PRE-EMPLOYMENT CHECKLIST - spartin.net Packet Printable.pdfMANAGER TO COMPLETE THIS FORM NOT EMPLOYEE ... PRE-EMPLOYMENT CHECKLIST ... disciplinary action up to and including termination

MANAGER TO COMPLETE T H I S FORM NOT EMPLOYEE N e w H i r e / R e - H i r e E m p l o y m e n t F o r m s

E m p l o y e e Name.

Pos i t i on S t o r e #

F i rs t d a y o f w o r k Pay Rate.

S e n d t o t h e Payro l l D e p a r t m e n t f o r al l New a n d R e - H i r e e m p l o y e e s .

C h e c k w i t h pay ro l l d e p a r t m e n t f o r p r e v i o u s e m p l o y m e n t

1-9 f o r m ( M u s t be c o m p l e t e d w i t h i n 2 4 h o u r s )

A f f i r m a t i v e A c t i o n D a t a Record

W - 4 f o r m

A p p l i c a t i o n f o r E m p l o y m e n t a l o n g w i t h d o c u m e n t s i n i t i a l ed a n d s i g n e d by e m p l o y e e .

M a k e s u r e t h e e m p l o y e e has f i l led o u t t h e s e f o r m s c o m p l e t e l y a n d c o r r e c t l y a n d s i g n e d w h e r e n e c e s s a r y b e f o r e s e n d i n g t h e m t o t h e o f f i ce . P lease , no e m p l o y e e s s h o u l d s t a r t u n t i l al l o f t h e f o r m s a re c o m p l e t e d .

Has t h e e m p l o y e e w o r k e d d u r i n g t h e c u r r e n t p a y pe r i od? I f s o , has t h e n a m e a n d h o u r s w o r k e d b e e n a d d e d t o t h e c o m p u t e r t i m e s h e e t ? .

No h i r e is c o m p l e t e d u n t i l al l f o r m s a re f i l l ed o u t , c h e c k o f f a n d s e n t t o t h e Payro l l D e p a r t m e n t .

PRE-EMPLOYMENT CHECKLIST

Property of Spartin Investments LLC and Speedy's Convernience One 1

Employee n

n s

Personal Information

Full Name : Last

A d d r e s s :

First M.I.

Street Address Apartment/Unit #

City

H o m e Phone :

State ZIP Code

Al te rna te Phone :

Emai l

Emergency Contact Information

Full Name : Last

A d d r e s s :

First M.I.


City State ZIP Code

Pr imary Phone: A l te rna te Phone :

Re la t ionsh ip :

Emergency Contact Information

Full Name : Last

A d d r e s s :

First M.I.


City State ZIP Code

Pr imary Phone:

Re la t ionsh ip :

A l te rna te Phone :

EMPLOYEE INFORMATIONSPARTIN INVESTMENTS LLC AND SPEEDY'S CONVENIENCE ONE


Employee’s initials __________ Manager’s initials __________

WELCOME LETTER

You can help us be the Benchmark!

The success of Spartin Investments LLC and Speedy’s Convenience One depends upon the quality of the relationships between our employees, customers, vendors, owner’s representatives, and the general public. Our customers’ impression of Spartin Investments LLC and Speedy’s Convenience One and their interest and willingness to stay with us is dependent upon how you decide to treat them every day. In a sense, regardless of your position, you are Spartin Investments LLC and Speedy’s Convenience One’s ambassador. The more goodwill you promote, the more our clients will respect and appreciate you, Spartin Investments LLC and Speedy’s Convenience One, and our services. Below are several things you can do to help give clients a good impression of Spartin Investments LLC and Speedy’s Convenience One. These are the building blocks for our continued success.

1. Act competently and deal with clients in a courteous and respectful manner 2. Communicate pleasantly and respectfully with other employees at all times.

3. Follow up on orders and questions promptly, provide businesslike replies to

inquiries and requests perform all duties in an orderly manner.

4. Take great pride in your work and enjoy doing your very best.

Congratulations on your hire. We are excited to have you as part of our team. Spartin Investments LLC and Speedy’s Convenience One



EQUAL EMPLOYMENT OPPORTUNITY

Spartin Investments LLC and Speedy’s Convenience One’s continuing policy is to effort Equal Employment Opportunity to qualified individuals regardless of their race, color, sex, religion, age, creed, marital status, national origin, ancestry, physical or mental disability, sexual orientation, affection preference, veteran status or citizenship status, or any other classification protected by law. This policy of equal opportunity encompasses all aspects of the employment relationships, including applications and initial employment, promotion and transfer, selection for training opportunities, wage/salary administration, recruiting, hiring, reassignments, sponsored training, compensation, benefits, layoff and rehires, termination of employment, recreation programs, and the application of services, retirement, seniority, employee benefits plan policy and other terms and conditions of employment as provided by law.



