h

FREDERIC M. UMANE PRESIDENT

ROSANNA VARGAS SECRETARY

JOSE MIGUEL ARAUJO JOHN FLATEAU, PH.D.

LISA GREYMARIA R. GUASTELLA

MICHAEL MICHEL MICHAEL A. RENDINO

ALAN SCHULKIN SIMON SHAMOUN

BOARD OF ELECTIONSIN

THE CITY OF NEW YORK 118-35 QUEENS BOULEVARD

111 FloorFOREST HILLS, NY 11375

(718) 730-6730www.vote.nyc.ny.us

MICHAEL J. RYAN EXECUTIVE DIRECTOR

DAWN SANDOW DEPUTY EXECUTIVE DIRECTOR

PAMELA GREEN PERKINS ADMINISTRATIVE MANAGER

GEORGEA KONTZAMANIS OPERATIONS MANAGER

BARBARA A. CONACCHIO CHIEF CLERK

COMMISSIONERS BART HAGGERTYDEPUTY CHIEF CLERK

Date,_ __

Dear Applicant:

Thank you for your interest in becoming a Student Election Day Poll Worker for the Board of Elections. Please make sure you have the following information and all forms when submitting your application. The information must be submitted by the April 28, 2017 deadline. Please use the following checklist of what is required:

I completed the application

I selected the shift and dates you would like to work

I signed the student agreement section

I had a school official fill out and sign the School Official Permission Section

I had my parent or guardian fill out and sign the Parental I Guardian Section

I filled out and signed the W-4 form

I filled out the IT-2104-E form (if you are tax exempt)

I have the Certification Affirmation signed by my Parent I Guardian and notarized

I filled out and completed a Voters Registration card

I have included a valid copy of my working papers

*If you have any questions please do not hesitate to call Anna Cicio or Sonya Roberts at 718 730-6730

Thank You;

Poll worker Department

17 Year Old Poll Student Worker Program

APPLICATIONThe Board of Elections in the City of New York is preparing for the Primary Election on Tuesday,

September 12, 2017 and the General Election on Tuesday, November 7, 2017, and is now accepting

applications for the 17 Year Old Student Poll Worker Program. The program promotes civic awareness

and educates high school students about the election process by allowing them to serve as poll workers

on Election Day. The program is supported by Education Law§ 3207-a, which states:

''Aschool district may permit an enrolled student, with the consent of such student's parent, guardian or

other person inparental relation, to serve as an election inspector orpoll clerk pursuant to section 3-400

of the election law (and other applicable provisions of this chapter and the labor law). For thepurposes

of attendance, any student so serving while school is in session shall be recorded as in attendance. "

Be 17years old by Election Day and get permission from school official and parent/ guardian.• Be a U.S. Citizen.• Bilingual students fluent in Spanish, Chinese, Korean, Hindi and Bengali are encouraged to apply!

Attend school in New York City. Have a GPA of at least 2.5 (B or 80).

• Register to be a "future voter."

Submit a completed application by April 28, 2017. Space is limited, so apply early!

Attend a mandatory four (4) hour training class. Classes are offered at various times on Saturdays and Sundays in July and August in each borough. You will be paid $100.00 for attending the class and passing the exam and working one election event.

On Election Day, if you are working the full day, report to your assigned polling place at 5:00AM and work until the polls close, you will be paid $200 for the full day. If you are assigned to the peak hour assistance shift, report to your assigned polling place at 3:00PM and work until the polling place closes, you will be paid $100.00.

• Earn up to $500.00 to work two elections and take the training class.Getjob experience for your resume: shows both colleges and potential employers you have a record of responsibility, teamwork and leadership.

• Fulfill school requirements: hours worked may count toward your school's community servtce graduation requirements.Learn about the election process frrst-hand.

CHECK YOUR EMAIL! Students who are accepted will receive a confirmation email indicating the date and time of their scheduled training class.

Depending on the order in which we receive your application, we will place you at a conveniently located polling place near your home. The sooner you apply, the closer to home we can place you. We will inform you by mail of your assignment.

We do our best to assign every student to a poll site close to home.

We understand that emergencies do arise. If you are no longer able to work on Election Day, please contact us immediately and speak to Anna Cicio (718-730-6781) or Sonya Roberts (718- 730-6725).

Poll worker checks will be mailed approximately six (6) weeks after Election Day.

