Department of Human Resources 600 Temple Avenue

Camarillo, CA 93010 (805) 445-8645

CERTIFICATED SUBSTITUTE TEACHER EMPLOYMENT PACKET 2019 -2020

POSITION FOR WHICH YOU ARE OFFERED ___________________________________________________

PERSONAL INFORMATION

Last Name First Name Middle Name Social Security Number

Mailing Address City State Zip Code

Home Phone Cell Phone Other Phone

E-mail Address:

EMERGENCY CONTACT INFORMATION

Contact Last Name Contact First Name Contact Middle Name

Mailing Address City State Zip Code

Home Phone Cell Phone Other Phone

E-mail Address:

Relationship:

Oath or Affirmation of Allegiance

Civil Defense Workers and Public Employees

(Section 3100, 3102 and 3103, Government Code of California)

PLEASANT VALLEY SCHOOL DISTRICT STATE OF CALIFORNIA ) ) ss. COUNTY OF VENTURA ) As an officer, member or employee of PLEASANT VALLEY SCHOOL DISTRICT I, ________________________________________________, do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter. I understand that as a public employee I am a disaster service worker pursuant to Government Code 3100 and 3102 and that I am required to take this oath before entering the duties of my employment. In the event of natural, manmade or war-caused emergencies which result in conditions of disaster or extreme peril to life, property and resources, I am subject to disaster services activities assigned to me by my supervisor. Employee’s Signature: ________________________________________________ Date: _____________________ ----------------------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY Subscribed and sworn to before me this __________ day of ___________________, 20 ___________. ______________________________ Certificated Human Resources Specialist

Pleasant Valley School District Department of Human Resources

600 Temple Avenue Camarillo, CA 93010

(805) 445-8645

Ethnic Designation

Name ______________________________________________________ Site: ______________________________________________________ Date: ______________________________

In accordance with the U. S. Department of Education (ED) final guidance published in the Federal Register, Vol. 72, No. 202, on Friday, October 19, 2007, (59265-59279) and the California Government Code Section 8310.5, the Pleasant Valley School is required to collect race and ethnicity data on all employees. Please make a selection from the list below. If you do not self-identify, the ED guidance states that third party observers must identify your race/ethnicity; therefore, one will be selected for you. INFORMATION ON THIS FORM IS CONFIDENTIAL AND MAY BE RELEASED ONLY WITH THE APPROVAL OF THE ASSISTANT SUPERINTENDENT OF HUMAN RESOURCES.

A. Ethnicity – Check one box Hispanic or Latino of any race Non-Hispanic or Latino of any race

B. Race – Check one box

White American Indian or Alaska Native

Asian

Chinese

Japanese

Korean

Vietnamese

Asian Indian

Laotian

Cambodian

Native Hawaiian or other Pacific Islander

Guamanian

Samoan

Filipino

Black or African American

Pleasant Valley School District Department of Human Resources

600 Temple Avenue Camarillo, CA 93010

(805) 445-8645

Freedom from Tuberculosis Verification

Last Name First Name Middle Name Date

Position

The above named person has:

A negative tuberculin skin test and is free from tuberculosis

OR

Received a chest x-ray and is free from active tuberculosis. Validation Signature: ____________________________________________________ Public Health Agency and/or Physician

PLEASANT VALLEY SCHOOL DISTRICT

DIRECT DEPOSIT AUTHORIZATION AGREEMENT

Employee Name: ______________________________________________________________________

PSL # ____________________ Department/Location _________________________________

Please Check One of the Following:

Send my Paycheck via U.S. Mail Begin Direct Deposit Change Information

Deposit Amount Net Check or $ ___________________ each pay period

COMPLETE THIS SECTION ONLY IF YOU HAVE CHOSEN DIRECT DEPOSIT

The numbers on the bottom of your check or on your savings account statement are used by the Payroll Department to electronically transfer your pay directly into your designated account.

