Trade: Name: Driver s License #: DL State: Former Employers Date Name of Employer Phone Position Pay Rate Reason for Leaving From To From To From To

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1 2270 Drew Street, Ste D Clearwater, FL Office: (727) Fax: (727) Personal nformation Trade: Name: Driver s License #: DL State: Address: Vehicle Make: City: State: Zip: Color: Year Home Phone: Cell Phone: Emerg Phone: Former Employers Date Name of Employer Phone Position Pay Rate Reason for Leaving From To From To From To Trade Schools School Study Year Grad Experience Wage Range Expected: CARPENTRY MECHANCAL MASONRY Years Trade Years Trade Years Trade Wood Frame Electrician Block Concrete Form Res Comm New Serv Brick Trim HVAC Concrete Pour Metal Stud Board Sheet Metal Concrete Finish Drywall Hang nstall Changeout Tile Drywall Finish Plumber Paint nt/ext Res Comm New Serv REMODEL Specify below Welding Cart to Other

2 "' SouTH{AsT HRSONNH LUSNG NC. Fax Numbers Payroll: Online Payroll: New Client Setup: (727) (727) (727) SOUTH EAST PERSONNEL LEASNG, NC. (SPL) EMPLOYEE LEASNG APPLCATON * Client Company: Location: Southern Construction Staffing, nc. Florida SECTON 1 -TO BE COMPLETED BY THE APPLCANT * tastname * First Name Ml * Application Date (mmddyy) D ; l1 * SSN * Date of Birth (mmddyyyy) Gender ; OM OF l1 * Applicant Address Line 1 (Street Number and Name) * Applicant Address Line 2 (Apt/Lot/Unit/etc.) Phone Number Address * State * Zip Ethnicity 0 White/ Caucasian 0 Black/ African American OHispanic/ Latino 0 Asian/ Asian ndian 0 American ndian/ Alaskan Native 0 Hawaiian/ Pacific slander 0 Other/None Provided understand and agree to the following: am not yet a leased employee of SPL. f suffer an injury or have suffered an injury related to work while working for the Client Company but before am accepted as a leased employee by SPL, the Client Company (not SPL) will be responsible for providing Workers' Compensation Coverage, even if am paid by SPL or subsequently accepted as an employee of SPL. will not be accepted as an employee ofspl, and workers' compensation coverage will not be provided by SPL for any accidents until after all pages of the SPL Employee Leasing Application are completed and signed by me, the complete SPL Employee Leasing Application is delivered to SPL, and SPL accepts me as a leased employee. The SPL Employee Leasing Application includes all of the following documents: This page, the Applicant Acknowledgement, the Safe Working Practices Acknowledgement, Acknowledgement of the Post Accident/Reasonable Suspicion Program, Form -9, and Form W-4. also acknowledge have received my copy of the Drug and Alcohol Abuse Notice. * Applicant Signature * Date SECTON 2- TO BE COMPLETED BY THE CLENT COMPANY i Origirl Hiri Date with Client (mmddyy) * Work State * Pay Method &Rate (must comply with FLSA guidelines) 1/ W/CCode 0 Hourly $1 0 Salary $1 0 Commission/Piecework * Job Description Home Department Check if salary 0 employee qualifies for overtime exemption * Pay Cycle EmployeeiD O Weekly 0 Bi-Weekly 0 Other: * Employment Type 0 Full Time Employee(> 30 hours avg. per week) 0 Part Time Employee(< 30 hours avg. per week) 0 Variable Hour Employee (cannot determine whether the employee will avg. at least 30 hours per week) 0 Seasonal Employee(< 6 consecutive months worked during calendar year) (SPL) means South East Personnel Leasing, ~nc and its subsidiaries. *Required Fields Florida-Revised 10/ l/2014

