Dixie District Schools Substitute Checklist

Important Notice: Please fill out paperwork included in this packet and return to Erica Anderson. Upon completion of paper paperwork, Erica will schedule a date and time for you to be fingerprinted. On your

fingerprint date you will need to bring your High School Diploma or higher, your Driver's License and Social Security Card and $58.50 fee for processing. Once your fingerprints have been processed and approved, your name will be submitted to the board for approval. Upon board approval, your name will be sent to the schools to be added to the substitute list. This checklist is for Office Use ONLY to verify that all paperwork and processing is completed.

Please complete all paperwork in your legal name as printed on your social security card.

�•-- <

Verify Paperwork Is complete

Step 2 Verify Back­ground

Step 3 Enter Into Payroll

For Office Use ONLY: Keep the following items in FDLE file

__ Coversheet __ Fingerprint Application __ Personal Data Sheet-copy for Payroll• __ Background Reports and Training __ Grievance Procedures-copy for payroll• __ Substitute Training Verification Form __ Substitute Application __ Why Do We Need Social Security Cards? __ Social Security Number Privacy Notice __ Employment Not Covered By Social Security

W-4 Form __ l-9Form __ Direct Deposit Authorization __ Loyalty Oath __ Drug Free Workplace __ Security Policy for Auxiliary Services __ Race and Ethnicity Data Collection Form __ Bencor __ Personal File Update __ Patient Protection and Affordable Care Act-Health Ins. Coverage Checklist __ Florida New Hire Reporting Form

FRS

Fingerprint Date __ Social Security Card Drive�s License __ High School Diploma ... HIGHER___ NEED TRANSCRIPT __ Fingerprint Fee $58.50 Cash/Check-to Dixie District Schools __ Background Verified via FDLE __ Submit to Board for approval __ All lines checked above? If yes, okay to send substitute file to payroll

Board Approval date: _,,..,-.,....,�.,------­-- Enter Demographics into Skyward __ Submit New Hire Report Online

Your name WILL NOT be submitted for board approval until all paperwork has been turned in and your fingerprints have been processed.

TO: All Substitutes

From: Erica Anderson

RE: Substitute Applicants

All substitutes must be Board approved prior to working in the Dixie District School system.

The Dixie District School Board meets the second Tuesday of each month. Agenda items for that

meeting are due in the Superintendent's office two weeks in advance.

Therefore all paperwork, fingerprints, etc have to be completed in this time frame.

Please keep this in mind when picking up and returning an application.

Appointments for fingerprinting will be made when registration is complete.

Any questions please call Erica Anderson at 352-541-6261.

PLEASE RETURN ALL PAPERS WITH THE APPLICATION INCLUDING THE BENCOR FICA

ALTERNATIVE PLAN BOOKLET.

li\1JPORT;\Nr

f NOl"'

ICE TO Ei\lPLOYEES

RE: SIGNING YOUR PAPERWORK

All documents in this packet MUST be signed as your name appears on your Social Security card.

FOR EXAMPLE:

�-CQeOOCQ, -------

All personnel forms would be signed Alice D. Employee just as the name appears on �e above sample Social Security Card.

If you have recently married or divorced and do not have your new name on your card, then the paycheck and personnel forms must reflect your prior name. Please send the Payroll Department a copy of your new Social Security card when you complete the application process for a name change. Use the following web address to change your name .on your card or apply for a replacement card. http://www.ssa.gov/

Last Name

Sex Race Hgt

Single 0 Married O

Date of Birth Month

Place of Birth

Fingerprint Applicant

Dixie District Schools

823 Se 349 HWY

Old Town, FL 32680

First Name

Wgt

Divorced

Day Year

Eyes

D

----------------------

Socia I Security Number ________ _

Phone Number (

Middle Name

Hair

Widowed 0

Physical 911 address __________________________ _

Mailing Address ____________________________ _

If fingerprinting as a VENDOR please provide the following information

Company Name ____________________________ _ Address ______________________________ _

Phone number ______________ _

I HEREBY CERTIFY THAT THIS INFORMATION I HAVE GIVEN IS TRUE AND CORRECT AND GIVE MY CONSENT TO BE FINGERPRINTED.

Signature Date

NOTICE:

SCHOOL BOARD OF DIXIE COUNTY

PERSONAL DATA SHEET

The following information is required for statistical and record keeping purposes only and is not used in evaluation of applications and/or in the selection of personnel for positions with Dixie County School Board.

PLEASE TYPE OR PRINT

Name _________________________ SS# __ _ (Last)

Date of Birth

(First)

----------

(Month)

(Middle/Maiden)

(Day) (Year)

Place of Birth ______________ _ Height Ft. In.

Color of Hair ----------

Color of Eyes ________ _

U.S. Citizen ----

Weight __ _

Sex ------

RACE: 1.

2.

3.

____ White Non-Hispanic

____ Black Non Hispanic

_____ Hispanic

4.

5.

American Indian -----

Asian or Pacific Islander ------'

Nearest Living Relative _______________ Relationship ___________ _

Names(s) and Relationship ofRelative(s) Working for the Dixie County School Board _________ _

Have You Ever Been Bonded? _______ --'By What Company? _____________ _

Has Bond Ever Been Refused You? _______ .If yes, Explain. _______________ _

**************************************************************************************************************

The information furnished above is true and accurate to the best of my knowledge.

Signature Date

AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER Updated: 07/06/2004

Dixie District Schools

Dear New Substitute Applicant:

Subjects: (1) Background Reports and (2) Training

ill Background Reports: The state of Florida requires fingerprinting of all public school employees. In order to comply with state regulations and to ensure the safety and welfare of our students, all applicants are fingerprinted electronically. These fingerprints are sent in and reports are received from the FBI. If the FBI report is not completely clear, it shall be reviewed for possible further consideration. The cost for fingerprinting is $58.50, payable to Dixie District Schools.

ill Training: Pursuant to SB 2986, beginning with School Year 2004-2005, all substitutes will be provided a substitute teacher handbook.

Upon receipt of a clear background check, an applicant may be recommended to the School Board for approval.

NOTIFICATION OF AVAILABILITY OF

DIXIE DISTRICT SCHOOLS

EMPLOYMENT GRIEVANCE PROCEDURES

Employees, applicants for employment, bargaining units and

the general public have access to available grievance procedures for complaints of discrimination and / or harassment for employees and applicants for employment by contacting the Personnel Office of Dixie District Schools.

Instructional Services 16077 NE 19 Hwy Cross City, FL 32628 (352) 541-6334

I have read the above notification.

