70LGLY18QSSB00008_Solicitation_and_Attachments.pdf

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U.S. Department of Labor Wage and Hour Division PAYROLL

(For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. NAME OF CONTRACTOR OR SUBCONTRACTOR ADDRESS OMB No.: 1235-0008 Expires: 02/28/2018

PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO.

(1) (2) (3) (4) DAY AND DATE (5) (6) (7) (9)

(8)

DEDUCTIONS

O

NAME AND INDIVIDUAL IDENTIFYING NUMBER

(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY

NUMBER) OF WORKER N

. O F

W

IT

H H

LD

iN G

E

XE

M

P

TI

N

S

WORK

CLASSIFICATION

T.

R

T.

HOURS WORKED EACH DAY

TOTAL

HOURS

RATE

OF PAY

GROSS

AMOUNT

EARNED FICA

WITH-

HOLDING

TAX OTHER

TOTAL

DEDUCTIONS

NET

WAGES

PAID

FOR WEEK

Rev. Dec. 2008

Rev. Dec. 2008

While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.

Public Burden Statement

We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W.

Washington, D.C. 20210

(over) nthai

Date

I, (Name of Signatory Party) (Title) do hereby state:

(1) That I pay or supervise the payment of the persons employed by on the (Contractor or Subcontractor)

; that during the payroll period commencing on the (Building or Work) day of , , and ending the day of , , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below:

(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

− in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below.

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

− Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below.

(c) EXCEPTIONS

REMARKS:

EXCEPTION (CRAFT) EXPLANATION

NAME AND TITLE SIGNATURE

THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE

31 OF THE UNITED STATES CODE.

address:

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FTC-FMD-42 (12/09) 1 of 2

CONTRACT NO. TITLE AND LOCATION DATE

REPORT NO.

CONTRACTOR (Prime or Subcontractor) NAME OF SUPERINTENDENT OR FOREMAN

WEATHER - A.M. TEMPERATURE - A.M.

WEATHER - P.M. TEMPERATURE - P.M.

EMPLOYER

SPEC.PARA.

AND / OR

DRAWING NO.

EQUIPMENT / MATERIAL RECEIVED TODAY

TO BE INCORPORATED IN JOB

(Description, Sizes, Quantity)

SUBMITTAL NO. OR

CERTIFICATION

DATE

APPROV

WERE THERE ANY LOST TIME ACCIDENTS THIS DATE?

REMARKS

RESULTS OF INSPECTION

TESTING

LOCATION AND / OR

ELEMENT OF WORK

TOTAL WORK HOURS FROM

START OF CONSTRUCTION

TOTAL WORK HOURS

ON JOB SITE THIS

DATE

CUMULATIVE TOTAL

OF HOURS FROM

PREVIOUS REPORT

HOURS

INSPECTION AND / OR TESTING

PERFORMED TODAY - - FOLLOW

WITH REPORT

DAILY REPORT TO INSPECTOR

LOCATION AND DESCRIPTION OF WORK

PERFORMED(Use additional sheets if required)

PRIME CONTRACTOR / SUBCONTRACTOR WORKFORCE

NUMBER TRADE

YES NO

Side 1

NON-DISCLOSURE AGREEMENT

Protected Critical Infrastructure Information (PCII)

DHS Form 11000-6 (08-04)

I, _______________________________________, an individual official, employee, consultant, or subcontractor of or to

_____________________ (the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer’s willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

Initials:

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical

Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law

107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager’s designee.

Sensitive Security Information (SSI)

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, “Protection of

Sensitive Security Information,” “Policies and Procedures for Safeguarding and Control of SSI,” as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

Other Sensitive but Unclassified (SBU)

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under

Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an

Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use

Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement

Sensitive (LES); Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

I understand and agree to the following terms and conditions of my access to the information indicated above:

2. By being granted conditional access to the information indicated above, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement and the laws, regulations, and directives applicable to the specifi c categories of information to which I am granted access.

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives applicable to the specifi c categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager’s designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program

Manager or the PCII Program Manager’s designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the

United States Government or the Authorized Entity. By granting me conditional access to information in this context, the

United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

DHS Form 11000-6 (08-04) Page 2

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure

Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order No. 12958, as amended; Section 7211 of Title 5, United

States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the

Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section

2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50

USC 421 et seq.) (governing disclosures that could expose confidential Government agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC 783(b)). The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are controlling.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

DHS Form 11000-6 (08-04)

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Acknowledgement

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.

Signature:

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

Signature:

WITNESS:

This form is not subject to the requirements of P.L. 104-13, “Paperwork Reduction Act of 1995” 44 USC, Chapter 35.

Badge Application Addendum for Non-U.S. Citizens, Lawful Permanent Residents and Naturalized U.S. Citizens

Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 552a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary.

Failure to provide requested information may result in denial of access to the FLETC property.

TO BE COMPLETED BY APPLICANT

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2.Country of Citizenship:

(List more than one if applicable)

Place of Birth:

(City, State and/or Country)

3. Status:

US Citizen (Naturalized)

Permanent Resident Provide A#

Non-Immigrant Status Provide I-94#

Employment Authorization Card Holder Provide A#

Border Crossing Card Holder Provide Card#

Other Status Indicate:

4. Non-US Citizens must provide copies of documentation related to their status in the US, including employment authorization, passport and visa.

ATTACHED:

if no Passport or Visa exists, insert "None" in provided space

Copy of Passport

Country of Issue: Passport Number:

Date:

Copy of Visa

Visa Number: Visa Type: Date:

Copy of Naturalization Certificate

Copy of Permanent Resident/Alien Card

Copy of Employment Authorization Card

Border Crossing Card

Other document verifying non-immigrant status

5. I certify the information provided is true and accurate to the best of my knowledge. I acknowledge that knowingly or willingly falsifying information in the document is a violation of 18 US Code Section 1001.