Please check one account type to deposit your pay into: (Separate form per each type)

Checking ATTACH HERE A VOIDED CHECK OR CHECK COPY

Savings ATTACH HERE A COPY OF YOUR SAVINGS STATEMENT SHOWING THE ACCOUNT NUMBER ONLY

I hereby authorize Pleasant Valley School District (PVSD) and/or their agents to initiate electronic deposits and, as necessary, debit corrections to previous deposits to the above account.

I UNDERSTAND:

Direct deposit status is not activated until the month following a $0 test transaction. I must submit a new authorization form if I change my account (name, branch, etc.). Direct deposit status may be temporarily suspended if my wages are garnished.

I AGREE:

To hold harmless and indemnify PVSD and its officers and employees from any claim or demand of whatever nature for failure or delay in making deposits and/or correction to deposits as herein authorized.

To pay all fees incurred because of failure on my part to notify PVSD of any changes in my account information that would result in a return of my deposit.

This authorization replaces any previously made by me and is to remain in effect until changed or canceled by submission of a new Direct Deposit Authorization Agreement.

Employee's Signature ___________________________________ Date _______________________

TO BE COMPLETED BY THE PAYROLL DEPARTMENT

Routing Transit Number: ________________________________

Account Number _______________________________________ Checking Savings

4151 E-1 Rev. 09/05

Pleasant Valley School District Department of Business Services

600 Temple Avenue Camarillo, CA 93010

(805) 445-8645

.

E-Mail of Employee Check Stub

I understand I have an option to receive my paycheck stub via an e-mail address that I provide to the school district. I would like to change this option to:

Please begin Direct Deposit and e-mail my pay stub to my e-mail account (must complete and return the District’s Direct Deposit form).

I currently participate in Direct Deposit. Please e-mail my pay stub to my e-mail account provided below.

Name _________________________________________

E-mail address _________________________________________

Employee ID (PSL #) _________________________________________

School/Work site _________________________________________

You may access your pay stub by entering your six-digit Employee ID number which can be located on the top line of your pay stub next to your name.

Signature: _______________________________________ Date: ____________________ Payroll Representatives:

Last Names A-L x8635

Last Names M-Z x8634

VENTURA COUNTY SUPERINTENDENT OF SCHOOLS OFFICE RETIREMENT SYSTEM STATUS QUESTIONNAIRE

Social Security Number Last Name First Middle Birth Date

Date: _______________________ Signature: ________________________________________________________

Original: Ventura County Office of Education – SBAS Copy: School District Revised 01/02/2019

Are you currently or have you ever been a member of the Public Employees' Retirement System (CalPERS)? **

Yes No Retired, drawing a pension Inactive, funds remain on account Inactive, funds withdrawn

If yes: Name of Employer(s) _______________________________ Years of Service Credit ________

Are you still working for this employer? Yes No If Yes: Full-Time Part-Time

** If you have reciprocal rights with another agency, please complete the Member Reciprocal Self-Certification Form

Are you currently or have you ever been a member of the State Teachers' Retirement System (CalSTRS) Defined Benefit Plan?

Yes No Retired, drawing a pension Inactive, funds remain on account Inactive, funds withdrawn

If yes: Name of Employer(s) _______________________________ Years of Service Credit ________

Are you still working for this employer? Yes No If Yes: Full-Time Part-Time

Are you currently or have you ever been a member from another retirement system other than Ca/STRS or CalPERS? Yes No

If yes: Name of Retirement Plan (s):_________________________________ Separation Date: __________

EMPLOYER USE ONLY District Name Pleasant Valley – 608 Hire Date: _________________

Position Status F/T P/T Sub

Position Designation Classified Certificated Timecard Assignment

Position Title: _____________________________________

CalPERS Member Date: _______________________________________ Non-Member Yes

CalSTRS Member Date: _______________________________________ Non-Member Yes

Pleasant Valley School District Department of Business Services

600 Temple Avenue Camarillo, CA 93010

(805) 445-8645

Warrant Recipient Designation As provided in Section 53245 of the California Government Code, in the event of my death I hereby designate the following person to receive any and all warrants payable to me issued by the PLEASANT VALLEY SCHOOL DISTRICT.

