Appendix_4_-_Special_Notices.pdf

APPENDIX 4 - SPECIAL NOTICES

Federal Open Channel Drainage Repair Work Order Contract Package 2

Contract No. 26-0694

In Pinellas County, Florida

CHANGES TO ITB:

Section 5.11 (A) of the ITB is amended to add the following:

The quantities shown on the “Pricing Proposal” (Schedule of Values) are approximate and only represent estimated planned requirements based on historical and anticipated needs. Pinellas County does not guarantee any maximum or minimum quantity, any range of quantities or the exact quantities shown for each item bid. The total bid amount will then be used to determine low bidder; however, actual payments under the awarded contract will be based on actual quantities completed.

Section 5.14. AFTER NOTICE OF AWARD TO CONTRACTOR: The term Preconstruction Conference shall mean: a review meeting prior to commencing each individual Work Order.

ASSIGNMENT OF WORK:

All work shall be executed by the contractor on an assignment-by-assignment basis, in the form of a Work Order authorized by the Engineer. Pinellas County does not guarantee Work Orders will be concurrent and/or consecutive. The Contractor shall perform no work under this Contract without the Engineer’s written authorization. The Contractor hereby agrees to waive any claim for compensation for any work performed without authorization.

Each individual location contained in a Work Order is to be considered an “individual project” such that all work, including demobilization and cleanup, must be fully completed in a reasonable time frame, as determined by the Engineer. The project limits shown on the location maps and/or plans contained in each Work Order are approximate; Contractor shall verify exact limits with the Engineer prior to beginning construction.

All work shall be performed in an expeditious and professional manner. The Contractor shall have sufficient crews and equipment to perform all work, including restoration, at the time the Work Order is assigned. The inability of the Contractor to meet contractual obligations, or to perform assigned work in a satisfactory manner, shall be grounds for reassignment of the work for construction by others. The Engineer reserves the right to add or delete sites and project locations from the Work Orders. There are no guaranteed Work Order locations in the “Pricing Proposal” (Schedule of Values).

In the event of a Federal Disaster Declaration, emergency projects may be distributed to the Contractor by the Engineer.

The Contractor shall only be compensated for that work satisfactorily completed. There will be no compensation to the Contractor for cancellation of the Contract or for any assigned work that is not constructed to the satisfaction of the Engineer. Prior to assignment of any Work Order, the Contractor shall prepare a detailed work plan for each project, which shall include a work schedule.

Sample projects provided in Appendix 6 are anticipated to be issued, however, are also subject to change and are not guaranteed. The capacity of this contract exceeds the needs of the sample projects and is intended to support future projects.

INSURANCE AND INDEMNIFICATION:

Contractor shall indemnify and name as additional insured Pinellas County and NRCS (National Resources Conservation Service). The contractor is advised if work is performed on local municipal roads or state roads in addition to unincorporated local roads, the contractor shall indemnify and name as additional insured Pinellas County, FDOT (Florida Department of Transportation), and/or the appropriate municipality. FEMA (Federal Emergency Management Agency) shall also be included as additional insured for work using funding from a FEMA agreement. Insurance requirements are shown in Section 6 of the contract document.

EXISTING PROPERTY MARKERS:

All property corners and section corners shall be protected through the contract period by the contractor, if a property corner is damaged, they will be restored by a Florida registered Professional Land Surveyor at no additional cost to the County.

RECORD DRAWINGS:

The Contractor shall supply Contract Documents, including but not limited to, a set of record drawings and signed and sealed contract Plans that are maintained by the Contractor for the express use of recording as-built information. Record drawings shall be submitted to the County upon Final Acceptance of the Project.

GRANT INFORMATION AND DISCLOSURE

This solicitation is either fully or partially grant-funded. In addition to other terms and conditions required by Pinellas County and the applicable federal agency, see exhibit B; all contracts awarded to the qualified Contractor are subject to all applicable requirements of 2 CFR Part 200, commonly known as Uniform Guidance, and are subject to all Executive Orders and legislative changes, both existing and as may be issued hereafter through bid submittal due date and related to the services provided under the contract.