.·

High School Poll Worker Program Application

Name of School:

Title (circle one): Mr. Ms. Home Address & Apt#:

Legal First Name: Social Security # (required by law for payroll):

Middle Name:

Last Name:

Home Phone:

Cell Phone

City, State, and Zip:

You MUST provide an email address below. Email will be used to inform you of acceptance to the program, and to confirm your Training Schedule and Polling Place assignment. Check your email frequently!

Email:

Date of Birth (Month!DayNear): __/__/

Grade 11 12 G.P.A:

- -/-·. ,·: _--;·= - - - ·.:-.= ·?-. =- -:- · -: -- :=

tie 1anguag= Il

.... -··-·-i

Mandarin Cantonese Korean Hindi Other

There are 2 Elections during 2017. Please indicate which election dates you would be available to work:

Primary Tuesday, September 12

*General Election Tuesday, November 7

*Training for the 2017-2018 Poll Worker Year begins in July. You would need to attend a training class and

pass the test in July or August to be certified to work for the Primary and General Elections.

In order to participate you must:• Be at least 17 years old by Election Day• Attend a public or private high school or college in NYC• Obtain permission from parent/guardian and school official• Be a U.S. Citizen• Have at least a 2.5 (B or 80) GPA• Register as a "future voter"

w

By submitting this application, I commit to serve on Election Day.

I select the full day shift which is from 5:00AM until the polls close: _

I select the peak hour assistance shift, which is from 3:OOPM until the polls close: _

I must attend a four (4) hour training class and pass a test prior to Election Day. It is my responsibility to get permission from my Dean of Students, Guidance Counselor or equivalent position so that I may serve at the polls on Election Day. I must also obtain permission from my parent/guardian. By signing this, I affirm that the facts set forth in it are true and complete. If I am accepted, any false statements, omissions, or misrepresentations made by me on this aoolication maY result in immediate dismissal.

Student Name

Date:

Your student would like to serve the community as a poll worker for The Board of Elections in the City ofNew York. Even though New York State law requires that students be given excused absences for serving in the election, they are still required to receive written permission from school administration to participate in this program. Your signature is required to ensure that the school understands that the student will be absent from classes, exams or other school activities on Election Day and in accordance with Section 3-400 of New York State Election Law and other applicable provisions of this chapter and the labor law, "for the purposes of attendance any student serving while school is in session shall be recorded as in attendance." Thank you for allowing your student to participate in the Board of Elections in The Citv of New York 17 Year old Student Poll Worker Pro!!ram!

School Official -· and Title:

Email (required)

The 17 Year Old Student Poll Worker Program allows students to provide an invaluable service to our community and gain critical insight into the election process while earning a stipend. Hours served may count toward a student's graduation requirement for community service hours and the leadership experience is a great addition to a resume or college application. Students assigned to the full day serve on Election Day, from 5:00AM- closing (poll site closing times vary). If they are assigned to a peak hour assistance shift they work 3:00PM- until closing. Students who complete Election Day duties will be paid $200.00 ($100 for peak hour shift), per Election Day worked, in addition to a paid training class. Because the Board of Elections in the City ofNew York requires parental/guardian permissionand does not assume responsibility for the minor, we ask you the parent/guardian to sign below to authorizeparticipation. By signing this application, you, the parent/guardian, affirm that the facts set forth in it are true and complete. Please call the Board of Elections in the City ofNew York at (718) 730-6730 and speak to Anna Cicio or

Roberts ifvou have

Parent/Guardian Name Street Address: City, State, Zip:

Work Phone & Cell Phone

Parent/Guardian Signature Date

MAIL:

Student Program Poll Worker Administrators

BOARD OF ELECTIONS IN THE CITY OF NEW YORK

118-35 Queens Blvd.

Forest Hills, NY

11375

This is a first-come-first-served program, space is limited!

Apply as early as possible to be sure you get assigned to the work location of your choice. Deadline for applications is April28, 2017.

Home address (number and street or rural route) 3D Single 0 Married 0 Married, but withhold at higher Single rate.Note: If married, but legaUy separated, or spouse is a nonresident alien, check the 'Singte• box.

City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call1-800-772-1213 for a replacement card. ..,.. 0 5

6 $

W1!l cla1m adru tments t<_> mcome; tax credits; or See Pub.505 ror information on converting your other leglslatlo.n enacted after we rel!lase it) wm be posteditemiZed deduct1ons, on h1s or her tax return. creditsintowithholdingallowances. at www.trs.gov/w4 .