Applicant Signature Date

Dixie District Schools Application Notice

Dixie District Schools

Substitute Application

Date: ________ _

Name:------------------------,--,..,,--,-----(Middle) (Last) (First)

I am applying to substitute in the following area(s): (please check all that apply)

Substitute Teacher/Aide at:

__ Anderson Elementary Ruth Raines Middle

Substitute Custodian at:

_ _ Anderson Elementary Ruth Raines Middle

Substitute Food Service at:

__ Anderson Elementary Ruth Raines Middle

Substitute Bus Driver

Maintenance

__ Old Town Elementary __ Dixie County High School

__ Old Town Elementary __ Dixie County High School

__ Old Town Elementary __ Dixie County High School

__ Other (Explain) _______________________ _

Do you have verification of __ High School Diploma

AA

AS

__ Bachelor's degree or higher

__ valid Florida DOE Teacher certificate (not temporary)

To sub as a Teacher/Aide substitutes please provide this office with a copy of one of the above documents.

We need a copy of __ Social Security Card

Picture Id

If you have any questions please call Erica Anderson @ 352-541-6261

NON-INSTRUCTIONAL APPLICATION (PLEASE TYPE OR PRINT)

You may attach a recent photograph

&_ttp:l ldixiescbools.dixie.k12.f[.us)

Position(s) for which you are applying:

I.

2.

3.

In compliance with the Americans with Disabilities Act of 1990, accommodations for interview of the disabled will be provided when requested in advance.

Date, ______ _ Social Security No., ______ _ Telephone Number ________ _

Name. ___________________________ _ Are you 18 years of age. ______ _ Last First Middle

Address. ________________________________________ _ Number and Street City State Zip Code

Are you a citizen of the United States? _____ Resident ofF!orida? ____ _ Resident of Dixie County? _____ _

Have you ever been employed by the School Board ofDooe County? ______ _

Reason forleavin . .,_ ______________________________________ _

OTHER INFORMATION: (lf"yes", submit details on separate sheet)

I. Have you ever been dismissed from employment, asked to resign, or resigned in lieu of dismissal? __ _2. Have you ever received an unsatisfactory performance evaluation? __ _3. Have you ever bad any record sealed or expunged in which you were convicted, found guilty, had adjudication

withheld, entered a pretrial diversion program, or pied guilty or nolo contendere (no contest) to a criminal offenseother than a minor traffic violation? __ _

4. Have you ever been convicted, found guilty, bad adjudication withheld, entered a pretrial diversion program, or piedguilty or nolo contendere (no contest) to a criminal offense other than a minor traffic violation? __ _

List machines or equipment with which you have had training or experience, or any special skills that you possess.

REVISED: 0 1/06/10

Some Positions Require A Physical and/or Skills Examination

Dixie Non-Instructional Application page I of2

WORK EXPERIENCE RECORD:

Name & Address of Employer Dates of Title of Position Emolovment

Why did you leave your last position or why do you wish to change from your present position?

EDUCATION:

Name & Address of High School Graduated

College Address Major/Minor

Other Schools

REFERENCES: Please give complete names and addresses. Use former employers if possible.

I. 3. Name Name

Address Address

City/State Phone City/State Phone

2. 4.

Name Name

Address Address

City/State Phone City/State Phone ***************************************************************************************

The information furnished above is true and accurate to the best of my knowledge.

Signature Date

I An Affirmative Action / �ual 021!!!rtuDi!I EmJ!IO�tr I

Revised: 0 1/06/1 0 Dixie Non-Instructional A1;mlication 11age I of2

DIXIE DISTRICT SCHOOLS

WHY DO WE NEED A COPY OF YOUR SOCIAL

SECURITY CARD?

Correct names and social security numbers (SSN) on W -2 wage

reports are the keys to successful processing of your annual wage report submission. It allows the Social Security Administration to properly credit your earnings record, which will be important information in determining their social security benefits in the future.

WHY DO WE NEED A COPY OF YOUR DRIVER

LICENSE?

This provides picture identification, address verification, and date of birth verification.

I have provided a copy of my social security card and a copy of my driver

license to the Payroll Department with this new hire packet.

signature date

DIXIE COUNTY SCHOOL BOARD

NOTICE OF USE OF SOCIAL SECURITY NUMBERS

In compliance with Florida Statute 119.071 (5), this document serves to notify you of the purpose for the

collection and usage of your social security number.

Purpose

Employees:

Payroll Processing, Employee Benefit Forms and Human Resource

Bank Signature Cards, Direct Deposit, Bank Deductions and

Deduction Remittances

Social Security Contributions

Garnishments, Compliance with Court Requests, Child Support

Worker's Compensation

Unemployment Reports

Federal Forms W-2, W-4, and W-9

Florida Retirement System and Retirement Programs

Teacher Certification

State Directory of New Hires

Fingerprinting Identification/Criminal History/Sexual Predator Registration

Initial Employment Identification Including I-9's

Vendors/Consultants with no Tax ID number for 1099's

Students:

Student Enrollment,Student Demographic Record, Student ID

Student Assessment Accountability Measures

State Reporting of Student Data

Student Athletic Forms

Student Insurance and Student Health Records

Student Activities and Clubs FACTS.org

Scholarships

National lunch Program: Free/Reduced Lunch processing

Federal and State Regulations

Required by F.S. 119.071(5)(a)6

Required by Fla. Admin. Code 6A-l.0012 and F.S. 119.071(5)(a)6

Required by Fla. Admin. Code 60S-3.010 and F.S.

119.071(5)(a)2&6

Required by F.S. 61.1301(2)(e) and F.S.119.071(5)(a), and

required by 45 C.F.R. 307.11 and F.S. 61.13, 742.10 or 409.256.3

or 742.031 and required by Fla. Admin. Code 12E-1.028m

Required and/or authorized by F.S. 440.185 and Fla. Admin.

Code 69l-3.003 et seq., Fla. Admin. Code 60Q-6.103 and F.S.

119.071(5)(a)6

Required by F.S. Ch. 443, including 443.16, and F.S. 119.071

(5)(a)6 and Fla. Admin. Code 6088-2.2023

Required by F.S. and regulation 26 U.S.C. 6051 and U.S.C. 3402,

and 26 C.F.R. 31.60l(b)-2, and 26 C.F.R. 31.6051-1, and 26 c.F.R.

301.6109-1 and 31.3402(1)(2)-1, and F.S. 119.071(5)(a)6,

Required by Fla. Admin. Code 19-11.010, 19-11.006 and 19-

11.007 and F.S. 119.071(5)(a)2&6 or required by F.S. 121.051

and 121.071 and Fla. Admin. Code 19-13.003, required by 26

C.F.R. 301.6057-1, and authorized by F.S. 238.0let seq.,

including 238.07

Required by F.S. 1012.56, and 119.071 (5)(a)6, and/or authorize,

by F.S. 1012.21 and 119.071 (5)(a)6

Required by federal law 42 U.S.C. 653a and F.S. 409.2576 and

F.S. 119.071(5)(a)

Required by Fla. Admin. Code UC-6.003 and F.S.

