System. Albany. NY 12244: call toll-free at 1-866-805- 0990 or 518-474-7736' In the Albany Area. Name: Reinstatement to a former membership in accordance with Section 645 (Tiers 3, 4, 5 and 6). Note: Completion of this form does not constitute an application for reinstatement. Section 645 of the Retirement and Social Security Law allows members of a New York State public retirement system. whose original membership was terminated or withdrawn. to return to their former Tier or date of membership. Members with a former Tier 3. 4. 5 or 6 membership in the New York State and Local Employees? Retirement System will be automatically provided with the cost. if any. and procedures for reinstatement at a later date. Former Tier 3. 4. 5 or 6 members of any NYS public retirement system. other than the NYS Employees' Retirement-System. please complete the section below. We will provide you with the cost. it any. and procedures for reinstatement at a later date. Reinstatement to a former membership in accordance with Section 645 (Tiers 1 and 2). Members with a former Tier 1 or 2 membership in any New York public retirement system may apply for reinstatement by completing the section below. Important information: it you are not sure of your employer's current Tier 1 or 2 retirement plan. or if you are a member of the Police and Fire Retirement System or if you have any questions regarding reinstatement you should contact the Retirement System before completing the section below. If you are given Her 1 or 2 status. your Tier 3. 4. 5 or 6 contributions are not refundable and you will not be able to take a loan against these contributions. If your date of membership will be before April 1. 1960. you may owe contributions for services rendered prior to April 1. 1960. Any de?cit in contributions for service before the date noted will result in a reduction of your retirement bene?t. FORME MEMBERS 1 PLEASE CHECK THE FIRST FORM ER RETIREMENT SYSTEM YOU WERE A MEMBER OF: I: New York State Teachers? Retirement System New York City Board of Education Retirement System New York State and Local Employees' Retirement System New York City Teachers' Retirement System New York State and Local Police and Fire Retirement System New York City Police Pension Fund New York City Employees' Retirement System New York City Fire Pension Fund PLEASE COMPLETE THE FOLLOWING (if known): Former Registration Number: Date of Membership: Former Name (if applicable): Have you received credit for this former membership in any other retirement system? Yes No If Yes. what retirement system? Are you receiving or eligible to receive a retirement benefit based on this service? Yes El No Signature Date if you are eligible for a refund of contributions. the Retirement System is required to withhold 10% of the taxable amount of the refund for federal taxes unless you instruct us not to take the withholding. If you do not want the Retirement System to withhold federal income tax from your payment. sign and date this election. I DO NOT WANTTO HAVE FEDERAL INCOME TAX WITHHELD FROM MY PAYMENT. . Signed: Date: RS 5420 (Rev. 8116) Page 3 of 4 Name: If you have not already done so, please complete an Designation of Bene?ciary With Contingent Beneficiaries form to designate beneficiary?es) to receive an Ordinary Death Benefit. If there is no Designation of Beneficiary With Contingent Bene?ciaries form on ?le with this System, your Ordinary Death Benefit will become payable to your estate. WARNING: If you are receiving a pension from a public retirement system in New York State, contact the system providing your pension BEFORE signing this form. Failure to do so could result in the suspension of payment of your pension bene?t. IMPORTANT: You must sign and enter date below to affirm Retirement System membership. that my membership in the NewYork State and Local Employees' Retirement System is governed by the provisions of Article 15 cial Security Law and that I am entitled to all the benefits thereof. I understand that. as required by law. a deduction lary or compensation for retirement contributions. I. Date Employee Telephone Number? Employee E-Mail Address? 'Not Required FOR OFFICE USE ONLY Reviewed Examined RS 5420 (Rev. N18) Page 4 of 4 For Office Use Only Office of the New York State Comptroller New York State and Local Retirement System Employees' Retirement System Police and Fire Retirement System 110 State Street. Albany. New 12244-0001 Receipt Date Designation of Beneficiary With Contingent Beneficiaries RS 5127 (Rev. 9114) THIS FORM MUST BE SIGNED. NOTARIZED AND FILED WITHTHE RETIREMENT SYSTEM PRIORTOYOUR DEATHTO BE EFFECTIVE. Please PRINT clearly. using only blue or black ink. MemberlPensioner Information RegistrationfRetirement Number: Last 4 Digits of Social Security Number' Name: Former Name: Home Address: City. State. Zip_ Code: ate 0, Birth: Telephone Number: Email Address: Employed By: Employer Address: IMPO Tl FORM you ?nd this form is not suited to the type of designation you prefer please advise the Retirement System. In the meantime. for your protection and the protection of your beneficiary?es). you should make an'interim designation using this form. if you wish to designate more bene?ciaries than this form allows or to designate a Trust. Guardianship or payment under the Uniform Transfers to Minors Act please contact the Retirement System-for the appropriate form. - Attachments to your bene?ciary form are unacceptable. New bene?ciary forms filed will supersede any previous designation. Therefore. if you want to add or delete a bene?ciary. for example a new child. you must include on the new form all bene?ciaries you wish to designate. - The same person or persons cannot be designated as both primary and contingent beneficiaries. We make payment to a contingent beneficiary?es) only it all primary bene?ciary?es) die before you do. if you wish to have these benefits distributed through your estate. you should name "my estate? as beneficiary. Your estate can be named as either primary or contingent