.

Form W-4 (2017)Purpose. Complete Form W-4 so that youremployer can withhold the correct federal income tax irom yqur pay.CohSider completing a new Form W-4 each year and when your personal or fina ncial situation changes.Exemption from withholding. If you are exempt; complete only lines 1, 2, S, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15,2018.See Pub. 505, Tax Withholdingand Estimated Tax .Note: If another person can claim you as a dependent on his or her tax retum, you can't claim exemption from withholding if your total Income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions.Memployee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

The exceptions don't apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren't exempt, complete the Personal Allowances Worksheet below.The worksheets on page 2 further adjust your withholding allowances based on Itemized deductions, certain credits,adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However,you may claim fewer (or zero) allowances .For regular wages, withholding must be based on allowances you claimed and may not be a fiat amount or percentage of wages.Head of household. Generally ,you can claim head or household filing status on your tax return only If you are unmarried and pay more than 50% oftlie costs ol.keeplng up a home for yourself and your dependenl(s) or other qualifying lndlvlduals.See Pub. 501,E:xemptlons, Stan¢ard Deduction, and Filing Information, lor information.Tax credits. You can take projected tax credits into account In figuring your allowab le number of withholding allowances. Cre!1its for child or dependent

Nonwage income. If you have a large at11ount of nonwage Income, such as Interest or dividends , consider making estimated tiD\ ents using Form 1040-ES, Estimated Tax for IndiViduals.01/lerwise. you may owe additionaltax.If you have pension or annuity income, see Pub.505 to find out If you should adjust your withholding on Form W-4 or W-4P .Two earners or multiple jobs. If you have a working spouse or more than one job,llgure the total number of allowances you are entitled to claim on all jobs using worksheets from only one FormW-4.Your withholding usually wlll be most accurat e when all allowances are clalmed on the Form W-4 for the highest paying job and zero allowances are claimed on the others.S e Pub. 505 for details.Nonresident alien.If you are a nonresident allen, see Notice 1392,Supplemental Form W-4 Instructions for Nof)resldent Aliens, before completing this form.Check your withho lding. After your Form W-4 takes effeot, use Pub. 505 to see how·the amount you are having withheld compares to your projected total taxfor 2017. See Pub. 505! especially if your earningsexceed $130,000 (Sing e) orS160,000 (Married).

• Is blind, or

care expenses andihe chlld tax cred may be claimed Future developments. Information about any future

. . . . . usingitie Personal Allowan.ces Worksheet below. developments affecting Form W-4 ( uch as

Personal Allowances Work sheet (Keep for your records.)A Enter "1" for yourself if no one else can claim you as a dependent . A

• You're single and have only one job; or }B Enter "1" if:

{• You're married, have only one job, and your spouse doesn't work; or B• Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.

c Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-" may help you avoid having too little tax withheld .) . c

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . D E Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) E F Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married),enter "2" for each eligible child; then less' "1". !f you have two to four eligible children or less "2" if you have five or more eligible children.

• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. GH Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ..,.. H

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the DeductionsFor accuracy,\ complete allworksheets that apply.

and Adjustments Worksheet on page 2.• If you are sin'gle and have more than one job or are married and you and your spouse both work and the

combinedearnings from ail jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2to avoid having too little tax withheld.• If neither of the above situations applies, stDp here and enter the number from line H on line 5 of Fonn W-4 below.

-------------------- Separate here and give Form W-4 to your employer. Keep the top part for your records. - ------·----------

Form W•4 Employee's Withholding Allowance Certificate

Department of the Treasury

OMB No. 1545-0074

..,.. Whether you are entitled to claim a certain number of allowances or exemption from withholding Is @17Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.I Last name

1 Your first name and middle lnllial

Your social security number1 2

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)6 Additional amount, if any, you want withheld from each paycheck

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

L..;. ••

I :.... • •-.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and . -

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. J •

If you meet both conditions, write "Exempt" here . ..,.. I 1 lUnder penaltfes of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee's signature(This form is not valid unless you sign it.) .,_ Date.,.