EQUAL OPPORTUNITY COMPLIANCE

The Recipient, in accordance with the provisions of Title VI of the Civil Rights Act of 1964 (78 Stat. 252, 42 U.S.C. §§ 2000d to 2000d-4) and the Regulations, hereby notifies all bidders that it will affirmatively ensure that for any contract entered into pursuant to this advertisement, disadvantaged business enterprises will be afforded full and fair opportunity to submit bids in response to this invitation and will not be discriminated against on the grounds of race, color, or national origin in consideration for an award.

In accordance with Federal civil rights law and federal agency civil rights regulations and policies, federal agencies, offices, and employees, and institutions participating in or administering federal programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by a federal agency (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency.

To file a program discrimination complaint, complete a federal agency Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint at the federal agency.

USDA is an equal opportunity provider, employer, and lender.

DAVIS BACON ACT

The Davis Bacon Act does not apply to this contract.

OSHA REQUIREMENT

All contractors on NRCS assisted projects must perform work in accordance with Occupational Safety and Health Administration (OSHA) regulations and the Contract Work Hours Safety Standards Act (40 USC 3701-3708) as supplemented by Department of Labor regulations (29 CFR Part 5).

BUY AMERICA, BUILD AMERICA ACT

Contractor must adhere to the requirements of Buy America, Build America Act, See Exhibit C.

DISCLOSURE OF LOBBYING ACTIVITIES

If applicable, Contractor must fill out the Disclosure of Lobbying Activities form, see Exhibit A.

EMPLOYMENT ELIGIBILITY VERIFICATION FORM I-9

Contractor shall ensure that all employees complete the Employment Eligibility Verification Form I-9 to certify that they are eligible for lawful employment under the Immigration and Nationality Act (8 U.S.C.

§ 1324a), see Exhibit D. The Contractor shall comply with regulations regarding certification and retention of the completed forms.

GRANT FUNDING PROHIBITION

Contractor shall not engage with or provide any funding from this agreement to any entity or individual identified on any of the lists below.

1. U.S. Department of War: Entities Identified as Chinese Military Companies Operating in the United States in Accordance with Section 1260H of the William M. (“Mac”) Thornberry National Defense Authorization Act for Fiscal Year 2021 (Public Law 116-283). The recipient must utilize the 2025 list or the most current list published in the Federal Register.

2. U.S. Department of War: Response to Section 1286 of the National Defense Authorization Act for Fiscal Year 2019 (Public Law 115-232), as amended. The recipient must use the list cleared for publication on June 24, 2025, or the most current list released by DOW.

3. U.S. Department of State: State Sponsors of Terrorism List

4. U.S. Department of State: International Security and Nonproliferation List

5. U.S. Department of State: Foreign Terrorists Organization List

6. U.S. Department of Treasury, Office of Foreign Assets Control (OFAC), Consolidated Sanctions List which includes all OFAC non-SDN sanctions lists.

7. U.S. Department of Treasury, OFAC: Specially Designated Nationals (SDNs) List

8. U.S. Department of Treasury, OFAC: Additional Sanctions Lists which includes the below and any other similar list released by OFAC.

a. Sectoral Sanctions Identifications (SSI) List

b. Foreign Sanctions Evaders (FSE) List

c. Non-SDN Palestinian Legislative Council (NS-PLC) List

d. List of Foreign Financial Institutions Subject to Correspondent Account or Payable- Through Account Sanctions (CAPTA List)

e. Non-SDN Menu-Based Sanctions List (NS-MBS List)

f. Non-SDN Communist Chinese Military Companies List (NS-CMIC List)

9. Office of Management and Budget: Prohibition on certain telecommunications and video surveillance equipment or services (2 CFR 200.216(b))

10. a. Name and Address of Lobbying Registrant:

9. Award Amount, if known:

* Street 1

* City State Zip

Street 2

* Last Name

Prefix * First Name Middle Name

Suffix

DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 OMB Number: 4040-0013 Expiration Date: 02/28/2025

1. * Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. * Status of Federal Action:

a. bid/offer/application

b. initial award

c. post-award

3. * Report Type:

a. initial filing

b. material change

4. Name and Address of Reporting Entity:

Prime SubAwardee

* Name

* Street 1 Street 2

* City State Zip

Congressional District, if known:

5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime:

6. * Federal Department/Agency: 7. * Federal Program Name/Description:

Assistance Listing Number, if applicable:

8. Federal Action Number, if known:

b. Individual Performing Services (including address if different from No. 10a)

Prefix * First Name Middle Name

* Street 1

* City State Zip

Street 2

11.