bene?ciary. However. it you name your estate as primary bene?ciary. you may not name any contingent bene?ciary. - This form is for designating bene?ciaries to receive your ordinary death or post retirement death benefit. You may not designate beneficiaries to receive accidental death bene?ciaries entitled to receive accidental death bene?ts are mandated by statute. Make sure that you: - Complete all requested Information. - Sign and date the form. - Have the form' notarized. making sure the notary has entered the date his or her commission expires. - Mail your completed form to: New York State and Local Retirement System Member Employer Services Registration - Mail Drop 5-6 110 State Street Albany. NY 12244-0001 In accordance with the Personal Privacy Protection Law you are hereby advised that pursuant to the Retirement and Social Secun?ty Law. the Retirement System is required to maintain records. The records are necessary to determine eligibility for and to catcutate bene?ts. Failure to provide information may result in the System's inability to pay bene?ts the way you prefer.The System may provide certain information to participating employers. The of?cial responsible for maintaining these records is the Director of Member 8. Employer Services. NewYork State and Local Retirement Systems. Albany. NY 12244. Forquestions concerning this form. please call 1-066-805-0990 or510?474?7736. In accordance with the Federal Privacy Act of 1974. you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to sections 11. 31. 34 and 334 of the Retirement and Social Security Law. The number will be used In identifying retirement records and in the administration of the Retirement System. .. Please go to the reverse side-of this form to designate benefici rim BMQM and have the form notarized. RS 512? (iron!) OFFICE TOWN OF EL Do not alter this former make stipulations, The use of correction fluid or other alterationson this form will ren der. the designation invalid. To the Comptroller of the State of New York. Designation of Brim Beneficiary?es). I hereby name the following beneficiarylies) to receive any ordinary death or post retirement death benefit. payable on my behalf. If I have named more than one bene?ciary. it is my intention that those living at the time of my death should share equally any bene?t payable. I reserve the right to change this designation at any time. Name -- . . El Male CIFernale Name El Male EIFemale Address Address Relationship - Birth Date Relationship Birth Date Telephone Number Telephone Number Name Cl Male [Female Name Male EIFemale Address Address Relationship - Birth Date Relationship - Birth Date Telephone Number Telephone Number Name . UMale UFernale Name EIMale UFemale Address Address Relationship Birth Date . Relationship Birth Date Telephone Number Telephone Number Designation of Contingent Beneficiary?es). If all of the designated primary beneficiaries die before I do. any ordinary death or post retirement death benefit payable on my behalf shall be paid to the following. If] have named-more than one beneficiary. It Is my intention that those living at the time of my death should share equally any bene?t payable. If i out-live all of these contingent beneficiaries. any benefit payable should be paid to my estate. I reserve the right to change this designation at anytime. Name . UMate EIFernale Name [Male [Female Address . . Address Relationship Birth Date . Relationship Birth Date Telephone Number . Telephone Number Name - EIMale UFemale Name El Male EIFemale Address - . - Address Relationship . - Birth Date Relationship . Birth Date Telephone Number - Telephone Number This form must be signed. dated and notarized in order to be valid MemberiPensioner Signature . . . Date Acknowledgement To Be Completed by a Notary Public State of County of On the day of in the year before me. the undersigned. personally appeared . personally known to me or proved to me on the basis of satisfactory evidence to be the individualls) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that hefshefthey executed the same in hisrherrtheir capacitylies). and that by hisiheri'their signature(s) on the instrument. the individuat(s). or the personupon behalf of which the individual(s) acted. executed the instrument. Notary Public Stamp NOTARY PUBLIC (Please sign and affix stamp) RS 5127 (Flev.9r14] reverse Form W-4 Department of the Treasury Internal Revenue Service Employee's Withholding Certificate Complete Form so that your employer can withhold the your y. Give Form to yoyr employa-lOWN 0F CARMEL Your withholding ls subject to review by the OMB No. 1545-0074 2?20 Step 1: First name and middle initial ?at Last name g? 45pm Enter Personal Address Social securii number use your name ma 0 9 name on your social security card? It not. to ensure you get 131? (E53 [6924 information City credit for your eamings, contact SSA at 800-772-1213 Li?gu or Married ?ling separately Married ?ling jointly {or Qualifying widowlerii Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individualJ Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step. who can claim exemption from withholding, when to use the online estimator, and privacy. Step 2: Multiple Jobs or Spouse Works Complete this step if you (1) hold more than one job at a time. or (2) are married ?ling jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following. Use the estimator at for most accurate withholding for this step (and Steps or Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding: or If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This Option is accurate for jobs with similar pay; otherwise. more tax than necessary may be withheld . TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income. including as an independent contractor, use the estimator. Complete Steps 3-4(b] on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3?4(b) on the Form W-4 for the highest paying iob.) Step 3: If your income will be $200,000 or less ($400,000 or less if married filing jointly): Claim . . . . Dependents Multiply the number of children under age 17 by $2,000 Multiply the number of other dependents by $500 . Add the amounts above and enter the total here . . . . . . . . . . . . . 