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City of Atlanta New Hire Packet Instructions
*Please complete and return the following documents, within 5 days, to conclude your on-boarding process*
General Information: You do not have an employee number yet. Anywhere this is asked may be left blank. O.C.G.A. 50-36-1(e)(2) Affidavit:
• On the line before type of health benefit please write “Health Benefits”
• On the line before name of government entity please write “City of Atlanta”
• Your secure and verifiable document provided with the affidavit should be a driver’s license, birth certificate or passport. Whichever you use will be what you write on that line.
• We will notarize this page.
• Please include a copy of your ID with this page upon return Request for Outside Employment:
• Please complete section 1 AND either section 2 OR 3; Sign accordingly. Complete the W-4 Tax Form Complete State of Georgia’s Employee Withholding Allowance Certificate
• For section 3 – Marital Status, only one (1) option can be used (A-E). Write corresponding letter and total allowances in section 7.
Insurance Coverage Form (If applicable)
• Electing to receive benefits immediately means you pay 100% of the premium fees for the first 90 days.
• Electing to wait 90 days means the city will cover 70% of the costs and take the remaining 30% out of your bi-weekly check beginning after the 90-day period.
Health Insurance Enrollment Form (If applicable)
• Please provide a copy of your marriage certificate to add coverage for a spouse.
• Please provide copies of children’s birth certificates to add coverage for children.
Group Life Insurance Enrollment Form (If applicable)
• It is REQUIRED to list at least one (1) primary beneficiary. General Employees’ Pension Fund (If applicable)
• Please fill out all the lines in the top box.
• Beneficiaries include spouse, children or domestic partner
• If the above relationships do not apply to you, please list a Refund Designee with their social security number at the bottom of the page.
• Sign and date Voya Pension Form
• Complete sections 2 and 5
• Complete Beneficiary Information with at least one (1) beneficiary. Direct Deposit Form
• Provide a copy of a voided check or direct deposit slip from the bank
Transit Card Form
• This form is optional. If you do not want the discounted transit card, please leave this page blank.
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N Page 1 of 3
►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
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
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:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
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.)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
LISTS OF ACCEPTABLE DOCUMENTSAll 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
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. 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 as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
7. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 07/17/17 N
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.
O.C.G.A. § 50-36-1(e)(2) Affidavit
By executing this affidavit under oath, as an applicant for a(n) ____________________
[type of public benefit], as referenced in O.C.G.A. § 50-36-1, from
_________________________ [name of government entity], the undersigned applicant
verifies one of the following with respect to my application for a public benefit:
1) _________ I am a United States citizen.
2) _________ I am a legal permanent resident of the United States.
3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and
Nationality Act with an alien number issued by the Department of
Homeland Security or other federal immigration agency.
My alien number issued by the Department of Homeland Security or other
federal immigration agency is:____________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older
and has provided at least one secure and verifiable document, as required by O.C.G.A.
§ 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can best be classified as:
_______________________________________________________________________.
In making the above representation under oath, I understand that any person who
knowingly and willfully makes a false, fictitious, or fraudulent statement or
representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and
face criminal penalties as allowed by such criminal statute.
Executed in ___________________ (city), __________________(state).
____________________________________
Signature of Applicant
____________________________________
Printed Name of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
___ DAY OF ___________, 20____
_________________________
NOTARY PUBLIC
My Commission Expires:
City of Atlanta
Employee Ethics Pledge
To assure public confidence, I am committed to promoting integrity in city government by placing the best interest of the City above my own financial or personal interests. 1. I will not use my position to secure special advantage or benefit for myself, my family, or other
persons and will seek to avoid situations that may give the perception of an impropriety. When uncertain about the right thing to do, I will seek guidance from my supervisor, the Ethics Office, or the Board of Ethics.
2. I will not solicit or accept money or a personal gift, meal, ticket, travel, entertainment, or other thing of
value from a prohibited source unless the gift falls within one of the 11 exceptions to the ban on gratuities.
3. I will use public property, vehicles, equipment, labor, and services only for official city business and
not request or allow its use for the private advantage of any individual or private entity. 4. I will not knowingly vote or participate in any matter in which I have a financial or personal interest
and will not participate in any bid, proposal, contract, or subcontract if I or my immediate family, employer, prospective employer, or a related business entity have a financial or personal interest.
5. I will refrain from working for any business or entering into any contract to provide goods and services
to the City of Atlanta unless the business is conducted through a sealed competitive bid process. 6. I will not represent any individual or private interest for pay before any city agency or in matters
adverse to the City while working as a city employee.
7. I will not hold investments, engage in outside employment, or be paid to render services for a private interest when the work is adverse to and incompatible with the proper discharge of my official duties. I will seek permission from my department head for any extra job that I have.
8. I agree that I will not disclose any confidential information that I learn in my official capacity as a city
employee. 9. I agree to file my annual financial disclosure statement by the filing deadline, if I am identified as a
required filer, and file any report on conflicts of interest, travel, or gifts to the City when appropriate.