* Last Name Suffix

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

* Signature:

Completed on submission to Grants.gov

Completed on submission to Grants.gov

*Name: Prefix * First Name Middle Name

* Last Name Suffix

Title: Telephone No.: Date:

Federal Use Only:

Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

Regulation/Statute Title 2 CFR Part 25 Universal Identifier and System for Award Management

2 CFR Part 170 Reporting Subaward and Executive Compensation Information

2 CFR Part 175 Award Term for Trafficking in Persons

2 CFR Part 180 OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement)

2 CFR Part 182 Governmentwide Requirements for Drug-Free Workplace (Financial Assistance)

2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards

2 CFR Part 400 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards

2 CFR Part 400.2 Conflict of Interest

2 CFR Part 415 General Program Administrative Regulations

2 CFR Part 416 General Program Administrative Regulations for Grants and Cooperative Agreements to State and Local Governments

2 CFR Part 417 Nonprocurement Debarment and Suspension

2 CFR Part 418 New Restrictions on Lobbying

Regulatory and Statutory Requirements

As a condition of a USDA award , the recipient and subrecipient(s) shall remain in compliance for the duration of the award with the terms and conditions of the award and all applicable laws, regulations, and Executive Orders, National Policy Requirements including, but not limited to the following, as applicable. They can be included as part of the award or incorporated in the award by reference. Agency specific regulatory and statutory requirements not identified below are the responsibility of the awarding agency in accordance with applicable laws and statutes of the United States.

2 CFR Part 421 Requirements for Drug-Free Workplace (Financial Assistance)

2 CFR Part 422 Research Institutions Conducting USDA Funded Extramural Research;

Research Misconduct

7 CFR Part 1, Subpart A Official Records

7 CFR Part 1b National Environmental Policy Act

7 CFR Part 3 Debt Management

7 CFR Part 15, Subpart A Nondiscrimination in Federally-Assisted Programs of the Department of Agriculture – Effectuation of Title VI of the Civil Rights Act of 1964

8 U.S.C. 1324a. Unlawful employment of aliens

29 U.S.C. 794 Nondiscrimination under Federal grants and programs

41 U.S.C. 6306 Interest of Member of Congress

41 U.S.C. 4712 Pilot program for enhancement of contractor protection from reprisal for disclosure of certain information

Executive Order (EO) 13513 “Federal Leadership on Reducing Text Messaging While Driving”

Executive Order (EO) 13788 “Buy American and Hire American”

Frequently Asked Questions (FAQs) for the OMB’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR Part 200

Located at: https://cfo.gov//wp-content/uploads/2017/08/July2017- UniformGuidanceFrequentlyAskedQuestions.pdf

Appropriations Act provisions USDA awards must be in compliance with:

Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act current provisions or any successor provisions of law.

Government-wide provisions:

Per the Consolidated Appropriations Act, 2018, Public Law 115-141, and prior appropriations acts, USDA agencies and staff offices must comply with provisions contained Division E, Title VII, General Provisions Government-wide, Sections 743, 744, 745, 746 respectively or any successor provisions of law.

Sections 743 and 744 (making funds not available for entities that require employees to sign confidentiality agreements or statements prohibiting or restricting them from reporting waste, fraud or abuse) capturing the data can be achieved though solicitations and award terms and conditions.

Sections 745 and 746 (restrictions on financial transactions with corporations with tax delinquencies or felony convictions) data can be captured through the use of USDA OMB approved forms: Representations Regarding Felony Conviction and Tax Delinquent Status for Corporate Applicants, AD-3030, and Assurance Regarding Felony Conviction or Tax Delinquent Status for Corporate Applicants, AD-3031. Note: Adherence to the appropriations restrictions outlined in Forms AD-3030/3031 remain effect unless Congress decides to change and/or remove them in subsequent appropriations years.