8 Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) I 10 Employer identification number (EJN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat.No.102200 Form W-4 (2017)

Form W-4 (2017) Page2Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adju9tments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying hOIT\e mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce

I your itemized deductions if your income is over $313,800 and you're married filing jointly or you're a qualifying widow(er); $287,650if you're head of household; $261 ,500 if you're single, not head of household and not a qualifying widow(er); or $156,900 if you'remarried filing separately. See Pub. 505 for details . 1 $

$12,700 if married filing jointly or qualifying widow(er)

$6,350 if single or married filing separately3 Subtract line 2 from line 1. If z ro or less, enter "-0-" 3 $ 4 Enter an estimate of your 2017 adjustments to income and any aqditional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . 5 $ 6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7 $ a Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction a 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/JYiultiple Jobs Worksheet,also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W.-4, line 5, page 1 10Two-Earners/Multiple Jobs Worksheet (See Two earners or multiplejobs on paQe 1.)

Note: Use this worksheet only if the instructions under line H on page 1direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However,

if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter morethan "3" 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter"-D-j and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . 3

Note: If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet 4 5 Enter the number from line 1 of this worksheet 5 6 Subtract line 5 from line 4 . 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $ a Multiply line 7 by line 6 and enter the result here. This is the adqitional annual withholding needed a $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every

two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017.

Table 1 Table 2Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST paying jQb are-

Enter on line2 above

If wages from LOWEST paying job are-

Enteron line2 above

If wages from HIGHEST paying job are-

Enter online 7 above

If wages from HIGHEST paying job are-

Enter online 7above

$0 - $7,000 0 $0 - $8,000 0 $0 - $75,000 $610 $0 - $38,000 $6107,001 - 14.000 1 a,001 - 16,000 1 75,001 - 135,000 1,010 3a,001 - a5,000 1,010

14,001 - 22,000 2 16,001 - 26,000 2 135,001 - 205,000 1,130 a5.001 - 185,000 1,13022,001 - 27.000 3 26,001 - 34,000 3 205,001 - 360.000 1,340 185.001 - 400,000 1,34027,001 - 35,000 4 34,001 - 44,000 4 360,001 - 405,000 1,420 400,001 and over 1,60035,001 - 44.000 5 44,001 - 70,000 5 405,001 and over 1,60044.001 - 55.000 6 70,001 - a5,000 655,001 - 65.000 7 a5,001 - 110,000 765.001 - 75,000 a 110,001 - 125,000 a75.001 - 80,000 9 125,001 - 140,000 9ao,001 - 95,000 10 140,001 and over 1095,001 - 115,000 11

115,001 - 130.000 12130,001 - 140.000 13140.001 - 150,000 14150,001 and over 15

Privacy Act and Paperwork Reduction Act Notice.We ask for the information on this form to cany out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(1)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding .Failure to provide a properly completed form win result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses ofthis information include giving it to the Department of Justice for civil and criminal litigation; to cities.states, the District of Columbia,and U.S.corrunonwealths and possessions for use inadministeting their tax laws;and to the Department of Health and Human Selvices for use in the National Directory of New Hires.We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, 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 Paperwork Reduction Act unless the form displays a valid OMB control number.Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, 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 retum.

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.

EWRK

2 7 TE

Department of Taxation and Finance IT 2104 ECertificate of Exemption from Withholding - -New York State • New York City • Yonkers This certificate will expire on April 30, 2018.

To claim exemption from withholding for New York State personal income tax (and New York City and Yonkers personal income tax, if applicable), you must meet the conditions in either Group A or Group B:Group A

• you must be under age 18, or over age 65, or a full-time student under age 25; and• you did not have a New York income tax liability for 2016; ando you do not expect to have a New York income tax liability for 2017 (for this purpose, you have a tax liability if your return

shows tax before the allowance of any credit for income tax withheld) .Group B

• you meet the conditions set forth under the Servicemembers Civil Relief Act (SCRA), as amended by the Military Spouses Residency Relief Act. See Military spouses.

If you do not meet all of the conditions in either Group A or Group B above, stop; you cannot claim exemption from withholding (see Note below).