119.071(5)(a)2&6 and Authorized by F.S. 943.04351

Authorized by 8 U.S.C. 1324 a(b) and 8 CF.R. 274a.2

Required by 26 C.F.R. 31.2306-0, 26 C.F.R. 301.6109-1 and F.S. 119.071 (5)(a)2&6

Student-related uses are authorized by F.S. 1008.386

This is intended to be a general listing of uses of social security number by the Dixie County School Board. Any

individual having specific questions or concerns regarding the disclosure of their social security number should

contact the Personnel, Finance, or Student Service Department, dependent upon the area of their concern.

Social Security numbers are confidential and may only be released as authorized by Florida Statutes.

IMPORTANT NOTICE TO EMPLOYEES

Dixie District School Board takes seriously our role in protecting the privacy and

confidentiality of our employees. We comply with federal and state laws and meet

required standards for securing that information.

As required by Section 119.071 (5)(a), Florida Statutes, Dixie District School Board

hereby requests access to employee social security numbers to be used in

performance of official duties required for commercial activity. These official duties

include employment, compensation, and accurately compiling, storing, and retrieving

an individual's records for processes such as payroll and personnel.

Under Florida's Public Records Law, most records in our possession are subject to

inspection by or disclosure to members of the public upon their request. Information

must be retained according to applicable federal and state laws, and must be

available for inspection, unless exempt from the Public Records Law. The School

Board does not release or disclose social security numbers to other parties except as

allowed under state and federal law in performance of official school board business.

If you have questions regarding this important notice please contact Terri Jenkins at

352-541-6262.

Signature: _____________ _ Date: ______ _

Printed Name: ____________ _

Affirmative action/equal opportunity employer

Social Security Administration

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

Employee Name Employee ID# ------------

-------------

Em p Io ye r Name Em p Io ye r 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

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

------------------Date

--------

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)

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 allfederal income tax withheld because youhad no tax liability, and• For 2019 you expect a refund of allfederal income tax withheld because youexpect 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 Instructions If 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.lrs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if yo� 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 retum. 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 Instructions Personal Allowances Worksheet Complete 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 retum, 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 Fann W-4 to your employer. Keep the wo-(s) for your records. ----------

Fonn W•4 Employee's Withholding Allowance Certificate 0MB No. 1545-0074 ► Whether you're entitled to claim a certain number of allowances or exemption from withholding ts

�@19 Department Of the Treasury Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of thts form to the IRS.

1 Your first name and middle initial I

Last name 12 Your social security number

Home address (number and street or rural route) 3 Os1ng1e 0Mamed D Married, but wlthhold at higher Single rate. Note: If manied flHng separately, check "Married, but withhold at higher Sing& rate."

City or town, state, and ZIP code 4 ff your last name differs from that lhown on your aoclal security card, check here. You must call 800-772-1213 for a replacement cant. ►□

5 Total number of allowances you're claiming (from the applicable worksheet on the following pages) . 5 6 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 t�r ... , / • This year I expect a refund of all federal income tax withheld because I expect to have no tax \iabilitv .If you meet both conditions, write "Exempt" here . . ► I 1 I

Under penalties of pe�ury, I declare that I have examined this certificate and, to the best of my knowledge and behef, it is true, correct, and complete.Employee's signature (This fom, is not valid unless you sign it.) ►

8 Employer's name and address (Employer: Complete boxes 8 and 1 0 if sending to IRS and complete boxes 8, 9, and 10 If sending to State Directory of New Hires.)

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Date ►

9 Fir.rt date of 10 Employer identification employment number (EIN)

Cat. No. 102200 Fonn W-4 (2019)

Form W-4 (2019)

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

Line G. Other credits. You may be able to reduce the tax wlthheld 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 wlthholding to take these credits into account. Enter "-0-" on lines E and F � 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 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 entltled to claim and any additional amount of tax to wlthhold 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 FormW-4. See Pub. 505 for details.

Another option is to use the calculator atwww.lrs.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 anyallowances for credits or fill out theDeductions, Adjustments, and AdditionalIncome Worksheet.

Instructions for Employer Employees, do not complete box 8, 9, or 10. Your employer will complete thasaboxes 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,

Page2

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/employars.

If an employer is sending a copy of Form W-4 to a designated State Directory ofNew Hires to comply with the new hirereporting requirement for a newly hiredemployee, complete boxes 8, 9, and 1 Oasfollows.

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).

Fonn W-4 (2019) Page3

A a

C

D

E

F

G

Personal Allowances Worksheet (Keep for vour records.)

Enter "1" for yourseff Enter "1" if you will file as married filing jointly . Enter "1" if you will file as head of household

{ • You're single, or married filing separately, and have only one job; or

Enter "1" if: • 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. }

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 eacheligible child.• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter "1" foreach eligible child.• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter "-0-"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 everytwo dependents (for example, "-0-" for one dependent, "1" if you have two or three dependents, and "2" if you havefour dependents).• If your total income will be higher than $179,050 ($345,850 ff married filing jointly), enter "-0-"Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheethere. If you use Worksheet 1-6, enter "-0-" on lines E and F

---

a ---

---

D---

E

F

G

H 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 youhave 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 bothwork, and the combined earnings from all Jobs exceed $53,000 ($24,450 ff married filing jointly), see theTwo-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 FonnW-4 above.

Deductions, Adiustments, and Additional Income Worksheet

Note: 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

2

3 4

5 6 7 8

9 10

Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest, chantable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See Pub. 505 for details

{ $24,400 if you're married filing jointly or qualifying widow(er)

} Enter: $18,350 ff you're head of household $12,200 if you're single or married filing separately

Subtract line 2 from line 1. If zero or less, enter "-0-" 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) . Add lines 3 and 4 and enter the total Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) Subtract line 6 from line 5. if zero, enter "-0-". If less than zero, enter the amount in parentheses Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, above 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

1 ;c$ ___ _

2 ;:;$ ___ _

3 ..,_$ ___ _

4 -'-$ ___ _ 5 ':'$ ___ _6 -'-$ ___ _7 ;:;$ ___ _

8 9

10

orm F W-4 (2019) Page4

.-wo-Eamers/Multiole Jobs Worksheet

Note: Use this worksheet only if the instructionS under line H from the Personal Allowances Worksh,eet 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 10 line 2, subtract line 2 from line 1. Enter the result here (if zero, enter "-0-") and on Fomn 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 Fomn W-4, line 5, page 1. Complete lines 4 through 9 below to figure the addltional wlthholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet 4