NON-HARASSMENT POLICY Spartin Investments LLC and Speedy’s Convenience One strives to provide a work environment that is pleasant, professional, and free from intimidations, hostility or other offenses which might interfere with work performance. Harassment of any sort – verbal, physical, visual – will not be tolerated.

1. What is Harassment? Workplace harassment can take many forms. It may, be is not limited to, words, signs, offensive jokes, cartoons, pictures, posters, e-mail jokes or statements, pranks, sexual in nature. It may also take the form of other vocal activity including derogatory statements not directed to the targeted individual but taking the place within their hearing. Other prohibited conduct includes written material such as notes, photographs, cartoons, articles of a harassing or offensive nature, and taking retaliatory action against an employee for discussing or making a harassment complaint.

2. Responsibility All employees, regardless of their position(s), have a responsibility for keeping our work environment free of harassment. Any employee, who becomes aware of an incident of harassment, whether by witnessing the incident or being told of it, must report it to their immediate supervisor or the Management. When management becomes aware of the existence of harassment, it is obligated by law to take prompt and appropriate action, whether or not the victim wants Spartin Investments LLC and Speedy’s Convenience One to do so.

3. Reporting Any incidents of harassment must be immediately reported to their immediate supervisor or the Management. Upon receiving a report of harassment, an appropriate investigation and disciplinary action will be taken, if appropriate. All reports will be promptly investigated with due regard for the privacy of everyone involved. However, confidentiality cannot be guaranteed. Any employee found to have harassed a fellow employee or subordinate will be subject to severe disciplinary action up to and including termination. Spartin Investments LLC and Speedy’s Convenience One will also take any additional action necessary to appropriately remedy the situation. Retaliation of any sort will not be tolerated. No adverse employment action will be taken for any employee making a good faith report of alleged harassment.



SEXUAL HARASSMENT/DISCRIMMINATION POLICY The Equal Employment Opportunity Commission (EEOC) has issued guidelines setting forth the Commission’s interpretation regarding discrimination and sexual harassment as a violation of Title VII of the Civil Rights Act of 1964. These guidelines are consistent with store’s longstanding policies that discrimination against employees or job applicants on the basis of race, religion, color, sex, age, national origin, handicap, veteran status or any other protected status or condition; and that conduct creating an offensive working environment will not be tolerated and those violating this practice may be subject to disciplinary action up to and including discharge. Any applicant or employee who feels that he or she being subjected to sexual harassment or being discriminated against is urged to contact the main office at (800) 872-5003. All allegations and complaints will be investigated and kept strictly confidential by the officers of Spartin Investments, LLC. I,_________________________, have read the above statements and understand the procedures to be used in the event I witness or am subject to sexual harassment or discrimination during my employment with Spartin Investments LLC and Speedy’s Convenience One. Signature:__________________________ Date:_____________



EMPLOYEE WORK SCHEDULE POLICY You are expected to report to work on time, dressed appropriately, and ready to work whenever you are scheduled or called in to work. Unnecessary absenteeism and lateness is expensive, disruptive, and places an unfair burden on other employees and your supervisor. Unsatisfactory attendance will also result in disciplinary action up to and including dismissal. If you are going to be late or absent for any reason, you are required to notify your supervisor at a minimum of 2 hours in advance of your shift. Explain why you are going to be absent and when you expect to return to work. NOTE: IT IS YOUR REPSONSIBILTY TO INSURE THAT PROPER NOTIFICATION

IS GIVEN. ASKING ANOTHER EMPLOYEE, FRIEND AND RELATIVE TO GIVE THIS NOTIFICATION IS NOT CONSIDERED PROPER, EXPCEPT UNDER EMERGENCY CONDITIONS.

Any employee who fails to give such notification will be charged with an unexcused absence. Any no call/no show by an employee will be considered by management as job abandonment. If you are absent because of an illness for three (3) or more successive days, your supervisor may request that you submit written documentation form your doctor stating you are able to resume normal work duties before you will be allowed to return to work.



ALCHOHOL AND SUBSTANCE ABUSE Spartin Investments LLC and Speedy’s Convenience One prohibits at all times the unlawful manufacture, sale, distribution, use, dispensation, receipt, transportation or possession of illegal drugs or unauthorized control substances on the Company’s premises or while engaged in business for the Company off the premises. Spartin Investments LLC and Speedy’s Convenience One also prohibits the unauthorized use of alcoholic beverages on the premises. Further, it is a violation of Spartin Investments LLC and Speedy’s Convenience One policy for anyone to engage in work for the Company or to report to work in an impaired or intoxicated condition or under the influence of alcohol, drugs, or illegal substances. This policy applies to all regular and part-time employees and temporary workers of Spartin Investments LLC and Speedy’s Convenience One as well as to all consultants, vendors, and other individuals providing services to the Company at any time on the premises or while engaged in business for the Company. Employees may be required to submit to random drug and alcohol abuse screenings.