10. I understand that the City has a one-year cooling-off period and agree that for one year after leaving city employment I will not appear before any city agency for pay or be paid to work on any matter in which I was directly concerned, personally participated, or actively considered, or about which I acquired knowledge while with the City.
I acknowledge that I have received and read this pledge and agree to abide by the City’s Code of Ethics. I understand that the most current copy of the Code of Ethics is at the Board of Ethics’ website and that I can seek advice from the Ethics Office or Board of Ethics if I need guidance on how to avoid a conflict of interest and comply with the Code of Ethics. ____________________________________________________________________________________ Print Name Date ____________________________________________________________________________________ Signature Department 8/13/2010
CITY OF ATLANTA
KEISHA LANCE BOTTOMS
MAYOR 68 MITCHELL STREET, S.W. • ATLANTA, GEORGIA 30303-0306
TEL: 404-330-6360 • FAX: 404-658-6892
DEPARTMENT OF HUMAN RESOURCES
JEFFREY B. NORMAN
INTERIM COMMISSIONER
MEMORANDUM
TO: Jeffrey B. Norman, Interim Commissioner
Department of Human Resources
FROM: ______________________________ ____________________________
Employee Name Department
_______________________________ _____________________________ Classification Title Position Number
RE: EMPLOYEE ACCEPTANCE OF UNCLASSIFIED POSITION
This letter is to formally acknowledge that I understand I am accepting a position in the “Unclassified
Service” of Atlanta City Government, effective ________________________________.
Month/Day/Year
I understand that I serve in this position at the pleasure of the appointing authority.
To this attest with my signature this day.
___________________________________ _________________________
Signature Date
____________________________________
Social Security Number
CITY OF ATLANTA
KEISHA LANCE BOTTOMS
MAYOR 68 MITCHELL STREET, S.W. • ATLANTA, GEORGIA 30303-0306
TEL: 404-330-6360 • FAX: 404-658-6892
DEPARTMENT OF HUMAN RESOURCES
JEFFREY B. NORMAN
INTERIM COMMISSIONER This Agreement is made between ____________________________ (“EMPLOYEE”) and The City of
Atlanta (“The City”), on ___________________________, 20 ___.
EMPLOYEE will perform services for The City which may require The City to disclose confidential and
proprietary information (“Confidential Information”) to EMPLOYEE. (Confidential Information is any
information of any kind, nature, or description concerning any matters affecting or relating to Employee’s
and/or Retiree’s services for The City, the business or operations of The City, and/or the products,
drawings, plans, processes, or other data of The City). Accordingly, to protect Confidential Information
that will be disclosed to EMPLOYEE, the EMPLOYEE agrees as follows.
A EMPLOYEE will hold the Confidential Information received from The City in strict confidence and
prevent disclosure to others.
B. EMPLOYEE will not disclose or divulge either directly or indirectly the Confidential Information to
others unless first authorized to do so in writing by The City pursuant to Open Records requirements.
C. EMPLOYEE will not reproduce the Confidential Information nor use this information commercially or
for any purpose other than the performance of his/her duties for The City.
D. EMPLOYEE will, upon the request of The City or upon termination of his/her relationship with The
City, deliver to The City any drawings, notes, documents, equipment, and materials received from The
City or originating from its activities for The City.
E. The City reserves the right to take disciplinary action, up to and including termination for violations of
this agreement.
EMPLOYEE represents and warrants that s/he is not under any preexisting obligations inconsistent with
the provisions of this Agreement.
Signing below signifies that the EMPLOYEE agrees to the terms and conditions of the agreement stated
above.
The City of Atlanta Designee EMPLOYEE
__________________________________ ________________________________
Human Resources Signature Employee Signature
Date: ______________________________ Date: ___________________________
(See Other Side For Code)1
Name of Department or Agency_______________________
Request for Permission to Perform Outside Employment (Please type or print)
Part I: Employee Information
Name (print)________________________________________ Employee ID ______________________
Job Classification________________________________Bureau/Division ________________________
Part 2: No Outside Job (to be completed by employees who are not engaged in outside employment)
I am not employed in any outside employment at this time and understand that I must file a writtenrequest with my department head before performing outside employment.
Signature of Employee_______________________________________Date ______________________
Part 3: Outside Job (to be completed by employees who seek permission to perform an outside job) �
Name of Employer___________________________________Supervisor_________________________
Business Address _____________________________________________________________________
Telephone _________________________ Type of Business ___________________________________
Duties _____________________________________________________________________________
___________________________________________________________________________________
Days/Dates of work__________________________________Hours per week ____________________
Daily start/end time __________/____________Length of job ___indefinitely #___ weeks #___ months
Location where you will work ____________________________________________________________
I have reviewed the City of Atlanta’s policies on outside employment on page 2 and agree that myoutside job will not interfere with the performance of my official duties, involve a conflict ofinterest, or involve the use of city records or equipment. I understand that my department headhas the right to approve or deny this request.