5 Enter the number from line 1 of this worksheet 5 6 Subtrac1 line 5 from line 4 . 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter It here 7 $

8 Multiply line 7 by line 6 and enter the result here. This is the addltional 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 fomn on a date in late April when there are 18 pay periods remaining in 2019. Enter the result here and on Fomn W-4, line 6, page 1. This Is the addltional amount to be withheld from each paycheck 9 $

Table 1 Table2

Married FIiing Jointly All Others Married FIiing Jointly All Others If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST paying )Ob are- line 2 above paying job are- line 2 above paying job are-

$0 $5.000 0 $0 . $7.000 0 $0 · $24.900 5,001 - 9,500 1 1_,om . 13,000 1 24,901 - 84.450 9,501 - 19,500 2 13,001 . 27,500 2 84,451 - 173,900

19,501 - 35.000 3 27,501 32,000 3 173,901 - 326,950 35,001 40,000 4 32,001 - 40.000 4 326,951 - 413.700 40,001 . 46.000 5 40,001 - 60,000 5 413,701 - 617,850 46,001 - 55.000 6 60,001 - 75,000 6 SH,851 and over 55.001 - 60.000 7 75,001 - 85,000 7

60,001 - 70,000 8 85,001 - 95,000 8 70,001 75.000 9 95,001 - 100,000 9

75,001 65.000 10 100,001 - 110,000 10 85,001 95.000 11 110,001 - 115,000 11

95,001 - 125,000 12 115,001 - 125,000 12 125,001 - 155,000 13 125,001 - 135,000 13 155,001 - 165,000 14 135,001 - 145,000 14 165,001 - 175.000 15 145,001 - 160,000 15 175,001 - 160,000 16 160,001 - 160,000 16 180,001 - 195,000 17 180,001 and over 17 195,001 - 205,000 18 205,001 and over 19

Privacy Ac1 and Paperwork Reduction Act Notice. We ask for the infomnation on this fomn to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(ij(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 fomn displays a valid 0MB control number. Books or records relating

Enter on If wages from HIGHEST Enter on line 7 above paying job are- tine 7 above

$420 $0. $7.200 $420 500 7,201 - 36.975 500 910 36,976 - 81,700 910

1,000 81,701 - 158,225 1,000 1,330 158,226 - 201,600 1,330 1,450 201,601 - 507,800 1,450 1.540 507,601 and over 1,540

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 fomn simpler, we would be happy to hear from you. See the instructions for your income tax return.

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form 1-9 0MB No. 1til5-(l(q7 Expires 08/31 !WI 9

►START HERE: Read Instructions carefully before completlng this form. The instructions must be available, either In paper or electronlcally, 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 docurnent(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.

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

: Date of Birth (mmlddlyyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

DJ]-[D-11111 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 fonn.

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

' O 1. A Citizen of the United States - - - - - - -- ---- ----·-----·--------- - - --------- --------

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

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

'"t'.'.]-4. A� alien authorized to work �ntil (expiration date, if applicable, mm/dd/yyyy):Some aliens may write "NIA" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9: An Alien Reg1strat1on Number/USCJS Number OR Form /-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number: OR

2. Form 1-94 Admission Number:OR

3. Foreign Passport Number:

Country of Issuance:

: Signature of Employee

QR Code. SectJon 1

De 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.

I Signature of Preparer or Translator I Today's Date /mmlddlyyyy)

I

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

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

fonn 1-9 07117/17 N Page 1 ofJ

Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services

List A OR Identity and Employment Authorization

AND

USCIS Form 1-9

0MB No. 1615-0047

ListC Employment Authorization

I Oocuffient Title Document Title Document Title ' '

Issuing Authority

Document Number

Issuing Authority Issuing Authority

Document Number Document Number

I Expiration Date (1f any)(mmlddlyyyy) Expiration Date (if any)(mmlddlyyyy) Expiration Date (if any)(mmlddlyyyy) ' ' I Document TitleI

! Issuing Authority

1 Document Number

Expiration Date (if any)(mmlddlyyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mmlddlyyyy)

Additional Information QR Code - Sections 2 & 3

Do Not Write In This Space

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 mployee is authorized to work In the United Stat es.

The employee's first day of employment (mmlddlyyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mmlddlyyyy) Title of Employer or Authorized Representative

Bookkeeper 1

1

Last Name of Employer or Authorized Representative

' Anderson First Name of Employer or Authorized Representative

Erica

: Employer's Business or Organization Address (Street Number and Name)

823 SE 349 HWY

Last Name (Family Name) First Name (Given Name) Middle Initial

Employer's Business or Organization Name

Dixie District Schools

Date (mmlddlyyyy)

c. n the employee•• previous grant of emplayment authorilltion has expired, pro\lide the information for the document or receipt that establishescontinuing employment authorization in the space prolllded below.

Document Title Document Number Expiration Date (if any) (mmldd,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 (mmlddlyyyy) Name of Employer or Authorized Representative

Form 1-9 07/17/17 N Page 2 of3

1.

2.

3.

4.

5.

6.

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.

LISTA LIST B LIST C

Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization

Employment Authorization AND

U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number

Permanent Resident Card or Alien State or outlying possession of the card, unless the card indudes one of

Registration Receipt Card (Form 1-551) United States provided it contains a the following restrictions:photograph or information such as (1) NOT VALID FOR EMPLOYMENT

Foreign passport that contains a name, date of birth, gender, height. eye

(2) VALID FOR WORK ONLY WITHtemporary 1-551 stamp or temporary

color, and addressINS AUTHORIZATION

1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITHreadable immigrant visa government agencies or entities, OHS AUTHORIZATION

Employment Authorization Document provided it contains a photograph or

Certification of report of birth issued information such as name, date of birth, 2.

that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms 1-766) DS-1350, FS-545, FS-240)

3. School ID card with a photographFor a nonimmigrant alien authorized 3. Original or certified copy of birthto work for a specific employer 4. Voter's registration card certificate issued by a State.because of his or her status: county, municipal authority, or

5. U.S. Military card or draft record territory of the United Statesa. Foreign passport; and

b. Form 1-94 or Form l-94A that has 6. Military dependent's ID card bearing an official seal

the following: U.S. Coast Guard Merchant Mariner 4. Native American tribal document

(1) The same name as the passport; Card 5. U.S. Citizen ID Card (Form 1-197)

and8.

(2) An endorsement of the alien'sNative American tribal document

6. Identification Card for Use of

nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United

that period of endorsement has government authority States (Form 1-179)

not yet expired and theproposed employment is not in For persons under age 18 who are 7. Employment authorization

conflict with any restrictions or unable to present a document document issued by the

limitations identified on the form. listed above: Department of Homeland Security

Passport from the Federated States of Micronesia (FSM) or the Republic of 10. School record or report card

the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospijal record1-94 or Form l-94A indicatingnonimmigrant admission under the 12. Day�care or nursery school recordCompact of Free Association Betweenthe United States and the FSM or RMI

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.