FRATERNIZATION POLICY

Spartin Investments LLC and Speedy’s Convenience One has a policy of not allowing co-workers who are romantically involved or dating to work together or to work under circumstances where one co-worker has supervisory authority over the other. This policy is necessary because of the inherent opportunity for one co-worker to take advantage of another co-worker during the course of employment under such circumstances. In the event such a situation has developed, Spartin Investments LLC and Speedy’s Convenience One will, at its sole option, either make another position available to one or both of the co-workers and transfer one or both of the co-workers or terminate one or both of the co-workers. I have read and fully understand the above Rules of Conduct for Spartin Investments LLC and Speedy’s Convenience One office employees. I hereby agree to abide by the foregoing rules. I further agree that my employment with Spartin Investments LLC and Speedy’s Convenience One is an “at will” nature; that I may resign at any time with or without reason and whether or not I violate any of the foregoing rules; and that any agreement between me and Spartin Investments LLC and Speedy’s Convenience One must be in writing or it is not enforceable.

______________________________________________________________________________ I,_________________________, have read the above statements and have received a copy of the documents for my referenced. I have reviewed this information with the hiring manager and do not have any questions in regards to the information in this packet. _________________________________________ ___________ Employee’s Signature Date



RULES OF CONDUCT The purpose of this notice is to review the Rules of Conduct for all Spartin Investments LLC and Speedy’s Convenience One Employees. The rules are not intended to be all-inclusive. Company shall, when it deems such action necessary, establish and publish additional rules. Any employee who violates a rule shall be subject to disciplinary action up to and including dismissal.

ALL EMPLOYEES SHALL:

Fulfill all assigned duties, tasks, and responsibilities in a professional and

efficient manner and according to the training that has been received. Maintain a neat and clean personal appearance; Promptly report any accidents, equipment malfunction, damage and theft; Be courteous and polite to all and conduct himself/herself in an appropriate

manner; Perform his/her job responsibilities in a prompt, efficient, non-negligent and

careful manner; Handle all equipment and supplies with great care, ensuring the durability

and extending the life of such items.

All EMPLOYEES SHALL NOT:

Use a personal cell phone or a company phone for personal use unless it is

an emergency. Texting for social purposes or playing games on your cell phone is strictly prohibited;

Allow non-employees, including family members and children, to loiter around the cash wrap or on company property;

Fail to report for an assigned shift unless previously excused by his/her supervisor;

Maintain excessive amounts of cash in cash register or outside of safe or in an unlocked safe;

Allow credit purchases unless previously authorized by his/her supervisor. Engage in an unsafe work practice or willfully violate any safety regulation; Engage in abusive or profane language, horseplay, or gambling on the

premises; Consume while on shift, or arrive at work under the influence of, drugs or

alcohol; Steal or take anything regardless of value from the office or store; Carry or possess any type of weapon or firearm on the premises, such

activity is strictly and absolutely prohibited; Take gasoline or merchandise without first paying for and registering such

sale (payment must be made to another employee); Display disloyal, unethical, dishonest or improper conduct, or disobey his/her

supervisor’s directions.


APPLICATION FOR EMPLOYMENT(Pre-Emplo yment Questionnaire) (An Equal Opportunity Employer)

PERSONAL INFORMATION

NAME

DATE

SOCIAL SECURITY NO.

LAST FIRST MIDDLE

PRESENT ADDRESSSTREET CITY STATE ZIP

PERMANENT ADDRESSSTREET CITY STATE ZIP

PHONE NO. ARE YOU 18 YEARS OR OLDER? Yes ❑ No ❑

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYEDIN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? Yes ❑ No ❑

EMPLOYMENT DESIREDDATE YOU SALARY

POSITION CAN START DESIRED

IF SO MAY WE INQUIREARE YOU EMPLOYED NOW? OF YOUR PRESENT EMPLOYER?

EVER APPLIED TO THIS COMPANY BEFORE? WHERE? WHEN?

REFERRED BY

*NO OF*DID YOUEDUCATION NAME AND LOCATION OF SCHOOL YEARS

GRADUATE?SUBJECTS STUDIED

ATTENDED

GRAMMAR SCHOOL

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS OR CORRESPONDENCE

SCHOOL

GENERALSUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTlVITIES: (CIVIC ATHLETIC ETC.)EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED. SEX. AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

U. S MILITARY OR PRESENT MEMBERSHIP INNAVAL SERVICE RANK NATIONAL GUARD OR RESERVES

*This form has been revised to comply with the provisions of the Americans with Disabilities Act and the final regulations and interpretive guidance promulgated by the EEOC on July 26. 1991.

(CONTINUED )

LAS

TF

IRS

TM

IDD

LE


FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).