3 Step 4 Other income (not from jobs). If you want tax withheld for other income you expect (optional): this year that won't have withholding. enter the amount of other income here. This may Other include interest. dividends, and retirement income . 4(a) Adjustments . Deductions. If you expect to claim deductions other than the standard deductlon and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . Extra withholding. Enter any additional tax you want withheld each pay period 4(a) Step 5: Under >penalf?s/??pweclar hat this certi?cate, to the best of my knowledge and belief, is true. correct and compl 3. Sign Here 3919 >?Employ?e sfignatuie 1e?This form Is not valid unless you sign it.) ?Date Employers Employer' 5 n?rp? and add First date of Employer identi?cation Only employment number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 102200 Form W-4 {2020} Form [2020) Page 2 General Instructions Future Developments For the latest information about developments related to Form such as legislation enacted after it was published, go to Purpose of Form Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld. you will generally owe tax when you ?le your tax return and may owe a penalty. if too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or ?nancial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form see Pub. 505. Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 it (1) your total tax on line 16 on your 2019 Form 1040 or is zero (or less than the sum of lines 18a, 18b, and 18c). or (2) you were not required to file a return because your income was below the ?ling threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing "Exempt" on Form W-4 in the space below Step Then, complete Steps 1a, 1b, and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021. Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy. As an alternative to the estimator: if you have concerns with Step you may choose Step if you have concerns with Step you may enter an additional amount you want withheld per pay period in Step If this is the only job in your household, you may instead check the box in Step which will increase your withholding and signi?cantly reduce your paycheck (often by thousands of dollars over the year). When to use the estimator. Consider using the estimator at if you: 1. Expect to work only part of the year; 2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax; 3. Have self-employment income (see below); or 4. Prefer the most accurate withholding for multiple job situations. Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at to figure the amount to have withheld. Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Specific Instructions Step Check your anticipated ?ling status. This will determine the standard deduction and tax rates used to compute your withholding. Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married ?ling jointly and you and your spouse both work. Option most accurately calculates the additional tax you need to have withheld. while option does so with a little less accuracy. If you (and your spouse) have a total of only twa jobs, you may instead check the box in option The box must also be checked on the Form W-4 for the other iob. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs. Multiple jobs. Complete Steps 3 through 4(b) on only A one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job. Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you ?le your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can?t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so. add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return. Step 4 (optional). Step Enter in this step the total of your other estimated income for the year. if any. You shouldn't include income from any jobs or self-employment. if you complete Step you likely won't have to make estimated tax payments for that income. if you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals. Step Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both Itemized deductions and other deductions such as for student loan interest and IRAs. Step Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe. CAUTION Form W-4 (2020) Page 3 Step 2(bj?Multiple Jobs Worksheet {Keep for your records.) a if you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate it you complete the worksheet and enter the result on the Form W-4 for the highest paying job. Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs. see Pub. 505 for additional tables: or. you can use the online withholding estimator at 1 Two jobs. If you have two jobs or you're married ?ling jointly and you and your spouse each have one job. ?nd the amount from the appropriate table on page 4. Using the ?Higher Paying Job" row and the ?Lower Paying Job" column, ?nd the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . Three jobs. If you and/or your spouse have three jobs at the same time. complete lines 2a, 2b. and 2c below. Otherwise. skip to line 3. a Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the ?Higher Paying Job? row and the annual wages for your next highest paying job in the ?Lower Paying Job" column. Find the value at the intersection of the two household salaries and enter that value on line 2a . 2a$ Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the ?Higher Paying Job" row and use the annual wages for your third job in the "Lower Paying Job" column to find the amount from the appropriate table on page 4 and enter this amount on line 2b 213$ Add the amounts from lines 2a and 2b and enter the result on line Enter the number of pay periods per year for the highest paying job. For example. if that job pays weekly, enter 52; if it pays every other week enter 26: if it pays enter 12. etc. . . . 