Fonn 1-9 07/17/17 N Page 3 ofJ

DIRECT DEPOSIT AUTHORIZATION

I hereby elect to participate in the Direct Deposit of my paychecks. I authorize Dixie District School Board

to initiate credit entries for Direct Deposit (a type of ACH transaction) to my bank account at the

FINANCIAL INSTITUTION indicated below. In the event that an erroneous entry is made, I further

authorize Dixie District School Board to use a credit or debit entry to correct the error. I acknowledge

that the origination of the ACH transactions to my bank account must comply with the provisions of the

laws of the United States of America.

NEW ENROLLMENT D OR CHANGE IN BANK OR ACCOUNT NUMBER D

FINANCIAL INSTITUTION. ___________________ _

This authority is to remain in full force and effect until Dixie District School Board has received written

notification from me for the termination. The written notice must be received in such a timely manner

that it will allow a reasonable opportunity to act on the termination by both Dixie District School Board

and my FINANCIAL INSTITUTION.

EMPLOYEE'S PRINTED NAME. __________________ _

Signature ______________ _ Date _____________ _

Please attach a VOIDED CHECK to this form. The check is already encoded with the necessary Financial

Institution's Routing and Transit numbers and employee's account number. (Voiding can be

accomplished by writing VOID across the face of the check) If you do not have checks a statement from

your Financial Institution with the correct account numbers will be sufficient. If you chose not to sign up

for direct deposit, your check will be mailed to the address on the payroll system .

•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

I choose not to sign up for Direct Deposit and understand that my checks will be mailed to the address I

have provided to the Payroll Department. If for some reason my paycheck is lost in the mail, has

incorrect information or for any reason something must be changed, I understand my check will not be

reissued until 5 business days have expired.

Signature ______________ _ Date. ____________

_ PLEASE SEE MRS. VAL HENSON IN PAYROLL for Direct Deposit changes. 352-541-6264

'

Loyalty Oath

I, _________________ ____, a citizen of the State of Florida and of the United States of America, and being employed by or an officer of the Dixie District School Board and a recipient of public funds as such employee or officer, do hereby solemnly swear or affirm that I will support the Constitution of the United States of America and of the State of Florida.

NAME (please print) SIGNATURE

DATE

DRUG FREE WORKPLACE

No employee of the School Board shall manufacture, distribute, dispense, possess, or use in the workplace any alcoholic substance, and intoxication for auditory, visual, or mental altering barbiturate, marijuana, or any other controlled substance, as defined by Federal or State law or rule, or any counterfeit of such drugs or substances all being collectively referred to as drugs.

"Workplace" is defined to mean the site for performance of work done in connection with employment. That includes any school building or any sponsored or school-approved activity, event, or function, such as field trip or athletic event, where students are under the jurisdiction of the School District.

As a condition of employment:

1. An employee shall notify his or her supervisor of his or her conviction of violation of any criminal drug statuteoccurring in the workplace no later than (5) days after such conviction.

2. After such notification, the supervisor shall immediately notify the Superintendent of such conviction.

3. The contract of an employee who violates the terms of this policy may be non-renewed or his or heremployment may be suspended or terminated. However, at the discretion of the Board, in lieu of non­renewal, suspension, or termination, such employee may be allowed to participate in and satisfactorilycomplete a drug abuse assistance or rehabilitation and reentry program approved by the Board. Anytreatment will be at the expense of the employee. Any employee seeking information concerning any drugand/or alcohol counseling, rehabilitation, and reentry program that is available to them may get thisinformation from their immediate supervisor.

4. Sanctions and discipline against employees, including non-renewal, suspension, and termination shall be inaccordance with prescribed School District procedures and shall be commenced within 30 days of receivingnotice of an employee's conviction.

5. An employee who violates this policy is subject to criminal prosecution.

6. All current and prospective employees shall be notified of this policy and that its provision shall be a conditionof employment.

I hereby acknowledge that I have read, understand and will uphold the Dixie District School Board Policy on Drug Free Workplace.

NAME SIGNATURE

DATE

DIXIE DISTRICT SCHOOLS

Security Policy

I have read Use and Termination from DATA Base and Network Logons Policy as outlined in School Board Policy 8.341.

I understand that the computer system is the property of Dixie District Schools and should be used for school business. Employee use of the network is considered consent to the policy and to management's right to review all technology areas which includes but is not limited to computers, telephones, email and voice mail.

Foul, offensive, defamatory, pornographic or other inappropriate communication is prohibited. Employers and employees are liable for anything that can be construed as harassment that takes place over the network.

I understand that I do not have a personal privacy right in any matter created, received, or sent from the E-mail system. E-mail can be read or intercepted by others, including inadvertent disclosure, accidental transmission to third parties, or purposeful retransmission to another employee's internal mailing list. Anything I do over the network is public information and is subject to review.

E-mail policy violations will subject an employee to disciplinary action.

I understand that email received through this account is subject to Florida laws governing public records and federal laws. E­mail created or received by school employees in connection with official business, which perpetuates, communicates or formalizes knowledge, is subject to the public records law and is open for inspection. If your e-mail falls within the definition of a public record, you may not delete it except as provided in Florida record retention schedule. Unless it falls within one of the specific exemptions described in the public records statute, you must produce that e-mail message to any person upon request. A person need not have a "legitimate" need for public records to be entitled to inspect them.

I understand that policy prohibits the theft or other abuse of computing resources. Such prohibitions apply to electronic mail services and include (but are not limited to) unauthorized entry, use, transfer, and tampering with the accounts and files of

others, and interference with the work of others and with other computing facilities. Under certain circumstances, the law contains provisions for felony offenses. Users of electronic mail are encouraged to familiarize themselves with these laws

and policies.

I understand that electronic mail services may be used for incidental personal purposes provided that such use does not: directly or indirectly interfere with the operation of computing facilities or electronic mail services; interfere with the em ail user's employment or other obligations to the school system. Email records arising from such personal use may, however, be subject to the same rules as other school email. I understand that there is no confidentiality or privacy in electronic mail. Users, therefore, should exercise extreme caution in using email to communicate confidential or sensitive matters. This does not include uses requiring substantial expenditures of time, uses for profit or uses that would otherwise violate company policy with regard to employee time commitments or company equipment.

I understand that email or electronic messaging systems cannot be used to infringe the copyright or other intellectual property rights of third parties, to distribute defamatory, fraudulent or harrassing messages, or otherwise to engage in any illegal or wrongful conduct.

I understand that I am not to divulge personal student or staff information to anyone via email unless that em ail is password encrypted and the password supplied in a separate manner from the encrypted email.