___________________________________________________________________________________Signature of Employee Date
Part 4: APPROVED BY (if denied, attach reasons & include relevant section number from back):
□ Approved □ Denied__________________________________________________________________Immediate Supervisor Date
□ Approved □ Denied__________________________________________________________________ Bureau Director or Division Head Date
□ Approved □ Denied__________________________________________________________________Department Head Date
2
Relevant Provisions in the City’s Code of Ordinances Related to Outside Employment (including self-employment)
Sec. 114-436. Definitions and conditions.Outside employment shall constitute any paid employment of an employee which is in
addition to such employee’s employment with the city. As related to one’s employment with thecity, outside employment shall only be allowed under the following conditions:
(1) Such employment shall not interfere with or affect the performance of theemployee’s duties.(2) Such employment shall not involve a conflict of interest or a conflict with theemployee’s duties.(3) Such employment shall not involve the performance of duties which the employeeshould perform as part of such employee’s employment with the city.(4) Such employment shall not occur during the employee’s regular or assigned workinghours, unless the employee is on either annual leave, compensatory leave or leavewithout pay.(5) No employee engaging in outside employment shall work at such outsideemployment for a longer period of time than that stated in the employee’s request forpermission to engage in such employment.(6) Such employment shall be conditioned upon the employee’s being relievedimmediately for the return to and performance of the duties of such employee’semployment with the city, if such employee should be called for emergency service.(7) Such employment shall not involve the use of records or equipment of the city.Police uniforms shall not be considered equipment in the meaning of this subsection.
Sec. 2-811. Use of property & services.No official or employee shall request, use or permit the use of any publicly owned or
publicly support property, vehicle, equipment, labor or service for the private advantage of suchofficial or employee or any other person or private entity.
Sec. 2-820. Incompatible interests.(a) No official or employee shall invest or hold any investment, directly or indirectly, in
any financial, business, commercial or other private transaction, which creates a conflict withand adversely affects official duties of the official or employee to the detriment of the city.
(b) No official or employee shall engage in or accept private employment or renderservices for private interests when such employment or service is adverse to and incompatiblewith the proper discharge of official duties of the official or employee.
(c) No official or employee shall own stock in or be employed by or have any business,financial or professional connection with or ownership interest in any business, company orconcern which does business with the city, unless such business with the city is conductedthrough sealed competitive bidding or requests for proposal where such bids are opened andthe awards are made at meetings open to the public. . . . This section is not intended to apply toownership of less than ten percent of any publicly traded stock.
(d) Commissioners, deputy commissioners, department heads, chief operating officer,deputy chief operating officers, chief of staff, deputy chiefs of staff, bureau directors, andemployees of the office of the mayor who report directly to the mayor . . . may engage in privateemployment or render services for private interests only upon obtaining prior written approvalfrom the board of ethics.
Form #HR226OJ3/22/04Original to Department, copy to employee
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Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.
General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.
You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider
using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.
Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.
Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4Department of the Treasury Internal Revenue Service
Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
20191 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3 Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
4 If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card. ▶
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• 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.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties 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 boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of employment
10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)
Form W-4 (2019) Page 2
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 WorksheetComplete 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 WorksheetComplete 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 withheld. 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-”) 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 withholding 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 withhold 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 EmployerEmployees, 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,
and 10 to 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).
Form W-4 (2019) Page 3Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . BC Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C
D Enter “1” if: { • You’re single, or married filing separately, and have only one job; or• You’re married filing jointly, have only one job, and your spouse doesn’t work; or• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
} D
E Child tax credit. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child. • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each eligible child.
• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for each eligible child.
• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . EF Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).
• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” . . . . . . . FG Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet
here. If you use Worksheet 1-6, enter “-0-” on lines E and F . . . . . . . . . . . . . . . . . . GH Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . ▶ H
For accuracy, complete all worksheets that apply. {
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.
• If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 above.
Deductions, Adjustments, and Additional Income WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage
income not subject to withholding.
1
Enter an estimate of your 2019 itemized deductions. These 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. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $
2 Enter: { $24,400 if you’re married filing jointly or qualifying widow(er)$18,350 if you’re head of household$12,200 if you’re single or married filing separately
} . . . . . . . . . . . 2 $
3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any
additional standard deduction for age or blindness (see Pub. 505 for information about these items) . . 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7 $8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.
Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, above . . . . . . . . . . 9
10
Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 . . . . . . . . . . . . . . . . . . . 10
Form W-4 (2019) Page 4 Two-Earners/Multiple Jobs Worksheet
Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.