3 -/ = Applicant Complete * = Applicant Sign * = Client Company Complete/Sign APPLCANT ACKNOWLEDGEMENT, the undersigned applicant, acknowledge by my signature that have been informed that if accepted as a leased employee of SPL will be leased to:./ Southern Construction Staffing, nc. (Client Company). further understand that if accepted as a leased employee of SPL, either SPL or can terminate our relationship at any time, as will be an at-will leased employee of SPL. also understand and agree that if accepted, while am a leased employee of SPL, if SPL does not r&eive payment from the Client Company for services which perform, SPL will still pay me the applicable minimum wage (or the legally required overtime pay, at the applicable minimum wage rate, in a workweek in which have worked overtime) for any such pay period and agree to this method of compensation. As a term of employment with SPL, understand and agree that all of my compensation for work done for the Client Company must be paid by SPL. t is expressly prohibited for me to accept compensation from any source other than SPL for work done for the Client Company without the express written consent from SPL. The moment accept compensation from any source other than SPL for work performed for the Client Company without SPL's written consent, my employment with SPL will be automatically terminated/dissolved, effective the beginning of the pay period in which received that compensation, even if SPL is not yet aware of it and even if SPL continues to pay me. Therefore, understand and agree that if receive any compensation from any source other than SPL for work done for the Client Company without SPL 's written consent, will be considered an employee of that source and not an employee of SPL. understand and agree that this means that if get paid by any source other than SPL for work done for the Client Company without SPL' s written consent and get hurt while working, will riot be an employee of SPL and will, therefore, not be covered by SPL or SPL's workers' cor:npensation policy. This paragraph does not apply to tips from patrons. also agree to comply with any drug/alcohol testing policy, which SPL has or may adopt. specifically agree to post-accident drug/alcohol testing after every work injury regardless of whether am able to give consent at that time. This document is my authority to post -accident drug/alcohol testing in all instances. SPL is in agreement with the Federal Government that marijuana is a controlled substance and will not recognize medical marijuana as a legitimate prescription. A positive test result for marijuana will be treated the same as any other positive test result, even if an employee has a medical marijuana prescription. acknowledge "that am required to promptly report all incidents of discrimination, harassment, or retaliation, regardless of the offender's identity,or position, to the Client Company. further acknowledge that the Client Company is responsible for investigating my complaint and taking appropriate action, if any is determined to be necessary, to end or remediate the discrimination or retaliation. further acknowledge and agree that because SPL does not have actual control over my work with the Client Company, and as such is not in a position to know of any alleged discrimination, harassment, or retaliation, all action to end or remediate any discrimination, harassment, or retaliation must come solely from the Client Company. * Applicant's Signature -/ Date Florida - Revised 8/22/11

4 ./ = Applicant Complete * = Applicant Sign * = Client Company Complete/Sign SAFE WORKNG PRACTCES ACKNOWLEDGEMENT./ Southern Construction Staffing, nc. Client Company./ 2270 Drew Street #D, Clearwater, FL Address As a condition of acceptance by SPL as a leased employee,./ do hereby agree to comply with (Please print full name) the following safe working practices: 1. agree to follow all safety requirements, procedures and practices, including but not limited to those imposed or recommended by: any government entity, OSHA, Client Company, SPL or any other entity. whatsoever without exception. 2. agree to report any work-related accident, or injury, to my supervisor with the Client Company as soon as it occurs, without exception. 3. f need treatment for a work-related injury, agree to: A. Notify my supervisor with the Client Company of the need for treatment. B. Only go to Client Company/SPL directed physicians for the initial treatment. C. On the initial visit, hand carry a Medical Authorization for Treatment form to the authorized treating facility. D. Notify SPL or SPL's workers' compensation carrier when am referred to any specialist for treatment. E. Only go to SPL or SPL's workers' compensation carrier's directed specialists for care. understand that failure on my part, to follow the above procedures, could result in disciplinary action, not to exclude termination! agree to inform SPL of any safety violations encounter in the workplace. also understand that according to Section (4) of the Florida Workers' Compensation Law, my compensation benefits could be reduced for any injury, which occurs because of a failure ~o follow established safety procedures. understand if do not report my accident to South East Personnel Leasing, nc. within 30 days, my claim will be denied for lack of notice. * Applicant's Signature./ Date Florida- Revised 7/26/11