I understand that I am not to share my user logon credentials and passwords with anyone even if they work in the system. If someone has a need to access my data I will have the contact MIS staff for logon credentials to the network, phone system and NEFEC.

Signature (Print Name and Sign on line Above)

Location:

Date

•

CHAPTER 8.00 - AUXILIARY SERVICES

8.341

USE AND TERMINATION FROM DATA BASE AND NETWORK LOGONS

POLICY:

(1) Telecommunications network facilities, such as FIRN (Florida InformationResearch Network) and Internet, are to be used for providing expandedlearning opportunities for students and educators. The District providedaccess must be used in a responsible, efficient, ethical and legal manner.Failure to adhere to this policy and guidelines may result in suspension orrevocation of the user's network access and other disciplinary action asfound in the Dixie County School Board Code of Student Conduct andPolicies.

(2) Explanation of Internet: The Internet is an electronic superhighwayconnection thousands of computers all over the world and millions ofindividual subscribers. The user will have access to worldwide electronicmail communication, global information and news, public domain andshareware computer software of all types, discussion groups on manytopics, access to many libraries and many other sources of information.

(3) Parental Concerns:

(a) Access to computers and individuals worldwide brings theavailability of materials, which may not be considered to be ofeducational value in the context of the school setting. There maybe some material or communications which are not suitable forschool-aged children.

(b) Internet usage and other online activity by students shall bepursuant to staff authorization only and must be in pursuit of alegitimate pedagogical goal. Recreational use of the Internet andWorld Wide Web is prohibited. Internet or other online usage byminors shall be monitored by school staff. Staff shall takereasonable efforts to ensure that minors are not exposed toinappropriate or harmful matter on the Internet and World WideWeb.

•

Page 2 of 4 CHAPTER 8.00 - AUXILIARY SERVICES

8.341 (Continued)

School shall utilize an appropriate Technology Protection measure to block or filter Internet access for both minors and adults to visual depictions that are obscene; that constitute child pornography; or with respect to use of computers with Internet access by minors that is harmful to minors. An authorized person may disable the blocking or filtering measure during any use by an adult to enable access to bona fide research or other lawful purpose.

To ensure the safety and security of minor students, the following computer and Internet usage by minors is strictly prohibited, unless otherwise authorized by law:

(1) Use of electronic mail, chat rooms, and other forms of directelectronic communication, unless specifically authorized bystaff in pursuit of a legitimate pedagogical goal;

(2) Unauthorized internet, online, or other computer access,including so-called "hacking" and other unlawful activities;

(3) Disclosure use, and dissemination over the Internet ofpersonal information regarding minor students.

The District cannot, however, ensure that no user will access material that is within the District's educational mission, goals and policies. Should an inappropriate site be accessed the monitor should be turned off immediately and the supeNisor and technology specialist notified to collect the information and data from the machine.

(4) Guidelines

Internet access is coordinated through a complex association ofgovernment agencies and regional and state networks. The operation ofthe Internet relies heavily on the proper conduct of the users who mustadhere to strict guidelines.

(a) Acceptable Use -- The use of your account must be in support ofeducation and research that is consistent with the educational goalsand policies of Dixie District Schools. Use of other networks orcomputing resources must be consistent with the rules appropriatefor those networks.

•

•

Page 3 of 4 CHAPTER 8.00 - AUXILIARY SERVICES

8.341 (Continued)

This includes, but is not limited to: Copyrighted material, threatening or obscene material, or material protected by trade secret. Use · of Commercial activities, product advertisement, political lobbying, financial gain and illegal activity is prohibited. Use of profanity, obscenity and other offensive language is prohibited.

(b) Privileges -- The use of the Internet is not a right, but a privilege,and inappropriate use will result in cancellation of that privilege.Each individual who receives an account will receive informationpertaining to the proper use of the network. School and districtadministrators will decide what is inappropriate use and theirdecision is final. The District or service provider may close anaccount at any time deemed necessary or by recommendation ofthe administration, faculty or staff.

(c) "Netiquette" -- You are expected to abide by the generallyaccepted rules of network etiquette. Be polite. Do not use vulgaror obscene language. Students should not reveal their privateaddress or phone number or those of others. Even adults maywant to exercise caution in revealing name and address informationover the network. Electronic mail is not guaranteed to be private.

(d) Warranties -- The Dixie District Schools makes no warranties ofany kind, whether expressed or implied for the service it isproviding. Dixie District Schools will not be responsible for anydamages you suffer including loss of data. This District will not beresponsible for the accuracy or quality of information obtainedthrough this Internet connection.

(e) Security -- Security is a high priority. If you identify a securityproblem, you must notify a system administrator immediately. Donot show or identify the problem to others. Do not use anotherindividual's account or give your account number to anyone else.Attempts to log on as another user, or have another user log onwith your account will result in cancellation of your privileges. Anyuser identified as a security risk or having a history or problemswith other computer systems may be denied access. Immediatelyupon termination, resignation, leave of absence, or change of joblocation or classification the MIS staff shall delete the user accountin the network system as well as Finance and Student databasesystems.

..

CHAPTER 8.00 - AUXILIARY SERVICES

Page4 of 4 8.341 (Continued)

(f) Vandalism Vandalism will result in cancellation of yourprivileges. Vandalism is defined as malicious attempt to harm ordestroy data of another user, Internet, the Florida InformationResource Network (FIRN) or other networks. This includes thecreation of, or the uploading of, computer viruses on the Internet orhost site.

(g) Updating your user information -- You may occasionally berequired to update your registration, password and accountinformation to continue Internet access. You must notify the districtof any changes in your account information (address, school, etc.)

(h) Exception of Terms and Conditions -- All terms and conditions asstated in this document are applicable to all users of the Internetand other networks. These terms and conditions reflect anagreement of the parties and shall be governed and interpreted inaccordance with the laws of the State of Florida and the UnitedStates of America.

STATUTO/lYACJTHORJTY: 1001.41; 1001.42, F.S.

LAWS IMPI.£MENT£D:

HISTORY:

1001.43, F.S.

Adopted: August 14, 2007 Revision Date(s): Formerly: New

1 RACE AND ETHNICITY DATA COLLECTION FORM

Name: __________________ _

Date of Birth: ___ �'---�'----

PLEASE ANSWER BOTH QUESTIONS 1 AND 2.

1. Are you Hispanic or Latino? (Please, choose only one.)

o No, not Hispanic or Latino

o Yes, Hispanic or Latino -A person of Cuban, Mexican, Puerto Rican, South orCentral American, or other Spanish Culture or origin, regardless of race.