1
Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don’t enter more than “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 “-0-”) 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 . . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8 $
9
Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 $
Table 1Married Filing Jointly
If wages from LOWEST paying job are—
Enter on line 2 above
$0 - $5,000 05,001 - 9,500 19,501 - 19,500 2
19,501 - 35,000 335,001 - 40,000 440,001 - 46,000 546,001 - 55,000 655,001 - 60,000 760,001 - 70,000 870,001 - 75,000 975,001 - 85,000 1085,001 - 95,000 1195,001 - 125,000 12
125,001 - 155,000 13155,001 - 165,000 14165,001 - 175,000 15175,001 - 180,000 16180,001 - 195,000 17195,001 - 205,000 18205,001 and over 19
All Others
If wages from LOWEST paying job are—
Enter on line 2 above
$0 - $7,000 07,001 - 13,000 1
13,001 - 27,500 227,501 - 32,000 332,001 - 40,000 440,001 - 60,000 560,001 - 75,000 675,001 - 85,000 785,001 - 95,000 895,001 - 100,000 9
100,001 - 110,000 10110,001 - 115,000 11115,001 - 125,000 12125,001 - 135,000 13135,001 - 145,000 14145,001 - 160,000 15160,001 - 180,000 16180,001 and over 17
Table 2Married Filing Jointly
If wages from HIGHEST paying job are—
Enter on line 7 above
$0 - $24,900 $42024,901 - 84,450 50084,451 - 173,900 910
173,901 - 326,950 1,000326,951 - 413,700 1,330413,701 - 617,850 1,450617,851 and over 1,540
All Others
If wages from HIGHEST paying job are—
Enter on line 7 above
$0 - $7,200 $4207,201 - 36,975 500
36,976 - 81,700 91081,701 - 158,225 1,000
158,226 - 201,600 1,330201,601 - 507,800 1,450507,801 and over 1,540
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(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 will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information 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 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 aren’t required to provide the information requested on a form that’s 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 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.
City of Atlanta Employee Information Form
DHR 2/2011 Employee Personal Information Form
(EPI Form)
Employee Name: Last First Middle
Address 1:
Address 2:
City: County: State: Zip:
Home Phone Number: Other Phone Numbers: Type: Number:
SSN: Date of Birth:
Note: If Mailing address is different from home address, complete information below.
Mailing Address 1:
Mailing Address 2:
City: County: State: Zip:
EEOC Data
Gender: Female Male Marital Status: Single Married Divorced Widowed Domestic Partner
Legally Separated Living Together
Race: American Indian Asian Black/African Hispanic/ Native Hawaiian/ Two or White/
Or Alaskan Native American Latino Pacific Islander more races Caucasian
Highest Education Level:
Citizenship Status
US Citizen Naturalized Lawful perm. Resident (Alien#)A_______________________
Alien auth. To work until__________________ (Alien# or Admission #)______________________
Emergency Contact Name: Relationship:
Address:
City: State: Zip code:
Phone:
Employee Acknowledgement I certify that the above information is correct and understand that I am required to maintain this information on a current basis with the Department of Human Resources in accordance with the Civil Service Rules and Regulations of the City of Atlanta.
Signature of employee
Title Date
Departmental Acknowledgement Signature of Departmental Representative
Date
Department of Human Resources Acknowledgement Signature of DHR Representative
Date
CITY OF ATLANTA
KEISHA LANCE BOTTOMS
MAYOR 68 MITCHELL STREET, S.W. • ATLANTA, GEORGIA 30303-0306
TEL: 404-330-6360 • FAX: 404-658-6892
DEPARTMENT OF HUMAN RESOURCES
JEFFREY B. NORMAN
INTERIM COMMISSIONER
This is to certify that I, , have been informed that the
City of Atlanta health insurance coverage of my choice will become effective 90 days after the
effective date of my employment.
I further understand that I may elect to obtain health insurance coverage during the 90-day interim by
paying the employee’s share and The City’s share of the insurance premium.
I elect to wait 90 days for medical coverage
I elect to receive immediate medical coverage by paying 100% of the required premium
I elect to decline medical coverage
SIGNED
DATE
PERSONNEL WITNESS
ACTIVE EMPLOYEE INSURANCE ENROLLMENT
APPLICATION
CITY OF ATLANTA 68 Mitchell St., SW
City Hall – Suite 2120 Atlanta, GA 30303
EMPLOYEE LAST NAME FIRST NAME MIDDLE INITIAL ELIGIBILITY APPROVED BY
STREET ADDRESS DATE
CITY STATE ZIP CODE COUNTY DATE OF HIRE
HOME PHONE BUSINESS PHONE SOCIAL SECURITY NUMBER EFFECTIVE DATE
MARITAL STATUS: ☐ SINGLE ☐ MARRIED ☐ WIDOWED ☐ SEPARATED ☐ DIVORCED DATE OF MARRIAGE PROCESSED BY
DATE OF HIRE DEPARTMENT DATE
Instructions for Enrollment: New employees (if you are electing to pay 100% of premium for the first 90 days) use date of hire for effective date. If you are not electing to pay 100% of premium for the first 90 days, you must enroll by the 90th day from date of hire or you may enroll only during the next Open Enrollment for the following plan year. Effective date _____________________________ **PLEASE READ** Eligible dependents are: Your spouse/domestic partner and children up to age 26. Children for whom you have assumed legal obligation may be covered provided they are dependent on you for support. You must attach a copy of guardianship or adoption papers. For dependent spouse/domestic partner, attach marriage certificate or domestic partnership agreement. For each dependent child, attach birth certificate showing parent-child relationship. If you do not enroll your dependent(s) within 31 days of the date the dependent(s) is eligible to enroll (i.e., date of birth, marriage, etc.), you may enroll the dependent(s) only during the next Open Enrollment period to be effective the following plan year.