Name of Designee _________________________________________________

Relationship _________________________________________________

Designee’s Address _________________________________________________ City _________________________ State _______ Zip ___________

This designation form cancels and replaces any designation previously signed for this purpose and shall remain in effect until canceled in my writing. It is expressly understood and agreed that the school district is not obligated to deliver said warrants to the person designated above unless the designated person claims such warrants from the school district and provides the school district with sufficient proof of identity. Employee Signature: _____________________________ Date: __________________________

Pleasant Valley School District

Review of Annual and Mandated Notices Certificated Employee

I, _____________________________________, as an employee in the Pleasant Valley School District, Printed Name

acknowledge that I have reviewed the information listed below on _____________________________. Date

_____________________________ Signature

Go to the Pleasant Valley School District Webpage, www.pleasantvalleysd.org/Page/3198 and review the following mandated documents. Hard copies of the Mandated Notices are also available in the Human Resources Office (600 Temple Avenue, Camarillo) and each school site’s office.

A. Child Abuse Educator’s Responsibilities

B. Sexual Molestation and Abuse Prevention Manual

C. Code of Ethics (Board Policy 4119.21/4219.21/4319.21-Professional Standards)

D. Fraud Alert – WeTip Hotline Brochure

E. Safety 1. PVSD Employee Safety Handbook – Safety Matters 2. Bloodborne Pathogen Exposure Control Plan 3. Instructions for Injured Worker and WellComp Brochure 4. Workplace Injury and Illness Prevention Plan

F. Sexual Harassment Handbook for Employees and Supervisors

G. Workers’ Compensation Information

Pleasant Valley School District Acceptable Use Agreement and Release of District from Liability

The Pleasant Valley School District authorizes District employees to use technology owned or otherwise provided by the District as necessary to fulfill the requirements of their position. The use of District technology is a privilege permitted at the District's discretion and is subject to the conditions and restrictions set forth in applicable Board policies, administrative regulations, and this Acceptable Use Agreement. The District reserves the right to suspend access at any time, without notice, for any reason. The District expects all employees to use technology responsibly in order to avoid potential problems and liability. The District may place reasonable restrictions on the sites, material, and/or information that employees may access through the system. The District makes no guarantee that the functions or services provided by or through the District will be without defect. In addition, the District is not responsible for financial obligations arising from unauthorized use of the system. Each employee who is authorized to use District technology shall sign this Acceptable Use Agreement as an indication that he/she has read and understands the agreement. Definitions: District technology includes, but is not limited to, computers, the District's computer network including servers and wireless computer networking technology (wi-fi), the Internet, email, USB drives, wireless access points (routers), tablet computers, smartphones and smart devices, telephones, cellular telephones, personal digital assistants, pagers, MP3 players, wearable technology, any wireless communication device including emergency radios, and/or future technological innovations, whether accessed on or off site or through District-owned or personally owned equipment or devices. Employee Obligations and Responsibilities: Employees are expected to use District technology safely, responsibly, and for work-related purposes. Any incidental personal use of District technology shall not interfere with District business and operations, the work and productivity of any District employee, or the safety and security of District technology. The District is not responsible for any loss or damage incurred by an employee as a result of his/her personal use of District technology. The employee in whose name District technology is issued is responsible for its proper use at all times. Employees shall not share their assigned online services account information, passwords, or other information used for identification and authorization purposes, and shall use the system only under the account to which they have been assigned. Employees shall not gain unauthorized access to the files or equipment of others, access electronic resources by using another person's name or electronic identification, or send anonymous electronic communications. Furthermore, employees shall not attempt to access any data, documents, emails, or programs in the District's system for which they do not have authorization. Employees are prohibited from using District technology for improper purposes, including, but not limited to, use of District technology to:

1. Access, post, display, or otherwise use material that is discriminatory, defamatory, obscene, sexually explicit, harassing, intimidating, threatening, or disruptive

2. Disclose or in any way cause to be disclosed confidential or sensitive District, employee, or student information without prior authorization from a supervisor

3. Engage in personal commercial or other for-profit activities without permission of the Superintendent or designee 4. Engage in unlawful use of District technology for political lobbying 5. Infringe on copyright, license, trademark, patent, or other intellectual property rights 6. Intentionally disrupt or harm District technology or other District operations (such as destroying District

equipment, placing a virus on District computers, adding or removing a computer program without permission, changing settings on shared computers)

7. Install unauthorized software 8. Engage in or promote unethical practices or violate any law or Board policy, administrative regulation, or District

practice

Privacy: Since the use of District technology is intended for use in conducting District business, no employee should have any expectation of privacy in any use of District technology. The District reserves the right to monitor and record all use of District technology, including, but not limited to, access to the Internet or social media, communications sent or received from District technology, or other uses within the jurisdiction of the District. Such monitoring/recording may occur at any time without prior notice for any legal purposes including, but not limited to, record retention and distribution and/or investigation of improper, illegal, or prohibited activity. Employees should be aware that, in most instances, their use of District technology (such as web searches or emails) cannot be erased or deleted. All passwords created for or used on any District technology are the sole property of the District. The creation or use of a password by an employee on District technology does not create a reasonable expectation of privacy. Personally Owned Devices: If an employee uses a personally owned device to access District technology or conduct District business, he/she shall abide by all applicable Board policies, administrative regulations, and this Acceptable Use Agreement. Any such use of a personally owned device may subject the contents of the device and any communications sent or received on the device to disclosure pursuant to a lawful subpoena or public records request. Records: Any electronically stored information generated or received by an employee which constitutes a District or student record shall be classified, retained, and destroyed in accordance with BP/AR 3580 - District Records, BP/AR 5125 - Student Records, or other applicable policies and regulations addressing the retention of District or student records. Reporting: If an employee becomes aware of any security problem (such as any compromise of the confidentiality of any login or account information) or misuse of District technology, he/she shall immediately report such information to the Superintendent or designee. Consequences for Violation: Violations of the law, Board policy, or this Acceptable Use Agreement may result in revocation of an employee's access to District technology and/or discipline, up to and including termination. In addition, violations of the law, Board policy, or this agreement may be reported to law enforcement agencies as appropriate. Employee Acknowledgment: I have received, read, understand, and agree to abide by this Acceptable Use Agreement, BP 4040 - Employee Use of Technology, and other applicable laws and District policies and regulations governing the use of District technology. I understand that there is no expectation of privacy when using District technology or when my personal electronic devices use District technology. I further understand that any violation may result in revocation of user privileges, disciplinary action, and/or appropriate legal action. I hereby release the District and its personnel from any and all claims and damages arising from my use of District technology or from the failure of any technology protection measures employed by the District. I understand that I shall have no expectation of privacy when using District computing equipment or technological resources, including but not limited to District provided email, file storage systems, and other communication and collaboration services. I also understand that any District or school records maintained on any of my personal devices or messages sent or received on a personal device that is being used to conduct business may be subject to disclosure, pursuant to a subpoena or other lawful request. I also understand that any electronically stored information generated or received by an employee which consists of District student records shall be classified, retained or destroyed in accordance with BP/AR 3580. As such, I understand this may include such data being removed from my personal device by District personnel. I also understand that in order to comply with state and federal student privacy laws, I will not allow people who are not District employees (such as parents, volunteers or students) to use or access my District issued computing device since confidential or protected student information or sensitive District email communications may be stored or access from there.