2. What is your race? (Please mark all that apply.)

o American Indian or Alaska Native -A person having origins in any of theoriginal peoples of North and South America (including Central America) andwho maintains tribal affiliation or community attachment.

o Asian - A person having origins in any of the original peoples are the Far East,Southeast Asia, or the Indian subcontinent, e.g., Cambodia, China, India,Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, andVietnam.

o Black or African American - A person having origins in any of the black racialgroups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to"Black or African American."

o Native Hawaiian or Other Pacific Islander - A person having origins in any ofthe original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

o White - A person having origins in any of the original peoples of Europe, theMiddle East, or North Africa.

Signature: _______________ Date: ________ _

Welcome to the BENCOR FICA Alternative Plan

Dixie District Schools provides the BENCOR FICA Alternative Plan as an important retirement benefit for

all part-time, seasonal and temporary employees not covered under the Florida Retirement System.

This letter provides general information about the plan and outlines available resources for you to get

more detailed information.

Key Features of your FICA Alternative Plan

• All eligible employees are automatically enrolled in the program.

• All eligible employees make a 7.5% pre-tax contribution in to a retirement account in

their name.

• All contributions permanently save Social Security taxes.

• Income taxes are deferred on contributions to the plan until you withdraw the money.

• Contributions are 100% vested to you.

Where Can You Get More Information?

1. Your Employer's Benefits Department

Access Frequently Asked Questions and plan videos

through your employer's benefits department or

benefits web portal.

2. On-line

www.bencorplans.com

Click on the Participant Log On link to access your

personal account.

3. Customer Care Center

1-888-258-3422

(M-F 8:30 a.m. - 5:00 pm EST)

4. BENCOR Advisors:

Dan Adel

David Adel

(386) 755-9192

{386) 752-6895

FICA Alternative Plan Overview

The Dixie District Schools BENCOR 401(a) FICA

Alternative Plan (Plan) is a qualified retirement plan

under Federal tax law that covers part-time, seasonal

and temporary employees of the Di strict who are not

covered by the Florida Ret irement System. The Plan

provides an alternative benefit to Social Security and

exempts you from FICA (Social Security) payroll taxes.

You continue to pay Medicare taxes on your wages.

Enrollment in the Plan is automatic for every employee

who works in a position covered by the Plan.

How much is contributed? You contribute 7.S% of your

wages on a pre-tox basis (for income tax purposes)

instead of paying Social Secur ity taxes that otherwise

would be determined and paid by you on an after-tax

basis. You will see your Plan contribution amount

reflected on your paycheck stub. Contributions are

cred ited to an individual account in your name under

the Plan.

How can I access my account? Go to

www.bencorplans.com, click on Participant Log On,

then select the Get Started box and follow the prompts

to create your personalized user ID and password.

How is my account invested? The Plan offers different

investment opt ions in wh ich you may choose to invest

amounts contributed to your account. If you do not

choose investment options, your account will be

invested automat ically in the guaranteed option, wh ich

may or may not be the best opt ion for your particular

circumstances. Therefore, It is very important for you

to log on to your account at www.bencorplans.com as

soon as possible to obtain informat ion about all the

ava ilable investments and choose the options that are

appropriate for your own objectives and preferences.

Can I withdraw my account? Your account is always

100% vested and belongs only to you. The balance of

your account will be available 5 months aher your

termination of employment, retirement or total

disability. In the case of your death, the benef1c1ary or

benef iciar ies you name under the Plan w ill be able to

withdraw your account balance. Funds may be

withdrawn as a lump sum cash distribution, which Is

taxable for the year of withdrawal, or as a direct

rollover to an IRA or eligible retirement plan, which

defers your income tax

obligation. To request a withdrawal, download a

Distribution Request Form from

www.bencorplans.com. Additional information about

income taxes and rollovers is included with the form

Your account is subject to the IRS Required Minimum

Distribution rules aher you reach age 70 ½, or

retirement, if later.

Individuals who are "active participants" for the year in

certain tax-advantaged retirement plans, such as this

FICA Alternative Plan, are subJect to federal tax law

lim itations on deducting contributions for the same

year to an IRA account. These hm1tat1ons also may

affect a spouse's IRA deductions. Consult an

independent tax advisor if you wish to take federal

income tax deductions for contr ibutions to an IRA.

Will I receive statements? Annual statements show ing

your account activity and ending balance are provided

after the close of each calendar year. You may enroll in

e-statements on line to �ave mail time, paper and ink.

Are there any fees? There are no adm inistrat ive fees

charged to your account unless your balance is less

than $1,000 and no contributions have been made to

your account for more than two years. At that t ime, if

you do not elect a distribution, a monthly maintenance

fee will apply.

How can I get mare information? To logon to your

account for plan and account information, go to

www.bencorplans.com Click on the Participant Log

On link to access your account. Logon tips for first time

visitors are located on the logon page. Aher logging on,

vIsIt the Communications section and choose Plan

Related Forms for an overview of the plan and website,

or dial a Bencor Customer Service Representative at 1-

888-258-3422. Representatives are available Monday -

Friday, 8:30 a.m. through 5:00 p.m., Eastern Time.

lilJBENCOR

l!BENCOR

, www bencorplans.com

Online

Click on Participant Login, select your

State, County and Employer then

click on Log In. Enter your social

security number as the User ID and the last four digits of your social

security number as the Password.

Select Participant from the drop

down and Login, follow the prompts

to create your personalized security

questions, user ID and password.

IBI \COR ___ ,

-- - - -- - ---·

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.... _..... -

., __

I -

•

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w o kr o v t,,out you

Once you have signed in, you can review the current status of your account,

make changes, and access tools to help you personalize your retirement strategy.

From the main menu, scroll over the five tabs- Dashboard, Transactions,

Performance, Statements/Forms, Tools and Support - and select the action you

want to take from the drop- down lists.

Check Account Balance

• Balance automatically appears on My Dashboard page (in the Dashboard menu

at the top of the screen).

• For account balance by fund, review "My Portfolio" on My Dashboard.

Review Investment Performance

• To get performance and fee details for all the funds in your plan, simply click on

the fund name on any page. This will display performance, as well as links to

the fund fact sheet and prospectus.

Change Future Investment Allocations (new contributions)

• To choose or change how new contributions will be invested, in the

Transaction menu, click "Manage Investments" then "Change Elections".

Transfer Between Investment Options (current assets)

• To transfer balances between individual or groups of funds in the Transactions

menu, click "Manage Investments" then" Transfer Funds".

Forms and Beneficiary Information

• To locate forms and beneficiary information, in the Forms & Reports menu, select

"Forms". You can also update your Beneficiary information online by selecting

the gear icon O in the upper right of the screen.

Customer service

• From the Support menu, select "Live Chat" to talk with a Client Care Manager,

or "Contact Us" for email and phone information.