I DO NOT WANT CITY HEALTH AND/OR DENTAL/VISION COVERAGE. I hereby certify that I have been given an opportunity to participate in the City of Atlanta Health, Dental, and Vision Insurance Plans for myself and my eligible dependents. All plans have been thoroughly explained to me and I decline to participate in:
☐ HEALTH ☐ DENTAL ☐ VISION EMPLOYEE SIGNATURE______________________________________________ DATE____________________
I ELECT: (INITIAL YOUR CHOICE OF PLANS)
Medical Dental Vision Anthem BCBS POS MetLife PPO High UHC Vision
Anthem BCBS HDHP MetLife PPO Low
Kaiser Permanente HMO Aetna DHMO (GA only)
Kaiser Permanente HMO HDHP
Enter below family members to be covered: YOURSELF, SPOUSE/DOMESTIC PARTNER, THEN CHILDREN Last Name, First Name, MI
Sex
Social Security Number
Rel.
Date of Birth
MED
DEN
VIS
I hereby apply for enrollment for myself and the eligible dependents listed above and swear and affirm that the above information is true and correct to the best of my knowledge and belief. I understand that my coverage and benefits may be affected by failure to provide complete and accurate information. I agree to pay the premium amounts applicable to the contract under which I am covered. I understand that I cannot change or stop deductions on any date other than at Open Enrollment except for a qualifying change in my family status. I authorize the Chief Financial Officer of the City of Atlanta to deduct from my pay such applicable premium amounts and to remit them to the insurance company/HMO I have chosen. I authorize my provider, insurance company/HMO, or person with any record of knowledge of my health to furnish the above insurance company/HMO with such information. Concurrent with my hospitalization, I authorize the above insurance company/HMO to release or obtain medical information from healthcare providers to administer the plan. I acknowledge that I and my spouse/domestic partner have read the Notification of Continuation of Coverage shown on the back of this form. EMPLOYEE SIGNATURE DATE SPOUSE/DOMESTIC PARTNER SIGNATURE DATE
You and your spouse/domestic partner must sign this form, make a copy for yourself, and return the original form to DHR – Employee Benefits. If you need help in completing this form, call DHR – Employee Benefits at 404-330-6036.
REV 10/18
CONTINUATION OF COVERAGE NOTICE
Under COBRA, the Consolidated Omnibus Reconciliation Act of 1985 Title X, terminated employees and their eligible dependents may continue group health plan coverage. We urge you to read this description of the “continuation coverage” option carefully, and to make sure you and your spouse/domestic partner read and understand the rights and responsibilities in connection with this continuation of coverage. Both you and your spouse/domestic partner must sign the front page of this enrollment application.
THE BENEFITS
Effective January 1, 1987, if you are currently under the City of Atlanta Health Plan, including HMOs, you will be entitled to continue your and your family’s Health Plan coverage for up to 18 months from the date coverage would have terminated because of voluntary or involuntary termination. If a qualified beneficiary is deemed disabled for Social Security, at the date of the qualifying event or within the first 60 days following the qualifying event, the continuation coverage period is 29 months for all the members of your family who have elected COBRA. The 18-month period may be extended also if other events (such as a death or divorce) occur during that 18-month period. Employees discharged because of “gross misconduct” would not be eligible for continuation of coverage. Dependents who no longer qualify as dependents under the City of Atlanta Health Plan are eligible to apply for continuation of coverage. If you should die or become divorced, and if your spouse/domestic partner and dependents are covered by the City of Atlanta Health Plan at that time, they will be entitled to continue health coverage for up to 36 months. Continuation coverage also is available for your children for up to 36 months or up to age 26 if they are not covered under another group health plan that duplicates coverage. If an Eligible Person is 60 years old on the date COBRA continuation coverage starts, COBRA coverage may extend up to the time of Medicare eligibility. If you have a newborn child, adopt a child, or have a child placed in your home pending adoption (for whom you have financial responsibility), while your COBRA continuation coverage is in effect, you may add this child to your coverage.