First name and middle initial Last name Social security number Filing status: Mark an X in only one box

A SingleD B Married D

C Qualifying widow(er) with dependent child, or head of household with

qualifying person.............. D

Mailing address (number and street or PO box)

City, village , or post office

Apartment number Date of birth (mmddyyyy)

State ZIP code

Are you a full-time student? ......Yes D NoD I Are you a military spouse exempt under the SCRA? ..... Yes D NoD

I certify that the information on this form is correct and that, for the year 2017, I expect to qualify for exemption from withholding of New York State

income taxunder section 671(a)(3) of the Tax Law or under the SCRA. Iwill notify my employer within 10 days of any change requiring revocation of the exemption fromwithholding as explained in the instructions .Employee's signature (give the complete d certificate to your employer) I Date

Employer: complete this section only if you must send a copy of this form to the NYS Tax Department (see instructions).Employer name and address Employer identification number

Mark an X in the box if a newly hired employee or a rehired employee ....... D ,-----------.First date employee performed services for pay (mmddyyyy) (see instructions) :

Are dependent health insurance benefits available for this employee? .............................. Yes D No DIf Yes, enter the date the employee qualifies (mmddyyyy) : ........ L_ _j

EmployeeInstructions

Yonkers personal income tax, if applicable) from your wages. Do

Who qualifies- To claim exemption from withholding for New York State personal income tax (and New York City and Yonkerspersonal income tax, if applicable), you must meet the conditions in either Group A or Group 8:

Group Ao you must be under age 18, or over age 65, or a full-time student

under age 25; ando you did not have a New York income tax liability for 2016; and• you do not expect to have a New York income tax liability

for 2017 (for this purpose, you have a tax liability if your return shows tax before the allowance of any credit for income tax withheld).

Group B• you meet the conditions set forth under the Servicemembers

Civil Relief Act (SCRA) , as amended by the Military Spouses Residency Relief Act. See Military spouses.

If you meet the conditions in Group A or Group B, file this certificate,

Form IT-2104-E, with your employer. Otherwise, your employer must withhold New York State income tax (and New York City and

not send this certificate to the Tax Department.

Generally, as a resident, you are required to file a New York State income tax return if you are required to file a federal income tax return, or if your federal adjusted gross income plus your NewYork additions is more than $4,000, regardless of your filing status. However, if you are single and can be claimed as a dependent on another person's federal return, you must file a New York State return if your federal adjusted gross income plus your New York additions is more than $3,100.

If you are a nonresident and have income from New York sources , you must file a New York return if the sum of your federal adjusted gross income and New York additions to income is more than your New York standard deduction.

A penalty of $500 may be imposed for furnishing false information that decreases your withholding amount.

Note: If you do not qualify for exemption, or you want New York State, New York City, or Yonkers personal income tax withheld from your pay, file Form IT-2104, Employee's Withholding Allowance Certificate, with your employer. Follow the instructionson Form IT-2104 to determine the correct number of allowances to claim for withholding tax purposes.

IT-2104-E (2017) (back)

When to claim exemption from withholding - File this certificate with your employer if you meet the conditions listed in Group A or Group B above. You must file a new certificate each year if you wish to continue to claim the exemption.

Military spouses- Under the Servicemembers Civil Relief Act (SCRA), as amended by the Military Spouses Residency Relief Act, you may be exempt from New York income tax (and New York City and Yonkers personal income tax , if applicable) on your wages if:1) your spouse is a member of the armed forces present in New York in compliance with military orders; 2) you are present in New York solely to be with your spouse; and 3) you are domiciled in another state.

Liability for estimated tax - If, as a result of this exemption certificate, your employer does not withhold income tax from your wages and you later fail to qualify for exemption from tax, you may be ·required to pay estimated tax and be subject to penalty if it is not paid. For further information, see Form IT-2105, Estimated Tax Payment Voucher for Individuals.

Multiple employers -If you have more than one employer, you may claim exemption from withholding with each employer as long as your total expected income will not cause you to incur a New York income tax liability for the year 2017 and you had no liability for 2016.

Revocation by employee- You must revoke this exemption certificate (1) within 10 days from the day you expect to incur a New York income tax liability for the year 2017, (2) on or before December 1, 2017, if you expect to incur a tax liability for 2018, or(3) when you no longer qualify for exemption under the SCRA.

If you are required to revoke this certificate, if you no longer meet the age requirements for claiming exemption, or if you want income tax withheld from your pay (because, for example, you expect your income to exceed $3,100), you must file Form IT-2104, Employee 's Withholding Allowance Certificate, with your employer. Follow the instructions on Form IT-2104 to determine the correct number of allowances to claim for withholding tax purposes.