National Policy Requirements: A listing of National Policy Requirements recipients must adhere to, where applicable, is located at:

https://www.nsf.gov/bfa/dias/policy/fedrtc/appendix_c.pdf

5/24/2018 12:59 PM

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

OMB No.1615-0047 Expires 05/31/2027

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

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

Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Other Last Names Used (if any)

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

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

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States

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

3. A lawful permanent resident (Enter USCIS or A-Number.)

4. An alien authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

OR

Form I-94 Admission Number

OR

Foreign Passport Number and Country of Issuance

Signature of Employee Today's Date (mm/dd/yyyy)

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

List A OR List B AND List C

Document Title 1

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 2 (if any) Additional Information

Issuing Authority

Check here if you used an alternative procedure authorized by DHS to examine documents.

Document Number (if any)

Expiration Date (if any)

Document Title 3 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

First Day of Employment (mm/dd/yyyy):

Last Name, First Name and Title of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

Employer's Business or Organization Name Employer's Business or Organization Address, City or Town, State, ZIP Code

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

Form I-9 Edition 01/20/25 Page 1 of 4 http://www.uscis.gov/I-9 https://www.uscis.gov/i-9 https://www.uscis.gov/i-9 bcc105896 Text Box Exhibit D

LISTS OF ACCEPTABLE DOCUMENTS

All documents containing an expiration date must be unexpired.

* Documents extended by the issuing authority are considered unexpired.

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

Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A

Documents that Establish Both Identity and Employment Authorization OR

LIST B

Documents that Establish Identity

LIST C

Documents that Establish Employment

Authorization AND

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

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

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

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

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

4. Employment Authorization Document that contains a photograph (Form I-766) 2. Certification of report of birth issued by the

Department of State (Forms DS-1350, FS-545, FS-240)

3. School ID card with a photograph5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole:

a. Foreign passport; and

b. Form I-94 or Form I-94A that has the following:

(1) The same name as the passport; and

(2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

4. Voter's registration card 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. U.S. Military card or draft record

6. Military dependent's ID card

4. Native American tribal document

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (Form I-197)

8. Native American tribal document

6. Identification Card for Use of Resident

Citizen in the United States (Form I-179)9. Driver's license issued by a Canadian government authority

7. Employment authorization document issued by the Department of Homeland Security

For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central.

The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

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

10. School record or report card

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Acceptable Receipts May be presented in lieu of a document listed above for a temporary period.

For receipt validity dates, see the M-274.

● Receipt for a replacement of a lost, stolen, or damaged List A document.

● Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.

● Form I-94 with “RE” notation or refugee stamp issued to a refugee.

OR

Receipt for a replacement of a lost, stolen, or damaged List B document.

Receipt for a replacement of a lost, stolen, or damaged List C document.

*Refer to the Employment Authorization Extensions page on I-9 Central for more information.

Form I-9 Edition 01/20/25 Page 2 of 4 https://www.uscis.gov/i-9-central/handbook-for-employers-m-274/60-evidence-of-status-for-certain-categories https://www.uscis.gov/i-9-central/form-i-9-resources/handbook-for-employers-m-274/120-acceptable-documents-for-verifying-employment-authorization-and-identity/123-list-c-documents-that-establish-employment-authorization https://www.uscis.gov/i-9-central https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents/employment-authorization-extensions

Supplement A, Preparer and/or Translator Certification for Section 1

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

USCIS

Form I-9

Supplement A OMB No. 1615-0047 Expires 05/31/2027

Last Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1.

Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Date (mm/dd/yyyy)

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

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

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Date (mm/dd/yyyy)

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

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

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Date (mm/dd/yyyy)

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

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

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Date (mm/dd/yyyy)

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

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

Form I-9 Edition 01/20/25 Page 3 of 4

Supplement B, Reverification and Rehire (formerly Section 3)

USCIS

Form I-9

Supplement B OMB No. 1615-0047 Expires 05/31/2027

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

Last Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1.

Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274)

New Name (if applicable)Date of Rehire (if applicable)

Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

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

Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorized by DHS to examine documents.

Date of Rehire (if applicable) New Name (if applicable)

Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

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

Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorized by DHS to examine documents.

Date of Rehire (if applicable) New Name (if applicable)

Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

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

Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorized by DHS to examine documents.

Form I-9 Edition 01/20/25 Page 4 of 4 https://www.uscis.gov/i-9-central/form-i-9-resources/handbook-for-employers-m-274