Applicant's Signature: Date:

FTC-OSPR-17A (8/17) Page 1 of 1

Badge Application Addendum for Non-U.S. Citizens, Lawful Permanent Residents and Naturalized U.S. Citizens

Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 552a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

TO BE COMPLETED BY APPLICANT

(Last, First, Middle)

(List more than one if applicable)

(City, State and/or Country)

3. Status:

4. Non-US Citizens must provide copies of documentation related to their status in the US, including employment authorization, passport and visa.

ATTACHED:

if no Passport or Visa exists, insert "None" in provided space

5. I certify the information provided is true and accurate to the best of my knowledge. I acknowledge that knowingly or willingly falsifying information in the document is a violation of 18 US Code Section 1001.

FTC-OSPR-17A (8/17)

9.0.0.2.20120627.2.874785 place of birth,, city, state and/or country:

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Other document verifying non-immigrant status check box: 0

Visa Type::

Date 2 digit month, 2 digit day, 4 digit year:

Applicant's Signature::

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DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

NAME-BASED CRIMINAL HISTORY RECORD INFORMATION CONSENT/INQUIRY FORM

I hereby give consent for the Federal Law Enforcement Training Centers (FLETC) to receive any State or Interstate Identification Index (III) criminal history record information pertaining to me, as authorized under state and federal law for individuals seeking employment or access with a criminal justice agency. Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 522a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

(Last, First, Middle)

(Nicknames, Maiden Names, etc.)

United States Citizen?

Are you a United States Citizen? Check yes or no

*If answer is "No" you must contact OSPR/Internal Security for required paperwork*

Residential Address:

Race/Ethnicity:

Check all that apply

Gender:

check male or female

I certify that the information provided is true and accurate to the best of my knowledge. I acknowledge that knowingly or willfully falsifying information in the document is a violation of 18 U.S. Code Section 1001.

AGENCY USE ONLY

Inquiry resulted in the following:

If results found:

Final Decision:

FTC-OSPR-17Z (5/17)

11.0.0.20130303.1.892433.887364

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Instructions for Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

OMB No. 1615-0047 Expires 03/31/2016

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Form I-9 Instructions 03/08/13 N Page 1 of 9

EMPLOYERS MUST RETAIN COMPLETED FORM I-9

DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

What Is the Purpose of This Form?

Form I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors.

General Instructions

Section 1. Employee Information and Attestation

Newly hired employees must complete and sign Section 1 of Form I-9 no later than the first day of employment.

Section 1 should never be completed before the employee has accepted a job offer.

Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any.

Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "N/A."

Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should be written as 01/23/1950.

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011.

E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number. Department of Homeland Security (DHS) may contact you if DHS learns of a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "N/A" if you choose not to provide this information.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

www.justice.gov/crt/about/osc

Form I-9 Instructions 03/08/13 N Page 2 of 9

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix.

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box.

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as directed by USCIS or U.S. Customs and Border Protection (CBP).

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement) Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/ I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block;

and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Preparer and/or Translator Certification

If you check this box:

1. A citizen of the United States

2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form:

www.uscis.gov/I-9Central

Form I-9 Instructions 03/08/13 N Page 3 of 9

2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and expiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unused fields.

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field.

5. Sign and date the attestation on the date Section 2 is completed.

6. Record the employer's business name and address.

7. Return the employee's documentation.

If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2:

a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);

and the program end date from Form I-20 or DS-2019.

Employers or their authorized representative must:

1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents.

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form I-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Form I-9 before the first day of employment if the employer has offered the individual a job and the individual has accepted.

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Form I-9. Employers are still responsible for completing and retaining Form I-9.

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Section 2. Employer or Authorized Representative Review and Verification

Form I-9 Instructions 03/08/13 N Page 4 of 9

2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field.

1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable.

When the employee provides an acceptable receipt, the employer should:

2. Record the number and other required document information from the actual document presented.

3. Initial and date the change.

1. Cross out the word "receipt" and any accompanying document number and expiration date.

By the end of the receipt validity period, the employer should:

See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.uscis.gov/I-9Central for more information on receipts.

Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have the option to complete a new Form I-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, if the employee's name has changed, record the name change in Block A.

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpired Employment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security card within 90 days.

Section 3. Reverification and Rehires

1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date of hire.

There are three types of acceptable receipts:

2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and a photograph of the individual. The employee must present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary I-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.

Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below.

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form I-9 for a new hire or when reverification is required.

Receipts

Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274) or I-9 Central (www.uscis.gov/I-9Central) for examples.

Unexpired Documents

For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided.

Form I-9 Instructions 03/08/13 N Page 5 of 9

b. Record the document title, document number, and expiration date (if any).

3. Complete Block C if:

a. The employment authorization or employment authorization document of a current employee is about to expire and requires reverification; or

b. You rehire an employee within 3 years of the date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.)

To complete Block C:

a. Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United States; and

2. Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originally completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form.

Also complete the "Signature of Employer or Authorized Representative" block.

1. Complete Block A if an employee's name has changed at the time you complete Section 3.

To complete Section 3, employers should follow these instructions:

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date.

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify:

1. U.S. citizens and noncitizen nationals; or

2. Lawful permanent residents who presented a Permanent Resident Card (Form I-551) for Section 2.

Reverification does not apply to List B documents.

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766, Employment Authorization Document.

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below.

What Is the Filing Fee?

USCIS Forms and Information

For more detailed information about completing Form I-9, employers and employees should refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274).

4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date.

For reverification purposes, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previously completed Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee's original Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is a more current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form.

Form I-9 Instructions 03/08/13 N Page 6 of 9

ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S.