THE COST
Continuation of coverage is optional on the part of the employee or dependent. Those who elect continuation of coverage will be required to pay 102% of the total monthly group premium for the applicable class of coverage. For the extended disability coverage, employees may be required to pay up to 150% of the monthly group premium during the 19th through the 29th month. Persons 60 years old on the date of COBRA eligibility may be required to pay up to 120% of the premium for extended time. There will be no contribution made by the City of Atlanta. Premiums are due monthly and in advance. You should note that your continuation coverage will stop if the premiums for this coverage are not paid on time.
If you elect to continue coverage, new dependents may be added during the period of continuation on the same basis as they are added for active employees. If during continuation of coverage health benefits and premium rates change, your coverage and costs will be affected accordingly. Should Open Enrollment occur during the period of your continuation, you will retain your right to switch to a different option.
WHEN COVERAGE ENDS
If you or covered members of your family become entitled to Medicare or are covered under another employer-sponsored health plan that does not limit coverage due to preexisting conditions, the continuation coverage from the City of Atlanta Health Plan will cease. In addition, your coverage will cease if the City of Atlanta should terminate the Health Plan or you cease to pay premiums. Once the period of coverage continuation has expired, anyone receiving continuation coverage will be eligible to convert to individual policies, as provided under the City of Atlanta Plan.
WHAT YOU MUST DO
You or your spouse or dependents must notify the Employee Benefits Division when your dependent child reaches the maximum age under the plan or in the event you become divorced. It is important that you notify us of your or your dependent’s loss of Plan eligibility promptly — in advance, if possible, but no later than 60 days from the date coverage would otherwise have been terminated, in order to be eligible to elect continuation coverage. Within 14 days after the end of the month in which you notify the Employee Benefits Division, you or your eligible dependents will be mailed information and forms regarding continuation of coverage. You or your dependents will then have an additional 45 days to pay the applicable premium, retroactive to the date coverage would otherwise have terminated.
If you would like further information about continuation coverage under the City of Atlanta Health Plan, please contact DHR – Employee Benefits at 404-330-6036.
CONVERSION PRIVILEGE
When your group health insurance ends due to your termination of employment with the City of Atlanta or due to expiration of COBRA continuation of health care coverage under the group contract, you may apply for converted health coverage. For additional information contact DHR – Employee Benefits at 404-330-6036.
If you are a new employee, have previously waived your health insurance, or are adding a dependent other than a newborn (or child placed in your home pending adoption), you should provide copies of the CERTIFICATE OF GROUP HEALTH PLAN COVERAGE issued to you or your dependents by the previous employer(s) for CREDITABLE PRIOR COVERAGE so that you can avoid preexisting condition exclusions, if any.
Health/Dependent Care Flexible Spending Account Enrollment Form
Social Security Number (SSN)
First Name M.I. Last Name
Address
City State
Day PhoneZip Code
$ . x .
CONTRIBUTION PER PAY PERIODNUMBER OF PAY PERIODS
REMAINING IN THE PLAN YEAR YOUR ANNUAL ELECTION AMOUNT
I decline enrollment in my employer’s Flexible Spending Account Plan.
Employee Signature Date
Employer Section: Control # Employee Company Code Effective Date of Employee Election
© 2017 WageWorks, Inc. ALL RIGHTS RESERVED. v17.05.6
Need help deciding how much to elect or how much you will save using a Flexible Spending Account?VISIT OUR WEBSITE at www.spendingaccounts.info
=DEPENDENT CARE
FLEXIBLE SPENDING ACCOUNT
CANNOT EXCEED $5,000 PER HOUSEHOLD PER YEAR*
This form is designed to be completed by using your computer and tabbing through the designated fields. If completing a printed copy by hand, please use black or blue ink, print clearly and only in the spaces provided.
I elect to participate in my employer’s Flexible Spending Account Plan and agree to be bound by the terms of my employer’s Plan. I understand that the contribution(s) I have elected will be made with pre-tax salary reductions and that such reductions reduce my compensation for Social Security benefit purposes. I understand that this agreement is only for eligible services and treatment provided during the Plan Year and that said services must be provided before the submission of claims for reimbursement. I also understand that I am making a binding election for the entire Plan Year unless I have a qualified change of status as defined by my employer’s Plan. Any salary deductions that have not been used for expenses incurred in the Current Plan Year noted above will be forfeited unless your Plan offers certain exceptions (e.g., grace period or carryover).
If the Plan Administrator determines that an expense I submitted for reimbursement was not a qualified expense under the Plan Documents, I shall immediately reimburse the Plan for the entire amount of the unqualified expense. If I fail to timely reimburse the Plan, I understand that amounts may be withheld from wages or from otherwise valid expenses under the Plan in order to reimburse the unqualified expense.
Please select your enrollment option below, sign and date your form and submit to your benefit services department:
Prior to completing this form, contact your benefit services group to determine your employer’s preferred enrollment method.
I have reviewed the terms of my employer’s Plan and I understand that I may elect coverage under either or both of the accounts below, subject to the terms of the Plan, for the Plan Year .