Name: Position:

School/Work Site:

Signature and Date

Board Approved: May 19, 2016

Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision

Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Date

Form SSA-1945 (01-2013) Destroy Prior Editions

Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment; • Get the employee’s signature on the form; and • Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at ofsm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (01-2013)

Today's Date (mm/dd/yyyy)

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

►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 presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family 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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR 2. Form I-94 Admission Number:

OR 3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

Signature of Employee

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status

List A OR List B AND List C 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 any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy)

Document Title Additional Information QR Code - Sections 2 & 3

Do Not Write In This Space Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: 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 (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) 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

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

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 (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A Documents that Establish

Both Identity and Employment Authorization OR

LIST B LIST C Documents that Establish Documents that Establish

Identity Employment Authorization AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

1. A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION

(3) VALID FOR WORK ONLY WITHDHS AUTHORIZATION

2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)

3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine- readable immigrant visa

2. ID card issued by federal, state or localgovernment agencies or entities,provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Employment Authorization Documentthat contains a photograph (FormI-766)

2. Certification of report of birth issuedby the Department of State (FormsDS-1350, FS-545, FS-240)

3. School ID card with a photograph5. For a nonimmigrant alien authorized

to work for a specific employerbecause of his or her status:a. Foreign passport; andb. Form I-94 or Form I-94A that has

the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long asthat period of endorsement hasnot yet expired and theproposed employment is not inconflict with any restrictions orlimitations identified on the form.

3. Original or certified copy of birthcertificate issued by a State,county, municipal authority, or territory of the United States bearing an official seal

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card4. Native American tribal document 7. U.S. Coast Guard Merchant Mariner

Card 5. U.S. Citizen ID Card (Form I-197)8. Native American tribal document 6. Identification Card for Use of

Resident Citizen in the UnitedStates (Form I-179)

9. Driver's license issued by a Canadiangovernment authority

For persons under age 18 who are unable to present a document

listed above:

7. Employment authorizationdocument issued by theDepartment of Homeland Security

6. Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with Form I-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMI

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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 W-4 (2019)

income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter "-0-" on lines E and F if you use Worksheet 1-6.

Deductions, Adjustments, and Additional Income Worksheet

Complete this worksheet to determine if you're able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You're not required to complete this worksheet or reduce your withholding if you don't wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don't need to complete any of the worksheets for Form W-4.

Two-Earners/Multiple Jobs Worksheet

Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you

don't complete this worksheet, you might have too little tax wlthheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Figure the total number of allowances you're entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero ("-0-'1 on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to make your wlthholding more accurate.

Tip: If you have a working spouse and your incomes are similar, you can check the "Married, but withhold at higher Single rate" box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the "Married, but wlthhold at higher Single rate" box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

Instructions for Employer Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary.

New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9,

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and 1 Oto comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn't previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs..gov/css!employers.

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows.

Box 8. Enter the employer's name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders.

Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee's first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer's service for at least 60 days, enter the rehire date.

Box 10. Enter the employer's employer identification number (EIN).

Pleasant Valley School District

Notification of Reasonable Assurance

To: Substitute Employee

From: Assistant Superintendent, Human Resources

Re: Notification of Reasonable Assurance

You are hereby notified that you have reasonable assurance to return to work as a substitute after the close of all holiday and recess periods during the 2018 / 2019 school year. Your services will not be needed during the recess periods unless you are notified in writing.

We are required by law to inform you that you may file an Unemployment Insurance (UI) claim during school recess periods. If you choose to file a claim, your entitlement to benefits will be determined by the Employment Development Department (EDD) and not by this school district. If you are not rehired after the recess period, you may be entitled to UI benefits retroactive to the date you filed an initial UI claim, if you are otherwise eligible and you filed a claim for each week, and if a claim for retroactive benefits is made within 30 days of the start of the next school year/term. If you have any questions concerning UI benefit eligibility, please contact the Employment Development Department at 800-300-5616 or visit their website at www.edd.ca.gov/eddhome.htm.

If you file a UI claim, the following address should be written on your claim form:

Pleasant Valley School District

C/O TALX UCeXpress

PO Box 23020

Oakland, CA 94623-2302

Signature_______________________________ Date__________________