5 -/ = Applicant Complete * = Applicant Sign * = Client Company Complete/Sign ACKNOWLEDGEMENT OF THE POST -ACCDENT/REASONABLE SUSPCON PROGRAM understand that SPL maintains a Post-Accident/Reasonable Suspicion Program requiring all leased employees to report to work in a substance free condition. have read, or had read to me, a copy of this policy and understand the consequences of violating the policy, including my obligations under the Post-Accident/Reasonable Suspicion Policy. f did not understand the policy, have asked for and have received an explanation. specifically understand that if am injured on the job and have a confirmed positive test result; refuse to consent or submit to a drug or alcohol test; tamper with or adulterate a drug and/or alcohol specimen, refuse to authorize the release of drug or alcohol test results to Southeast, or otherwise violate this policy may forfeit all benefits under this state's workers' compensation and unemployment compensation laws. SPL is in agreement with the Federal Government that marijuana is a controlled substance and will not recognize medical marijuana as a legitimate prescription. A positive test result for marijuana will be treated the same as any other positive test result, even if an employee has a medical marijuana prescription. understand that as a condition of my continued employment, where reasonable suspicion of drug and/or alcohol use exists, SPL will require me to undergo substance screening by urinalysis for drugs and blood for alcohol. hereby agree to submit to such tests including follow up to rehabilitation testing and the required postaccident testing. further consent to the results of any such drug or alcohol tests. being released to SPL's authorized representative by the Medical Review Officer (MRO). understand that am legally authorized to receive a copy of this consent form if requested. The results will not be released to any additional parties without my written authorization, except acknowledge that SPL, agents of SPL'S, and the testing laboratory will have access to the test results and may disclose such results to its attorney in connection with workers' compensation proceedings, and may use the test results when relevant to its defense in other civil or administrative matters. release any testing facility personnel and/or any physicians who have tested me from any liability arising from a release or use of any and all test results, written reports, medical records and data concerning my test(s) to the appropriate SPL officials. further release all SPL officials from liability arising from the release or use of the test results. also understand that the Post-Accident/Reasonable Suspicion Policy and related documents are not intended to constitute a contract between the SPL and me. acknowledge receipt of a copy of this policy. * / Applicant's Signature Printed Name Date -/ Florida - Revised 8/22/11

6 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and mmigration Services US CS Form 1-9 OMB No Expires 03/31/2016 Read in tructions carefully before completing this form. The instructions must be available during completion of this form. ANT-DSCRMNATON NOTCE; t S illegal to discnm1nate agamst work-authonzed mdividu"'s. mploy rs CANNOT spec1fy which document(s) they will accept from an employ~e. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee nformation and Atte tation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (G1ven Name) Middle nitial Other Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State Zip Code Date of Birth (mmlddlyyw) U.S. Social Security Number Address Telephone Number D-0-C_J am aware that federal jaw provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. attest, under penalty of perjury, that am (check one of the following): 0 A citizen of the l!nited States 0 A noncitizen national of the United States (See instructions) 0 A lawful permanent resident (Alien Registration Number/USCS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCS Numqer OR Form 1-94 Admission Number: 1. Alien Registration Number/USCS Number: OR 2. Form 1-94 Admission Number: D Barcode Do Not Write in This Space f you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of ssuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of ssuance fields. (See instructions) Signature of Employee: Date (mmldd/yyyy): Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) attest, under penalty of perjury, that have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator: Date (mmlddlyyyy): Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State Zip Code Employer Completes Next Page Form -9 03/08/13 N Page 7 of9

7 Section 2. Employer or Authorized Representative Review and Verification (Employers or their aut!jorized representative must complete and ~ign Section 2 willlin 3 twsiness days of tl?e employee's first day of employment. You must phystcal/y examme one document from Ltst A OR examme a combination of one document from Ltst B and one document from List Cas listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title. issuing authority, document number, and expiration date, if any) Employee Last Name, First Name and Middle nitial from Section 1: List A dentity and Employment Authorization OR List 8 dentity. AND List C Employment Authorization ssuing Authority: ssuing Authority: ssuing Authority: Expiration Date (if any)(mmldd/wyy): Expiration Date (if any)(mmldd!wyy): Expiration Date (if any)(mmldd!wyy): - ssuing Authority: Expiration Date (if any)(mmldd!wyy): 3-0 Barcode Do Not Write in This Space ssuing Authority: Expiration Date (if any)(mmldd!wyy): Certification attest, under penalty of perjury, that (1) have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mmlddlyyyy)" (See instructions for exemptions.) Signature of Employer or Authorized Representative Date (mmldd/yyyy) Title of Employer or Authorized Representative Last Name (Family Name) First Name (Given Name) Employer's Business or Organization Name - Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code Southern Construction Staffing, nc Drew Street, Suite D. Clearwater FL Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle nitial 1 B. Date of Rehire (if applicable) (mmlddlyyyy): C. f employee's previous grant of employment authorization has expired, provide the mformation for the document from L1st A or List C the employee presented that establishes current employment authorization in the space provided below. Expiration Date (if any)(mmlddlyyw): attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative: Date (mmlddlyyyy) Print Name of Employer or Authorized Representative: Form l-9 03/08113 N Page ll of9