First-Time Callers

• Call 866-296-97U, option 3

• Enter your Social Security number.

• Enter your Personal Identification

Number (PIN) - last four digits of your

Social Security number.

866-296-9712

1 2 3

4 5 f,..1 �. '

7 8 i':j,;• ./,' 'l

* 0 #

+.l a

Frequent Users

• Call 866-296-9712, option 3.

• Enter your Social Security number.

• Choose the account you wish to

access.

• Enter your PIN.

Call 866-296-9712

Check Account Balance

• Personal account information, press 1; then

• For balance information, press 1.

Review Investment Performance

• Personal account information, press 1; then

• For current investment rates of return, press 2.

Change Future Investment Allocations (new contributions)

• Personal account information, press 1; then

• For investment information, press 2.

Confirmation sent the following business day.

Transfer Between Investment Options (current assets)

• Personal account information, press 1; then

• To transfer between funds, press 3.

Confirmation sent the following business day.

Customer Service

• From the main menu, for customer service, press 1.

lifflBENCOR

PERSONNEL FILE UPDATE NEEDED

Public records are available for inspection, examination and duplication according to Florida Statute. There are exemptions under particular circumstances. For the employees that meet the criteria outlined below, certain elements of your personnel file such as home addresses and telephone numbers are exempt from the Public Records Act.

__ I do not qualify for exempt status. Sign at the bottom and return.

__ I do qualify for exempt status based upon the criteria I have checked below.

□

□

□

□

If you choose this option, you must check the criteria below that best describes your

exemption status. After checking a box below, sign at the bottom and return.

I am the : Actual Person Husband Wife

(Circle one of the above)

Son Daughter of

Active and former law enforcement, firefighters, correctional and correctional probation officers that are currently or have been reported under special risk or special risk administrative support plan or class codes.

Active or formal law enforcement, firefighters, correctional and correction probation officers that are currently in or have been in DROP or rehired retiree.

Local government employees whose responsibilities include revenue collection and enforcement of child support enforcement.

Active or former human resource, labor relations, or employee relation directors, assistant directors, managers, or assistant managers of any local government or water management district whose duties include hiring and firing employees, labor contract negotiations, administration, or other personnel-related duties.

□ Current or former code enforcement officers. Spouse or dependent of one of the qualifiedexemptions listed above.

Employee Signature:. _____________ _

Employee Name Printed:. ____________ _

Date:. ___________________ _

Dixie District Schools

Patient Protection and Affordable Care Act

Health Insurance Coverage Checklist

Name:

Address:

Employment Start Date:

Do you have current Health Insurance Coverage? Yes __ _ No __ _

If Yes, Who is the Health Insurance Carrier:

What are the effective dates of coverage?

Are you planning on keeping your Health Insurance?

FLORIDA NEW HIRE REPORTING FORM

Employee Information

Social Security Number: _______________ _

Employee Name:. __________________ _

(must be listed as it printed on your social security card)

Employee Address:, _________________ _

City/State/Zip Code: ________________ _

Date of Hire: _________ Date of Birth:. _____ _

___ Payroll Verified this form to Social Security Card (Erica)

___ SS # Verification (Val)

___ Florida New Hire Reporting (Erica)

___ FRS Verification of prior service (Val)

Florida Retirement System (FRS) - Certification Form I This form is not an offer of employment or an enrollment form. 1f hired, a Retirement Choice kit may be mailed to your home with enrollment instructions.

Name _________________________ _ SSN (last 4 digits) ____________ _

Agency Name __________________________________________ _

Previous or Current FRS Employer ___________________________________ _

11�rr�•..-�••••�m�,•�����,tif!1WJ1t1m�••1�&11I. I have never been a member of a State of Florida administered retirement plan.

STOP HERE

SIGNATURE DATE

II. I was or currently am a member of the following State of Florida administered retirement plan (also complete Section Ill or IV) 1D FRS Pension Plan (incl. DROP) D FRS Investment Plan D State University System Optional Retirement Program (SUSORP) D State Community College System Optional Retirement Program (SCCSORP) D Senior Management Service Optional Annuity Program (SMSOAP) D Other

Ill. I am not retired from any State of Florida administered retirement plan. I understand that if it is later determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or after my DROP termination date, or at any time during the 7th through the 12th months after I retired orafter my DROP termination date, I must repay all unauthorized benefits received (see Section IV for de­tails). or. if in the Investment Plan, terminate my employment. My employer may also be liable for repaying any unauthorized benefits I received.

SIGNATURE DATE

IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement ef­fective date, DROP termination date, or date I received my first distribution from the FRS InvestmentPlan, SUSORP, SCCSORP, SMSOAP, or other plan was ________ _

I understand that as a Pension Plan retiree: a. If I am employed by an FRS-covered employer in any type of position' during the first 6 calendar

months after I retired or after my DROP termination date, my retirement and DROP sJatus arevoided, all retirement and DROP benefits I received must be repaid, 3 and I must reapply forretirement in order to receive future benefits.

b. If I am reemployed by an FRS-covered employer at any time during the 7th through the 12th monthsafter I retired or after my DROP termination date, my monthly retirement benefit must besuspended4 and any unauthorized benefits received must be repaid.3 My employer may also beliable for repaying any unauthorized benefits I received.

I understand that as an Investment Plan, SUSORP, SCCSORP, or SMSOAP retiree: a. If I am employed by an FRS-covered employer in any type of position2 during the first 6 calendar

months after I retired, I must repay3 any benefits received or terminate employment for anadditional period to satisfy the 6 calendar month termination requirement.

b. If I am reemployed by an FRS-covered employer at any time during the 7th through the 12th monthsafter my retirement. I will not be eligible for additional distributions until I terminate employment or complete 12 calendar months of retirement.4

SIGNATURE DATE

1 If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you terminated FRS-covered employment. You may have a one-time 2nd Election to switch FRS retirement plans. Also, alternative retirement programs are available to certain employ­ees. Contact your employer for deadline and other information. 2Positions include OPS, temporary, seasonal, substitute teachers, adjunct professors, part-time, full-time, regularly established, etc. 3Florida law requires a return of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination or reemployment provisions. Similar provisions apply to unauthorized SUSORP, SCCSORP, or other state-administered plan distributions - contact that plan's administrator for details. 4 There is one exception to the restrictions on reemployment limitations after retirement. If you are a retired law enforcement officer, you may only be reemployed as a school re­source officer by an FRS-covered employer during the ?1h through 12th months after your retirement date or after your DROP termination date and receive both your salary and re­tirement benefits.

CERT Rev 01/1919-11.009 F.A.C. EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE'S PERSONNEL RLE. DO NOT SEND THfS FORM TO THE FRS, UNLESS REQUESTED.