3 4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and' In Step 4(cj of Form W-4 for the highest paying job (along with any other additional amount you want withheld). Step 4(bj? Deductions Worksheet (Keep for your records.) a 1 Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-812?. Such deductions may include qualifying home mortgage interest. charitable contributions. state and local taxes (up to $10,000). and medical expenses in excess of 10% of your income . . . . . . . . 1 2 Enter: - $18,650 if you're head of household - $24,800 if you're married filing jointly or qualifying widow(er) . 2 - $12.400 if you're single or married ?ling separately 3 If line 1 is greater than line 2. subtract line 2 from line 1. If line 2 is greater than line 1, enter . . 3 4 Enter an estimate of your student loan interest. deductible IRA contributions. and certain other adjustments (from Schedule'l (Form 1040 or 1040-SFlj). See Pub. 505 for more information . . . 4 5 Add linesSand 4. Enterthe result here and in Step 40:} of Form . . . . . . . . . . . 5 35 Privacy Act and Paperwork Reduction Act Notice. We ask for the Information on this form to carry out the lntemal Revenue laws of the United States. lntemal Revenue Code sections 3402mm and 6109 and their regulations require you to provide this information: your employer uses it to your federal Income tax withholding. Failure to provlde a properly completed form will result' In your being treated as a single person with no other entries on the form: providing fraudulent intonnatlon may subject you to penalties. Routine uses of this information include giving It to the Department of Justice for civil and criminal litigation; to cities. states. the District of Columbia. and U. S. commonwealths and possessions for use in administering their tax laws: and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this lnfonnation to other countries under a tax treaty. to federal and state agencies to enforce federal nontax criminal lavvs. or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Papemork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its must be retained as long as their contents may become material in the administration of any lntemal Revenue law. Generally. tax returns and retum information are con?dential. as required by Code section 6103. The average time and expenses required to complete and file this form will vary depending on Individual circumstances. For estimated averages. see the instructions for your income tax return. If you have suggestions for making this form simpler. we would be happy to hear from you. See the Instructions for your income tax return. .9 Form 1434 (2020) Page 4 Married Filing Jointly or Qualifying Widowler) Higher Paying Job Lower Paying Job Annual Taxable Wage 8; Salary Annua'Taxable $10,000- $20,000- $30,999- $49,009- $59,090- $30,990- $70,000- $39,009- $99,090- $199,000- $110,009- Wage 3. Salary 9.999 19.999 29.999 39.999 49.999 59.999 39.999 79.999 39.999 99.999 109,999 129,009 $0 - 9.999 $0 $229 $350 $900 $1,920 $1,920 $1.020 $1.920 $1.020 $1.219 $1.370 $1.379 $19,000 - 19.999 229 1,220 1,990 2,100 2.229 2.229 2.229 2,229 2.410 3.410 4.070 4,070 $20,900 - 29.999 350 1.900 2.730 2,930 3.050 3.059 3.059 3.240 4.240 5,240 5.900 5,900 $30,009 - 39.999 990 2.100 2.930 3,130 3.250 3.259 3,449 4.440 5.440 3,440 7,100 7,199 $40,009 - 49.999 1.020 2.220 3.959 3.250 3,370 3.570 4,570 5.570 3,570 7,570 3,229 3,220 $50,099 - 59,999 1,020 2.229 3,959 3.250 3,570 4,570 5,570 3,579 7,570 3.570 9,220 9.229 $30,090 - 39.999 1.920 2,229 3,959 3.440 4.570 5.570 3,579 7,570 3,570 9.579 10.229 10.229 $79,990 - 79.999 1,920 2.220 9.240 4.440 5.579 3.570 7,579 3,570 9.570 10.570 11.229 11,240 $30,000 - 99.999 1,930 3.230 5.990 3.290 7.420 3,429 9.420 19,420 11.420 12.420 13.230 13.430 $109,000 - 149.999 1.379 4.070 5,990 7,109 3.229 9,320 10.529 11.720 12.920 14.120 14.930 15.130 $150,000 239.999 2.049 4.440 3,470 7,370 9.190 10.399 11.599 12.799 13.990 15.199 13.050 13.250 $249,099 - 259.999 2.040 4.440 3.479 7,370 9.190 19.399 11.590 12.790 13.999 15.520 17,170 13,170 $230,090 - 279.999 2.040 4,449 3,479 7.370 9.190 19,390 11.590 13.120 15.120 17.129 13,770 19.770 $239,900 - 299,999 2,949 4.449 3,470 7.379 9.190 19.720 12.729 14,720 13,720 13,720 20.379 21.379 $300,000 - 319,999 2,040 4.449 3.470 3,290 10,320 12.320 14.320 13.320 13.320 29,320 21,970 22,979 $320,009 - 334.999 2.720 5.920 3.750 19.959 13.979 15.079 17.070 19.970 21.299 23.590 25.540 23.340 $335,099 - 524.999 2.970 3.470 9.300 12.100 14.539 13.330 19.139 21.430 23.730 23.030 27,939 29,230 $525,900 and over 3,140 3,349 19.179 12.370 15.500 13.000 29.500 23.009 25,500 23,009 30,159 31,359 Single or Married Filing Separately Higher Paying Job Lower Paying Job Annual Taxable Wage 81 Salary AnnualTaxable $10,090- $20,099- $39,909- $40,900- $50,090- $39,900- $70,000- $39,990- $90,099- $100,009- $110,990- Wage 3 Salary 9,999 19,999 29.999 39.999 49,999 59.999 39.999 79.999 39.999 99.999 199.999 129.999 $0 - 9.999 $430 $940 $1.029 $1.020 $1.470 $1,370 $1.379 $1.370 $1.370 $2.049 $2.049 $2.940 $10,099 - 19,999 949 1.539 1,310 2,039 3,930 3,430 3.430 3,430 3.340 3,330 3.330 3.339 $20,090 - 29.999 1,920 1,310 2,130 3,130 4,130 4,549 4,549 4.720 4.920 5,110 5.110 5,110 $39,000 - 39.999 1.920 2.030 3.130 4,139 5,130 5.549 5.720 5.920 3.120 3,310 3,310 3,310 $40,009 - 59.999 1.379 3.430 4.540 5,540 3.390 7,299 . 7.490 7.390 7.399 . 