,
* Your employer’s maximum contribution may be less than the statutory limit. Please verify your employer’s Plan limit prior to enrolling in the Plan.
$ . x .
CONTRIBUTION PER PAY PERIODNUMBER OF PAY PERIODS
REMAINING IN THE PLAN YEAR YOUR ANNUAL ELECTION AMOUNT
=HEALTH CARE
FLEXIBLE SPENDING ACCOUNT
CANNOT EXCEED $2,600 PER PERSON PER YEAR*
,
Group Life Insurance Enrollment Anthem Life
EMPLOYER NAME: City of Atlanta Group Number:1. Complete sections A, B, and D.2. If you are electing coverage on your dependents, complete section C.3. Return completed and signed form to your Human Resources representative.
A. EMPLOYEE INFORMATIONFirst name Middle initial Last name
Email address
Street address City State Zip code
Date of birth Social Security number Date of employment Gender
FemaleMale
Total amount of Supplemental insurance requested ($10,000 increments to a maximum of $200,000)
Decline coverage$Employer sponsored $40,000 Basic Life and AD&D (1X salary to a maximum of $210,000)
Decline coverageElect
B. BENEFICIARY INFORMATION (EMPLOYEE IS THE BENEFICIARY OF ANY DEPENDENT COVERAGE)Employer sponsored $40,000 beneficiary designation (include full name and address) The person or persons named will receive the benefits.
Share % (Must total 100%)RelationshipSocial Security Number Date of birthPrimary Beneficiary(ies) The person or persons names will receive the benefit
Contingent Beneficiary(ies) If the primary beneficiary(ies)is no longer living, the benefit is paid to this person
Basic Life and AD&D beneficiary designation (include full name and address) The person or persons named will receive the benefits.
Social Security Number Date of birth Relationship Share % (Must total 100%)Primary Beneficiary(ies) The person or persons names will receive the benefit
Contingent Beneficiary(ies) If the primary beneficiary(ies) is no longer living, the benefit is paid to this person
C. DEPENDENT INFORMATIONSpouse first name Middle initial Last name
Email address
Date of birth Social Security number Gender
FemaleMale
List of names and dates of birth for your eligible childrenChild's name Date of birth Child's name Date of birth
Child's name Date of birth Child's name Date of birth
Dependent Term Life Coverage
Decline coverageChild Only ($5,000) Spouse ($5,000) & Child ($5,000)Spouse Only ($5,000)
D. AUTHORIZATIONI authorize my employer to make these change(s) and to withdraw any premiums from my salary to pay for supplementalinsurance coverage.
Employee signature Daytime phone number Evening phone number Date signed
X
City of Atlanta
Tobacco Use Attestation
A $50 per month surcharge will be added to your medical premium, effective May 1, 2017, if you use a tobacco product.
The surcharge will not apply if you pledge to enroll in a tobacco cessation program, offered through your selected Medical Plan (BCBS or Kaiser). You must be tobacco-free for two months to avoid the surcharge.
Tobacco use is defined as any use of tobacco products within the past two months. It does not include the religious or ceremonial use of tobacco.
I attest I do not regularly use a tobacco product in any form (cigarettes, electronic cigarettes, cigars, pipes, oral tobacco products, etc.).
I acknowledge that I do regularly use a tobacco product in some form (cigarettes, electronic cigarettes, cigars, pipes, oral tobacco products, etc.).
I pledge to enroll in a tobacco cessation program, offered by the Medical Plan.
Active / Retired Employee Signature
Active / Retired Employee Name (Printed)
Employee ID Number
Date
Page 1 of 2 Order #144111 09/01/2014 TM: BENEMAINT
REQUEST TYPE
c Initial Designation c Change to Designation
1. Plan InFORMaTIOn (Required)
Billing Group/Plan # Plan Name
BENEFICIARY DESIGNATION – NON-ERISA
Voya Retirement Insurance and Annuity Company (“VRIAC”)Voya Institutional Plan Services, LLC (“VIPS”)Members of the VoyaTM family of companiesOne Orange Way, Windsor, CT 06095-4774Phone: 800-584-6001
As used on this form, the term “Voya,” “Company,” “we,” “us” or “our” refer to VRIAC or VIPS as your plan’s funding agent and/or administrative services provider. Contact us for more information.
For immediate assistance in designating or changing your beneficiary designation please call our Customer Service Center at 800-584-6001. If you contact the Customer Service Center via the 800 number you do not need to complete this form to designate your beneficiary.
GOOD ORDERGood order is receipt at the designated location of this form accurately and entirely completed, and includes all necessary signatures. If this form is not received in good order, as we determine, it may be returned to you for correction and processed upon re-submission in good order at our designated location.
(Beneficiaries continued on next page.)