8 Form W-4 (2015) 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. f you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, See Pub. 505, Tax Withholding and Estimated Tax. Note. f another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: s age 65 or older, s blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. A 8 c D E F G H The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. f 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 you! dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing nformation, 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. Personal Allowances Worksheet (Keep for your records.) Enter "1" for yourself if no one else can claim you as a dependent. Enter "1" if: [ You are single and have only one job; or l 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. Nonwage income. f 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 ndividuals. Otherwise, you may owe additional tax. f 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. f 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. f you are a nonresident alien, see Notice 1392, Supplemental Form W-4 nstructions for Nonresident Aliens, before completing this fonn. 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 See Pub especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. nformation about any future developments affect1ng Form W-4 (such as legislation enacted after we release it) will be posted at gov/w4 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.). Enter number of dependents (other than your spouse or yourself) you will claim on your tax return. Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for deta!ls.) Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. f your total income will be less than $65,000 ($1 00,000 if married), enter "2" for each. eligible child; then less "1" if you have two to four eligible children or less "2" if you have five or more eligible children. f your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. G 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 l f you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all f you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. avoid having too little tax withheld. f neither ot the above situations applies, stop here and enter the number from l1ne 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 Employee's Withholding Allowance Certificate OMB No Form W 4 Dop.:utmcnt of the Troanury ~ Whether you are entitled to claim a certain number of allowances or exemption from withholding is ~@ 15 lntern;:!l Revenue Servlt.;e subject to review by the RS. Your employer may be required to send a copy of this form to the RS. 1 Your first name and middle imtial Last name Your social security number Home address (number and street or rural route) City or town, state, and ZP code ~ 3 0 Single 0 Married 0 Married, but withhold at higher Single rate. 12 Note. f married, but legally separated, or spouse is a nonresident alien, check the "Single" box. 4 f your last name differs from that shown on your social security card, check here. You must call for a replacement card.., Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck 6 $ 7 claim exemption from withholding for 2015, and certify that meet both of the following conditions for exemption. Last year had a right to a refund of all federal income tax withheld because had no tax liability, and This year expect a refund of all federal income tax withheld because expect to have no tax liability. f you meet both conditions, write "Exempt" here. ~171.. Under penalties of pequry, declare that have exam1ned th1s cert1f1cate and, to the best of my knowledge and belief, 1t 1s true, correct, and complete. Employee's signature (This form is not valid unless you sign it.) ~ 8 Employer's name and aodress (Employer: Complete lines 8 and 10 only if sending to the RS.) 9 Office code (optional) 10 Employer identification number (EN) Date~ t A 8 c D E F For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4(2015)

9 Form W-4 (2015) 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 2015 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 bom before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details 1 $ 2 $12,600 if married filing jointly or qualifying widow(er) ( l Enter: $9,250 if head of household $6,300 if single or married filing separately 2 $ 3 Subtract line 2 from line 1. f zero or less, enter "-0-" 3 $ 4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (nclude any amount for credits from the Converting Credits to Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.). 5 $ 6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. f zero or less, enter "-0-" 7 $ 8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. f you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this totc:tl 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) 1 2 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 f 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. f 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 4 5 Enter the number from line 1 of this worksheet 5 6 Subtract line 5 from line Find the amount in Table 2 below that applies to the HGHEST 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 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 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 1 Table2 Married Filing Jointly All Others Married Filing Jointly All Others f wages from LOWEST Enter on f wages from LOWEST Enteron f wages from HGHEST Enteron f wages from HGHEST Enter on paying job are- line 2 above paying job are- line 2 above paying job are- line 7 above paying job are- line 7 above $0 - $6,000 0 $0 -. $8,000 0 $0 - $75,000 $600 $0 - $38,000 $600 6,001-13, ,001-17, , ,000 1,000 38,001-83,000 1,000 13,001 24, ,001-26, , ,000 1,120 83,001 ~ 180,000 1,120 24,001-26, ,001-34, , ,000 1, , ,000 1,320 26,001 34, ,001-44, , ,000 1, ,001 and over 1,580 34,001-44, ,001-75, ,001 and over 1,580 44,001-50, ,001-85, ,001-65, , , ,001-75, , , ,001-80, , , , , ,001 and over , , , , , , , , ,001 and over Privacy Act and Paperwori< Reduction Act Notice. We ask for the infonnation on this fonn to carry out the nternal Revenue laws of the United States. nternal Revenue Code sections 3402(0(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 fonn 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 lntonnation include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwea~hs 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 ag~ncies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. Page2 You are not required to provide the infonnation requested on a fonn that is subject to the Paperwork Reduction Act unless the fonn displays a valid OMS control number. Books or records relating to a fonn or its instructions must be retained as long as their contents may become material in the administration of any nternal Revenue law. Generally, tax returns and return infonnation are confidential, as required by Code section 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. f you have suggestions for making this fonn simpler, we would be happy to hear from you. See the instructions for your income tax return.