3.930 3,930 3,030 $30,009 - 79.999 1,379 3,430 4.399 5.390 7.090 7.390 7,390 3,099 3,290 3.430 9.230 10,030 $30,009 - 99,999 2,929 3,319 5.099 3.290 7,499 3,090 3,290 3,499 9.470 19,439 11.230 12.039 $190,009 -124,999 2,940 3.330 5,110 3,310 7,510 3,430 9,439 19.430 11.430 12.420 13.520 14.329 $125,900 -149,999 2,040 3,330 5.110 7,039 9,930 10,430 11.430 12.530 13,339 15,170 13,270 17,379 $150,009 -174.999 2.339 4,950 7.030 9.039 11.039 12.730 14,930 15,339 13,330 17,920 19,029 20,129 $175,090 199,999 2,720 5.319 7.549 9.340 12.140 13,340 15,149 13,449 17.740 19.939 20.130 21.239 $200,900 249.999 2.970 5.339 3,240 10,540 12,340 14,540 ,1 5.349 17.140 13.440 19.739 29,330 21,930 $259,900 - 399.999 2.970 5.330 3,240 19,549 12.340 14.549 15.340 17.149 13.449 19.730 20.339 21,939 $499,009 - 449,999 2,970 5,330 3.249 19,540 12.349 14.549 15,340 17,149 13,450 19,940 21.249 22.549 $459,909 and over 3,149 3,290 3.310 11,310 13,310 15,710 17,210 13,710 29,210 21,790 23,000 24,399 Head of Household Higher Paying Job Lower Paying Job Annual Taxable Wage 81 Salary Annua'Taxab'e $19,000- $20,000- $30,000- $40,000- $50,000- $39,009 - $70,909- $30,000- $99,000- $100,000- $119,000- Wage 3 Salary 9.999 19.999 29,999 39,999 49,999 59.999 39.999 79,999 39,999 99,999 109,999 120,000 $0 - 9,999 $0 $339 $939 $1,029 $1,020 $1.920 $1.430 $1,370 $1 .379 $1,930 $2,040 $2,940 $10,900 - 19.999 330 1.929 2,130 2.220 2,220 2,330 3.330 4,070 4,139 4.330 4,440 4,440 $20,000 29,999 930 2.139 2,350 2,430 2,990 3.909 4,990 5.340 5,549 5,749 5.359 5,359 $39,000 - 39,999 1,020 2,220 2,430 2,930 3.939 4.939 3.940 3,339 3,330 7.030 7.140 7,140 $40,090 - 59.999 1,929 2,530 3,759 4.330 5.330 7,030 3.239 3,359 9.950 9.259 9,330 9,330 $30,990 - 79,999 1,370 4,070 5.319 3,390 7,309 9,000 19,200 19.730 10.939 11.130 11.530 12,330 $30,999 - 99.999 1.900 4.390 5.710 7.900 3,200 9,400 10.300 11.130 11.379 12,370 13.530 14.330 $100,000 - 124,999 2,040 4,440 5,350 7.149 3,340 9.549 11.330 12,759 13,750 14.750 15.770 13,379 $125,000 - 149,999 2,949 4.440 5.359 7,339 9.330 11,339 13,339 14.759 13.010 17.310 13.520 19.329 $150,090 - 174.999 2.040 5.030 7.230 9.330 11.339 13.430 15.739 17.430 13.739 20.039 21.279 22.379 $175,900 - 199.999 2.720 5.929 3.139 10,430 12,739 15.930 17.330 19.979 29,370 21.379 22.339 23.930 $290,009 - 249.999 2.970 3.470 3,999 11,370 13.379 15.979 13.270 19,939 21,230 22,539 23.770 24.379 $250,009 - 349,999 2,979 3,470 3,990 11 .379 13.379 15.979 13.270 19,939 21,230 22,539 23,779 24,370 $359,900 --449.999 2.979 3,470 3.990 11,370 13.379 15.979 13,279 19,930 21.239 22.530 23.909 25,209 $450,900 and over 3,140 3,349 9.530 12.140 14.340 17,140 19.349 21.530 23.039 24.530 25.949 27.240 7. Student Loan(s): Are you currently in default on Iguy outstanding student oan(s) made or guaranteed by the New York State Higher Education Services Corporation? Yes El No 8. Check the appropriate box to the right of each question: NOEI, A. Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds? Yes B. Have you ever resigned from any employment rather than face dismissal? Yes El No Er C. Have you ever been convicted of any crime (felony or misdemeanor)? Yes El No if D. Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any criminal charge? Yes No BK E. Are there any arrests or criminal accusations currently pending against you? Yes El No if you answered to any question(s) above. please use the space below to give speci?cs. If you elect not to provide an explanation, you may. be disquali?ed. or if such explanation is insuf?cient. you may be required to submit further information. Attach additional 81/2? 11" sheets if needed. None Of the above circumstances represents an automatic bar to employment. Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position(s) for which application is being made. 9. Education: - High School: Have you graduated from high school? Yes No El Issuing Governmental Authority: If Yes. name 8: location of high school: Mky?f?c #3 If High School Equivalency Diploma: Number: - Post High School Education: Name 8. Location of School asexu?e?i??k . No. of College Did You Type of Type of Course or Major Sub ect Credits Rec'd Graduate? Degree Rec'd TIE: 18?302?65'53 College. University, Professional or Technical School Other School or Special Courses - Partially Completed Course of Study: if credit is claimed for a partially completed college curriculum or course of study, attach a list of courses and credits completed. indicate how many credits or courses are required for graduation. - indicating Specific Coursework: lithe Examination or Position for which you are applying requires that you indicate speci?c course work. do so on an attached sheet. DO NOT send a transcript unless required for the Examination or Position for which you are applying. Required degrees and/or coursework will be veri?ed. 10. Licenses: if a license, certi?cate or other authorization to practice a trade or profession is a requirement for the position for which you are applying. please provide the following information: Name of Trade or Profession: Dates of Validation: From To City/State License No. Licensing Agency 11. Driver License: A Driver License may be a requirement for certain positions. Do you have a valid license to operate a motor vehici in New York State? Yes No License No. Class 3 Date of Expiration 12. Contacting Employers: For reference purposes. do you have any objections to our contacting present or past employers? Yes El No if yes. please explain: 13. Other Examinations: Have you previously taken any other examinations given by this department? Yes El if yes, list titles and dates: Meg?lgl ?ab 14. Performance Tests: If you have previously taken and passed any Putnam County Performance Test(s). indicate approximate dates below: STENO DATA ENTRY LANGUAGE ORAL OTHER (Describe) LANGUAGE it is the responsibility of the applicant to provide documentation of successful completion of performance tests. meanest-ts Ila-225m - mucus-1:2: rm PAGEZ 15. Employment Experience: Read The Following instructions Before Completing This Section: - Order: List most recent employment ?rst. - What to List: Any and all employment pertinent to the position or examination for which you are applying. - Professional Experience: Indicate whether or not professional experience occurred after your professional degree or coursework. - Volunteer/Unpaid Work: List volunteer or unpaid experience only if noted as qualifying experience on the examination announcement. Describe volunteerlunpaid work the same way as paid work. and write ?unpaid? in ?Earnings.? - Military Experience: If you have had military service that included experience pertinent to the position. list that experience. - Changes in Status: If your title or duties changed signi?cantly during your service in any one organization. list such changed status separately. - Duties: In the ?Duties? section. describe nature of work personally performed by you; estimate percentage of time spent on each type of work. - Supervisory Experience: For any supervisory role. state size and type of workforce supervised, as well as the extent of supervision by you. You are responsible for submitting an accurate. adequate, clear description of your experience Omissions or vagueness will NOT be interpreted in your favor If more space is needed, you may attach 8? 