3. BEnEFICIaRY InFORMaTIOn (Changes must be initialed by the Account Holder.)
Subject to the terms of my Employer’s Plan, I request that any sum becoming due upon my death be payable to the beneficiary(ies) designated below. I understand this designation shall revoke all prior beneficiary designations made by me under my Employer’s Plan. (All designations must be in whole percentages. Total percentage must equal 100% for Primary Beneficiary and 100% for Contingent Beneficiary, if designated. Example: 33%, 33%, 34%.)
Enter Complete Legal Name, Address and Phone #
Date of Birth(mm/dd/yyyy) Relationship SSN/TNN
Percentage of Benefit
c Primary
c Primaryc Contingent
c Primaryc Contingent
c Primaryc Contingent
c Primaryc Contingent
2. aCCOUnT HOlDER InFORMaTIOn (Required)
Name (last, first, middle initial) SSN (Required)
Work Phone (Include extension.) Home Phone
Page 2 of 2 Order #144111 09/01/2014 TM: BENEMAINT
Please return the completed form to: Voya Retirement Insurance and Annuity Company PO Box 990063 Hartford, CT 06199-0063 Fax: 800-643-8143
MaIl OR Fax InSTRUCTIOnS (Please keep a copy for your records.)
Unless otherwise noted:
• IfmorethanoneBeneficiaryisdesignated,paymentwillbemadeinthepercentagesdesignated(orinequalshares)tothePrimary Beneficiaries who survive the Account Holder or Annuitant. Or, if none survives the Account Holder or Annuitant, payment will be made in the percentages designated (or in equal shares) to the Contingent Beneficiaries who survive the Account Holder or Annuitant.
• IfnoBeneficiarysurvivestheAccount Holder or Annuitant, payment will be made pursuant to the terms of the Plan.
3. BEnEFICIaRY InFORMaTIOn (Continued)
Enter Complete Legal Name, Address and Phone #
Date of Birth(mm/dd/yyyy) Relationship SSN/TIN
Percentage of Benefit
c Primaryc Contingent
c Primaryc Contingent
c Primaryc Contingent
c Primaryc Contingent
c Please check if additional beneficiaries are noted on the back of this form and follow same format as above.
4. TRUST CERTIFICaTIOn (Only complete if naming a Trust as a Beneficiary.)
By signing below, I certify that:
A. Name of trust or trust Instrument:
B. The trust or trust instrument identified above, is in full force and effect and is a valid trust or trust instrument under the laws of the State or Commonwealth of .
C. The trust is irrevocable, or will become irrevocable, upon my death.
D. All beneficiaries are individuals and are identifiable from the terms of the Trust.
In the event that any of the information provided above changes, I will provide Voya with the changes, within a reasonable period of time.
By designating a Trust, additional documentation and/or certification may be required.
5. SIGnaTURES
Account Holder Signature Date (mm/dd/yyyy)
City and State Where Signed
Witness Name (Please print.)
Witness Signature Date (mm/dd/yyyy)
(Participant’s signature must be witnessed. Witness must be a person of legal age other than designated beneficiary. The witness need not be a Notary Public.)
I hereby certify under the pains and penalties of perjury that information I furnished herein is true, accurate and complete.
CITY OF ATLANTA
DIRECT DEPOSIT AUTHORIZATION
TYPE OR PRINT. THE INFORMATION MUST BE LEGIBLE.
Part I: Employee Information
Part II: Type of ACH Request
Part IV: Financial Institution Information Type of Account:
Please submit by clicking File from menu and Attach to Email ([email protected] or [email protected]) You can mail your form to City of Atlanta Attn: Disbursements Unit 68 Mitchell Street SW Atlanta, GA 30303. Please remember to attach your VOIDED check.
Part III: Employee Authorization
New Enrollment Change InformationCancel ACH
Checking Savings
Employee Name
Email Address
Phone Number
Employee ID #
Last Four of SSN
Department
Bank Routing/ Transit #/ABA
Financial Institution Name
Account Number
Amount
Request Date
Financial Institution Name
Bank Routing/ Transit #/ABA
Account Number
Amount
Type of Account: Checking SavingsAdditional Financial Institutions
Signature
Current Date
I authorize the City of Atlanta Payroll department to deposit my net pay to my account at the below named bank(s). The City of Atlanta is also authorized to adjust any overpayments made to my account. I will not hold my financial institution liable for any erroneous deposit or subsequent payroll adjustments by the City of Atlanta. I also agree that the financial institution listed below may treat each deposit the same as if it were deposited in person. The authorization will remain in effect until I have cancelled it in writing. I under- stand that this direct deposit authorization will be effective the first pay period after 30 days (60 days for the change from bank to another) from the receipt of this authorization by the City of Atlanta. I further authorize the City of Atlanta to use this information for any other work related reimbursements.
The City o
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___________
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___________
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2nd pay check
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__________
__________
__________
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ANSIT YOU WANT
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___________
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DEDUCTED FROM
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_____Date:_
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__________
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