DATEMONTH AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING

FROM

TO

FROM

TO

FROM

TO

FROM

TO

WHICH OF THESE JOBS DlD YOU LIKE BEST?

WHAT DlD YOU LIKE MOST ABOUT THIS JOB?

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

YEARSNAME ADDRESS BUSINESS ACQUAINTED

1

2

3

THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. [Fill in name of state.)IT IS UNLAWFUL IN THE STATE OF ________________________ TO REQUIRE OR ADMINISTER A LIE DETECTOR TESTAS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALLBE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.

Signature of ApplicantIN CASE OF EMERGENCY NOTIFY

NAME ADDRESS PHONE NO.

"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THATIF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF IAM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THATMY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANYTIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MYEMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. IUNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNEDBY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME,OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

DATE SIGNATURE

DO NOT WRITE BELOW THIS LINE

INTERVIEWED BY: DATE:

REMARKS:

NEATNESS ABILITY

HIRED: ❑ Yes ❑ No POSITION DEPT.

SALARY/WAGE DATE REPORTING TO WORK

APPROVED: 1. 2. 3EMPLOYMENT MANAGER DEPT. HEAD GENERAL MANAGER

This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Formis sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of theJob Applicant, may violate State and/or Federal Law.


Affirmative Action Voluntary Information Sheet

Completion Of Information Below Is Voluntary. Form is to be completed by applicant on a voluntary basis and is not for interview purposes. Form will be filed separately from application.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Applicant Information

______________________________________________________________________________________ Name LAST FIRST MIDDLE

Position(s) applied for Date of Application ______/______/______

Referral Source

Walk-In Government Employment Agency Private Employment Agency

Employee Relative School

Advertisement - Source ___________________ Other _________________________

Name of person who referred you (if applicable) __________________________________________

Please check one of the following Equal Employment Opportunity Identification Groups:

White (not of Hispanic origin)

Black (not of Hispanic origin) Hispanic

American Indian / Alaskan Native Asian / Pacific Islander Multiracial (having parents of different races)

For Administrative Use Only

Position(s) applied for Available Not Available Hired Yes No

Other positions considered for _______________________________________________________________

Position hired for _______________________________________________ Date of hire ______/______/_______

From the EEO job classifications listed below, which one best describes the position filled?

Officials and Managers Sales Workers Technicians Operatives (semi-skilled)

Professionals Office and Clerical Workers Service Workers Laborers (unskilled)Notes ______________________________________________________________________________________________________

Completed by _______________________________________________________________ Date ____/____/____Property of Spartin Investments LLC and Speedy's Convernience One 13

Form W-4 (2013)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. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2013 expires February 17, 2014. See Pub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends).

Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity

income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2013. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

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

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($95,000 if married), enter “2” for each eligible child; then less “1” if you have three to six eligible children or less “2” if you have seven or more eligible children.

• If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter “1” for each eligible child . . . GH Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 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 below.

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

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are 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

20131 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, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2013, 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 lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2013) Property of Spartin Investments LLC and Speedy's Convernience One 14

Form W-4 (2013) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2013 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1949) of your income, and miscellaneous deductions. For 2013, you may have to reduce your itemized deductions if your income is over $300,000 and you are married filing jointly or are a qualifying widow(er); $275,000 if you are head of household; $250,000 if you are single and not head of household or a qualifying widow(er); or $150,000 if you are married filing separately. See Pub. 505 for details . . . 1 $

2 Enter: { $12,200 if married filing jointly or qualifying widow(er)$8,950 if head of household . . . . . . . . . . .$6,100 if 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 2013 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2013 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2013 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $3,900 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

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

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter 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 2013. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2013. 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 0 5,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 30,000 430,001 - 42,000 542,001 - 48,000 648,001 - 55,000 755,001 - 65,000 865,001 - 75,000 975,001 - 85,000 1085,001 - 97,000 1197,001 - 110,000 12

110,001 - 120,000 13120,001 - 135,000 14135,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 16,000 1

16,001 - 25,000 225,001 - 30,000 330,001 - 40,000 440,001 - 50,000 550,001 - 70,000 670,001 - 80,000 780,001 - 95,000 895,001 - 120,000 9

120,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $72,000 $59072,001 - 130,000 980

130,001 - 200,000 1,090200,001 - 345,000 1,290345,001 - 385,000 1,370385,001 and over 1,540

All Others

If wages from HIGHEST paying job are—


$0 - $37,000 $59037,001 - 80,000 98080,001 - 175,000 1,090

175,001 - 385,000 1,290385,001 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 are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax 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.


Documents

PRE-EMPLOYMENT CHECKLIST - spartin.net Packet Printable.pdfMANAGER TO COMPLETE THIS FORM NOT EMPLOYEE ... PRE-EMPLOYMENT CHECKLIST ... disciplinary action up to and including termination