2" 11" sheet(s) of paper LENGTH OF EMPLOY ENT FROM TO ?01 l?i we ADDRESS lug? CITY. STATE EARNINGS (CIRCLE ONE) 5 TYPEOFBUSINESS YOUR EXACT TITLE SUPERVISORS MATTE SUPERVISORS TITLE DUTI . 4335 Saw. NO. or HOURS WORKED PER WEEK (EXCLUSIVE OF REASON FOR LEAVING LENGTH OF EMPLOY ENT FROM I Tom MO YR YR MO FIRM NAME . cw?vur ADDRESS ZMMEL CITY. STATE ,ufr EARNINGS (CIRCLE ONE) 5 WK MO YR TYPE OF BUSINESS YOUR EXACT TITLE NAME TITLE NO. OF HOURS WORKED PER WEEK OF REASON FOR LEAVING Kareem LENGTH or FROM TO Mo YR Mo YR FIRM NAME ADDRESS crrv. STETE EARNINGS ONE) 3 MO YR TYPE OF BUSINESS DUTIES: YOUR EXACT TITLE SUPERVISORS NAME TITLE NO. OF HOURS WORKED PER WEEK OF OVERTIME) REASON FOR LENGTH OF EMPLOYMENT FROM To MO YR MO YR FIRM NAME ADDRESS CITY. STATE ONE) EARNINGS 5 MO YR TYPE OF BUSINESS OUTES: YOUR EXACT TITLE SUPERVISORS NAME SUPERVISORS TITLE NO. OF HOURS WORKED PER WEEK (EXCLUSIVE OF OVERTIME) REASON FOR LEAVING Mum COW AN SWIM. Am ERPLOYER PAGE 3 The following Afl'innation And Authorization For Release OfPersonal information MUST be completed: AFFIRMATION AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION By my signature below. I hereby authorize the Putnam County Personnel Department. the County of Putnam. andior its respective departments. of?ces or agencies. andlor any municipality within Putnam County to request verbal or written veri?cation or records of any or all information contained herein. By signing this authorization. I give my consent for full and complete disclosure and review of all records concerning me. whether said records are of a public. private or con?dential nature. Further. I hereby release the Putnam County Personnel Department. Putnam County andlor its respective departments. of?ces or agencies. andlor any municipality within Putnam County. and their respective of?cers andlor employees from any and all liability which may be incurred as a result of collecting such information. By signing this authorization. I give my consent for a photocopy of the Application for Examination and/or Employment containing this release to be valid as an original thereof. even though said photocopy will not contain an original writing of my signature. I affirm that all statements made. on this application (including any attached paper) are true under the penalties of perjury. My signature below certi?es I have read and fully understano Authorization for Release of Personal Information." alas/9 Dine Applicant I Please indicate any ao . Itional 0mm relative to change of name. maiden name. use of an assumed name or nickname: APPLICATION COMPLETION CHECKLIST: DID YOU . . . Read, Sign and Date the Affirmation And Authorization For Release Of Personal information. above? Enter the Title and Number for the Examination. or the Title for the Position for which you are ?ling (top of application form)? El Enter your Social Security Number (In Section 1. Page 1 of this application form)? Include a Check or Money Order. for the correct ?ling fee. payable to Putnam County Personnel Department? El Include a Self-Addressed Stamped Envelope Business-size with appropriate amount of postage? It NEXT STEP YOU APPLY: Once your application materials are received. your application will be reviewed. If quali?ed. you vvili receive a Letter of Admission to the examination. if you are not qualified to take the examination. you will receive a letter and. in most cases. your ?ling fee will be refunded. important! Call the Putnam County Personnel Department .. (845) 225-0860 - if you have not received a letter within three (3) days of the date of the examination informing you whether or not you are to be admitted to the examination. DRUG 8: ALCOHOL TESTING: In accordance wIth Putnam County's comprehensive drug-free workplace policy and procedures, and commitment to maintain a safe. alcohol and drug-free work environment. yen may be required to submit to urinanalysis. breath andlor blood tests to be considered for County employment. EQUAL OPPORTUNITY: In compliance with the New York State Human Rights Law. which prohibits discrimination in employment based on age. race, creed. color. national origin. sexual onentation. military status. sex. disability. genetic predlsposition or carner status. manta! status OI criminal record, no part of this application form is intended or should be construed to express. directly or indIrectIy. any limitation. speci?cation or discrimination as to age. race. creed. color. national origin. sexual orientation, military status, sex, disability, genetic predisposition or carrier status. marital status or criminal record in connection with employment. Putnam County is an Equal Opportunity Affirmative Action employer APPLICANTS PLEASE BE ADVISED: Any and all statements made by the applicant in connection with Application for Examination and/or Employment are subject to veri?cation. including background investigation by prospective appointing authorities. Misrepresentations may constitute cause for disqualification or discharge. Pursuant to Section 210.45 of the New York State Penal Law, IT IS A CRIME PUNISHABLE AS A CLASS MISDEMEANOR TO KNOWINGLY MAKE A FALSE STATEMENT HEREIN. IMPORTANT APPLICANT INFORMATION ADMISSION TO EXAMINATION: Notice of admission to, or actual participation in. an examination does not necessarily mean that you have been found to fully meet the announced requirements. In some cases. applicants may be admitted to an examination conditionally. if conclusive prior review or veri?cation of the application