Filing status- Mark an X in one box on Form IT-2104-E that shows your present filing status for federal purposes.

EmployerKeep this certificate with your records. If an employee who claims exemption from withholding on Form IT-2104-E usually earns more than $200 per week, you must send a copy of that employee's Form IT-2104-E to: NYS Tax Department, IncomeTax Audit Administrator, Withholding Certificate Coordinator, WA Harriman Campus, Albany NY 12227-0865.See Publication 55, Designated Private Delivery Services, if not usingU.S. Mail. If the employee is also a new hire or rehire, see Notebelow.

The Tax Department will not accept this form if it is incomplete. We will review these certificates and notify you of any adjustments that must be made.

Due dates for sending certificates received from employees who claim exemption and earn more than $200 per week are: Quarter Due date Quarter Due dateJanuary- March April 30 July- September October 31 April- June July 31 October- December January 31

Revocation by employer- You must revoke this exemption within 10 days if, on any day during the calendar year, the date of birth stated on the certificate filed by the employee indicates the employee no longer meets the age requirements for exemption . The revocation must be in the form of a written notice to the employee.

New hires and rehires- Mark an X in the box if you are submitting a copy of this form to comply with New York State's New Hire Reporting Program. A newly hired or rehired employee means an employee previously not employed by you, or previously employed by you but separated from such employment for 60 or more consecutive days. Enter the first day any services are performedfor which the employee will be paid wages, commissions , tips and any other type of compensation. For services based solely on commissions, this is the first day an employee working for commissions is eligible to earn commissions. Also, mark an X inthe Yes or No box indicating if dependent health insurance benefitsare available to this employee . If Yes, enter the date the employeequalifies for coverage. Mail the completed form, within 20 days of hiring, to:

NYS TAX DEPARTMENT NEW HIRE NOTIFICATION PO BOX 15119ALBANY NY 12212-5119

To report newly hired or rehired employees online go towww.nynewhire.com.

Note: If the newly hired or rehired employee has also claimed exemption from withholding but usually earns more than $200 per week, mail Form IT-2104-E to the Tax Department at the New Hire Notification address above.

Privacy notificationSee our website or Publication 54, Privacy Notification .

Need help?• Information and forms are available on the Tax Department's website (at www.tax.ny.gov).• For help completing this form, employees may call (518) 457-5181 , and employers may call (518) 485-6654.

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OFFICE OF PAYROLL ADMINISTRATIONOne Centre Street, Room 200N, New Yorlc, New Yorlc 10007

ROY MOGILANSKI

Executive Director

WITmiOLDING CERTIFICATION AFFIRMATION

State of New York } SS:

County of _ }

I, being duly sworn, depose and say:

1. My Social Security Number is-------------'

2. The withholding tax certification(s) form(s) W-4 , IT-2104, or IT-2104E presented by me to the City of New York for processing are the best of my knowledge truthful and the allowances or exemptions claimed are valid.

3. These certificates are not being filed for the purpose of evading the lawful imposition of income tax upon me by the Federal, State, or City governments.

4. I understand that (a) filing a false or fraudulent certificate may result in civil and criminal prosecution and disciplinary action including, but not limited to, termination of employment; (b) I may voluntarily provide substantiation for the withholding allowances claimed or the basis for my claim of total exemptions from tax;(c) that all W-4 withholding certificates in which more than ten (10) allowances are claimed or total exemption is claimed will be forwarded to the Internal Revenue Service; and (d) all IT-2104s in which more than 14 allowances are claimed and all IT-2104Es in which total exemption is claimed will be forwarded tothe New York State Department of Taxation and Finance.

Date Employee's Signature

Sworn to before me this day of--------

Notary Public

MAYOR BILL DEBLASIO COMPTROLLER SCOTI M. STRINGER

DEADLINE- April28, 2017

APPLICATION CHECKLIST

• Did you complete all entries on the High School Poll Worker Application?• Did you select the shift you want to work?• Did you sign the Student Agreement section?• Did you have your school official fill out and sign the School Official

Permission section?• Did your parent or guardian completely fill in the Parent/Guardian

Permission section?

BRING THE FOLLOWING FORMS TO TRAINING CLASS:

• Did you fill out the W-4 Form?• Did you fill out the IT-2104-E form if you are tax exempt?• Did you have the Certification Affirmation signed by your parent or

guardian and notarized?• Did you apply for Working Papers?