has not been completed. or if further information has been requested but has not yet been received. Once conclusive review of the application is completed. and all further information has been received. it is possible that candidates who do not meet the requirements may be disquali?ed. and receive noti?cation of such disquali?cation after the examination has been held. Candidates who are disquali?ed subsequent to taking an examination will not be noti?ed of their score. CHANGE OF ADDRESS: Putnam County Personnel Department must receive written noti?cation of any change of address and/or telephone numberin order to communicate important examination andior employment information to you. Please note the number and title of examination in your letter. EXAMINATION ANNOUNCEMENT: Before completing an application. you must review the Examination Announcement for the examination for which you wish to apply. The Examination Announcement contains information about (1) the position for which the examination is testing. (2) the minimum quali?cations for that position (and for the examination}. (3) details about the subject of the examination. (4) last filing date. (5) filing fee. etc. VETERANS CREDITS: All claims for. and grants of. Veterans Credits are tentative and must be veri?ed through inspection of discharge papers and other related documents prior to the establishment of the eligible list. You will be advised as to which documents you must produce for such verification. All statements you make in support of your claim for additional credits are subject to investigation and substantiation by Putnam County. In the event of subsequent disclosure of any material misstatement or fraud in this claim. your appointment may be rescinded and you may be disquali?ed. 4001315 REMARKS: Use this space to provide any additional information. as necessary. If more Space is required. attach additional 11? sheet(s). DO NOT WRITE BELOW FOR CIVIL ONLY DATE RECEIVED: CI APPROVED I EI FEE WAIVER I Check Amount: TCheck No.: El DISAPPROVED El coumnonuh LOGGED BY PAGE4 Putnam County New York APPLICATION for EXAMINATION and/or EMPLOYMENT UI I 13?s.; .- EXAMINATION or POSITION TITLE EXAMINATION NUMBER This application is part of your examination: ANSWER ALL QUESTIONS NEATLY COMPLETELY. Use ink or type. Attach additional sheets if needed. Please retum completed application to: Putnam County Personnel Department. 110 Old Route Six. Building 3. Carmel. NY 10512 1. Name and Legal Residence - PLEASE NOTIFY PUTNAM COUNTY PERSONNEL came ruEIvr lN WRITING TELY IF ANY OF YOUR non CHANGES SOCIAL URITY NUMBER FIRST NAME 1.2? Ma 22> I #4157232. JVI/oro?fl ?aw/m STREET ADDRESS BOX NO TACCEP TABLE. Cl STATE ZIP CODE COUNTY 2. Mailing Address (if different from Legal Residence) LAST NAME Si REET ADDRESS BOX ACCEPTABLE) CITY STATE ZIP CODE 3. - Residence Information HOME TELEPHONE CODE BUSINESS TELEPHONE CODE NUMBER) E-MAIL ADDRESS (OPTIONAL) TOWN OR CITY OF RESIDENCE SCHOOL DISTRICT 4. Employment Eligibility: Do you have the legal right to accept employment in the United States? El Yes El No Are you under 18 years of age? El Yes No Proof of employment eligibility will be required upon employment. 5. Veterans Credits: If you are an active duty member during wartime. a wartime veteran, or a disabled wartime veteran of the Armed Forces of the United States. then you may be eligible to have extra credits added to your examination score.3 To claim Veterans Credits. active duty members of the Armed Forces must submit proof of active duty status 9. current military ID, military orders or other of?cial military document that substantiates active duty status); discharged andlor disabled veterans are required to submit a copy of their DD214 discharge papers. "Disabled Wartime Veteran" means that you are entitled to receive payments for a service-connected disability (rated at 10% or more) incurred during time of hostileaction or war. The "Armed Forces of the United States" means the Army. Navy. Marine Corps. Air Force or Coast Guard and all components thereof. or the National Guard when in the service of the United States pursuant to call as provided by law on a full-time. active duty basis other than active duty for training purposes. Please note that Veterans Credits can only be added to passing scores 4 "Active duty status" means full-lime active duty other than active duty for training purposes. - I am claiming credit as aIn) El Veteran Disabled Wartime Veteran Active Service Member - I have claimed Veterans Credits since January 1, 1951 for permanent appointment or promotion in New York State or a civil division of New York State Yes LI No - Check below to indicate your area(s) of service, and provide time periodic) of service: Time Period of Service (From Wt - To Mr) World War Public Health Service December 7. 1941 December 31. 1946 Korean Con?ict "June 27. 1950 January 31. 1955 US Public Health Service June 26. 1950 - July 3. I Vietnam Con?ict December 2g_1961 - May 7. 1975 Hostilities in Lebanon' . June 1. 1983 December 1. 1987 Hostilities in Grenada* October 23. 1983 - November 21. 1983 Hostilities in Panama? December 20. 1989- January 31. 1990 Persian Gulf Con?ict August2.1990? present 'lf you served during this conflict. to be eligible for Veterans Credits you must have received the Armed Forces Expeditionary Medal for service in Zone of Con?ict For more information about Veterans Credits. see any examination announcement. or contact the Putnam County Personnel Department (845) 2250860 6. Special Testing Arrangements: If you require Special testing arrangements due to religious observance, disability. an examination with another Civil Service Agency on the same date, or any other reason. please explain: PUTNAM COUNTY IS AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER PAGE 1 TOWN OF CARMEL Employment Application Please TYPE or PRINT clearly. This application must be completed and signed personally by the applicant. Each question must be answered in full. If answer is NO or NONE. indicate such. We appreciate your interest in employment with the Town of Carmel. We are an Equal Opportunity Employer. We consider all applications for all positions without regard to race. color. religion. gender. national origin. age. physical or mental disability. marital status. veteran status. sexual orientation. or any other legally protected status or class. Applicants requiring a reasonable accommodation to participate in the application andlor interviewing process are encouraged to contact the Town Supervisor?s Of?ce. This application for employment will be considered active for a period of time not to exceed 60 days. Any applicant wishing to be considered for employment beyond this time period should reapply by completing another employment application. Name (First. Middle. Last) E-Mail Address nouns: Psoc e? Address Pho (013' gross lei/a. 2 l3 - City Stat 31mm 1U 1/ Ase Position Applied For Salary or Hourly Wage Desired Are You Available to Work ErFuIl Time [3 Part Time Date Available Wile Temporary 3? 3 I I How were you referred to the Town of Carmel? [3 Newspaper El Internet Civil Service Job Posting Walk-in 2 Employee Referral E??her Are you currently employed? Mes No .m it yes. may we contact your employer to obtain employment information? was CI No 8 Have you ever filed an application or inte ed for employment with the Town of Carmel? B?Yes Cl No a If yes. give month and year Have you ever been employed with the Town of Carmel before? mes No If yes. give dates From [Di I 7! To Are you legally eligible for employment in the United States? B?Yes No Employment eligibility veri?cation will be required upon employment. if you are under 18 years of age. can you provide required proof of your eligibility to work? El Yes El No Not Applicable lf cu have been rovided with a 'ob descri ticn for the osition for which ou are a in . are you able to perform the Yes No essential functions of the position with or without reasonable accommodation? El Not Applicable Number of Years . Name and Location of School Completed Course of Study . (do not give dates) High School ?4 3 '2 or Preparatory School 5011College 3 .0 st LLI Other 9l05 Typing Speed: WPM Data Entry: ll Numeric Keystrokesli-lour it Alpha Keystrokesll-lour Computer Skills: List certi?cates. licenses (including driver license or am. endorsement) or professional achievements that would support your qualifications for employment: SKILLS It you are applying for a position which requires a Commercial Driver License. provide Driver License Number here: List any additional skills. technical or professional knowledge that you feel would support your application: List your previous four (4) employers whether or not they seem relevant to the position for which you are applying. Present ct Last-Employer Phone Number 985' ?230 7- Address;SP 578/23 5&6 Olly? i State Zip (057 Q. Employment Dates (Montleear) 7. I 3 Salary $52? Title of Position Name and Title of Supervisor Description of duties. responsibilities and signi?cant accomplishments Reason for leaving . m? ?Rift-A Next Name of Employerpvr Phone Number ??55 mag/m Employment Dates (MonthiYea ,7 ?rearm Title of Position a, Name and Title of Supervisor Description of duties. responsibilities and signi?cant accomplishments Reason for leaving Next Previous Employer Name of Employer ?ccz??v 7 e? Phone Number Address 2 :rq Citypl/ State/U 7 Zip Employment Dates (MonthiYear I a .7 522 Salary Title of Position Name and Title of Supervisor Description of duties. responsibilities and signi?cant accomplishments Reason for leaving 9I05 'Next?P'r??viou? Employer Name of Employer - Phone illumber Address City State Zip Employment Dates (Monthn'ear) Salary Title of Position Name and Tulle of Supervisor Description of duties. responsibilities and signi?cant accomplishments Reason for leaving Yes No US Military Branch Entry Date - Discharge Date - Training or Specialty ConVIctIon Record Stems Have you ever been convicted of andlor plead guilty to a felony? Yes Mo Have you been convicted of andlor plead guilty to a misdemeanor within the past ?ve years? El Yes If you answered 'yes' to either question, please provide additional information such as the crime(s), date(s)I court loo-lion. sentencing information. disposition oi sentence. and rehabilitation completed. Please note that a 'yes' answer to this question does not necessarily disqualify an applicant from employment with the Town. The nature of the violation and all other appropriate circumstances will be considered. The Town reserves the right to reject individuals for employment based on job-related convictions. Date CountyIState ConvictionlExplanation I certify that the facts contained on this application are true and complete to the best of my knowledge. I understand that any misrepresentation. is cause for voiding this application or termination of employment, if hired. authorize investigation of any information provided on this application form and understand that the Town of Carmel will conduct a background and consumer credit check. I also authorize investigatibn of my employment record and references, and release all parties from all liability for any damage that may result from iumishing same to you. i understand and agree that. if hired, my employment is for no de?nite period and may be terminated at any time. subject to applicable federal, state and/or local rules and regulations andlor collective bargaining agreements. For positions subject to the federal Department of Transportation regulations ieg?arding controlled substances and alcohol use testing (Part 382) i understand that as a condition for employment with the Town of Car a re-e plo ment controlled substance test will be required and alarms]!6 passed. Date: Signature of Applicant: [7y .- I .1 TOWN OF CARMEL EMPLOYMENT APPLICATION ONLY Candidate Name Civil Service Job'Title Competitive Civil Service Non-Competitive Job Classification Exempt Labor This application is for internal use only by the Town of Carmel and should not be filed with the Putnam County Personnel Department.