Emergency Contact: Relationship: Telephone:

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1 EMPLOYEE ENROLLMENT DOCUMENTS NOTE TO EMPLOYEES: Make sure you read all of the following carefully and sign where indicated. Corporate Office: 6407 Parkland Drive Sarasota, FL Phone: (888) (941) Payroll Processing Offices & Fax Numbers: Sarasota, FL / Pensacola, FL / Punta Gorda, FL / Tampa, FL / West Palm Beach, FL / Irving, TX Last Name: First Name: Middle Name: (as it appears on your social security card) Social Security #: Preferred Name: Employee Home Street Address: City, State, Zip: Telephone: Date of Birth: Gender: Male Female Emergency Contact: Relationship: Telephone: EEO Disclosure: Hispanic or Latino White Black or African-American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or more races Client/Worksite Employer Client /Worksite Employer Name: EE Hire Date: Status: New Hire Transfer Re-Hire Position: Workers Comp Class Code: Department: Pay Period: Weekly Bi-Weekly FLSA Status: Method and Rate of Payment: Original Hire Date Monthly Semi-Monthly ( 1 st & 15 th ) Exempt Hourly $ Salary $ Normal # of Hours Per Week: Nonexempt Commission Tipped Full-time Part-time Piecework Client / Worksite Employer Signature Date SECTION I- DISCLOSURE AND ACKNOWLEDGMENT NOTICE TO APPLICANT: The Client / Worksite Employer ( WSE ) named above has entered into a Client Service Agreement ( CSA ), with Progressive Employer Management Company or PEMCO, which is a subsidiary of Pemco Jobs, Inc. PEMCO is a professional employer organization, and upon acceptance of your application in the manner prescribed in the CSA, you will be assigned to work for the above named WSE and will become coemployed by PEMCO and your WSE. The specific subsidiary of Pemco Jobs, Inc. that you will be co-employed by will be identified on your paychecks. However, in no event will you be deemed co-employed by PEMCO for any pay period in which your WSE does not report your payroll hours or wages to PEMCO. In accordance with the CSA, PEMCO will provide payroll administration and perform various other employer responsibilities and functions. While you are co-employed by PEMCO, you will work under the day-to-day, on-site supervision, control, and management of your WSE. Your WSE will also determine the amount of wages or salary you will be paid. Your WSE must comply with all applicable federal, state and local laws related to your employment, including without limitation, all wage and hour laws, occupational health and safety laws, equal employment opportunity laws, and anti-discrimination laws. If you become co-employed by PEMCO, your employment will be subject to a 90 day probationary period. In addition, your employment with PEMCO is at will and may be terminated by PEMCO at any time with or without cause (unless and except to extent prohibited by applicable law). If the CSA between your WSE and PEMCO is terminated for any reason, your employment with PEMCO will also terminate as of the effective date of the termination of the CSA unless you are assigned by PEMCO to work for another WSE of PEMCO. If your employment with PEMCO terminates, it is up to your WSE to determine whether or not you will continue to remain an employee of your WSE, and if your WSE chooses to continue your employment, your WSE will be exclusively responsible for all employer related responsibilities. If your WSE does not make payment to PEMCO as required by the CSA, PEMCO s liability, if any, is to pay your wages during any period where you are employed by PEMCO shall be limited to the payment of the applicable minimum wage (or the legally required salary or overtime pay in a work week in which you have worked overtime). Upon the conclusion of each job assignment to a WSE, regardless of the duration of the assignment, you must contact PEMCO for possible reassignment to another WSE within 72 hours following the conclusion of any assignment. Failure to contact PEMCO (Monday through Friday, 8 a.m. - 5 p.m. EST) within 72 hours of the termination may result in a denial of unemployment benefits. RECEIPT & ACKNOWLEDGMENT OF EMPLOYEE HANDBOOK I, the undersigned employee, acknowledge by my signature, that I have been informed that I am an assigned employee of PEMCO. I am aware that PEMCO has an employee handbook applicable to all assigned employees, that a copy of PEMCO s employee handbook is posted on PEMCO s website and that I have either been provided a copy of PEMCO s employee handbook or that I have obtained a copy of it from PEMCO s website. I understand and agree that it is my responsibility to read and comply with all policies and guidelines in PEMCO s employee handbook. I understand that PEMCO s employee handbook does not establish any contractual relationship and that its provisions may be changed at any time by management, and that this handbook is not a guarantee of employment. I further understand that my worksite employer may also establish additional policies and guidelines that relate to my employment, and it is my responsibility to ask questions to my Manager or to PEMCO regarding any policies and guidelines that I do not understand. Revised

2 SECTION 2: SAFETY RULES NOTIFICATION 1. Comply with all applicable Federal, State and local safety laws, rules and regulations. 2. Report ALL injuries or unsafe acts to your supervisor IMMEDIATELY. Except in cases of emergency, your Supervisor must notify PEMCO in order for any treatment to be authorized. Report all job accidents on the same day of the occurrence. 3. The use or possession of intoxicating beverages, drugs, firearms or other weapons is forbidden and may be cause for immediate termination. 4. Personal protective equipment, i.e., work shoes, safety glasses, rubber gloves, oven mitts, etc. will be worn at all times when your work activities and surroundings dictate. SECTION 3: SEXUAL HARASSMENT POLICY Sexual harassment is a form of sexual discrimination prohibited by Title VII of the 1964 Civil Rights Act. PEMCO s policy is not to condone or permit sexual harassment. Sexual harassment includes unwelcome sexual advances or request for sexual favors, unwelcome verbal or physical conduct of a sexual nature, or any other unwelcome sexual conduct that has the purpose or effect of unreasonably interfering with an affected person's work performance, or creating an intimidating, hostile, or offensive work environment. In addition, it is sexual harassment to indicate that submission to or rejection of unwelcome sexual conduct is either explicitly or implicitly a term or condition of employment, or utilizing submission to or rejection of such conduct as a basis for an employment decision affecting the person submitting or rejecting to the conduct. Any employee who feels that he or she may have been subjected to sexual harassment must report it immediately to their Manager and notify PEMCO s Human Resources Department at All allegations of sexual harassment will be investigated promptly and thoroughly, and proper remedial action will be taken according to the specific circumstances of the situation. All investigations of alleged sexual harassment and other types of discrimination are strictly confidential. Federal, state, and local law prohibits taking adverse employment action in retaliation for reporting an incident of sexual harassment or other types of discrimination. Any person, who, after a full investigation of any allegation of sexual harassment, is found to have committed an act of sexual harassment, will be disciplined and, in appropriate situations, terminated from employment. SECTION 4: HARASSMENT IN THE WORKPLACE POLICY PEMCO and the client to which you are assigned are committed to provide a work environment that is free of discrimination and harassment. We do not tolerate any form of harassment, whether it comes from supervisors, fellow employees, or anyone else. Any employee guilty of committing any act of harassment may be disciplined, or where appropriate, discharged without notice. Harassment includes verbal or physical conduct that denigrates or shows hostility or aversion toward an individual because of his or her race, color, religion, sex, national origin, age, marital status, disability or any other characteristic protected by law, and that (1) has the purpose or effect of creating an intimidating, hostile, or offensive working environment; (2) has the purpose or effect of unreasonably interfering with an individual's work performance; or (3) otherwise adversely affects an individual's employment opportunities. Any employee who is subjected to any kind of discrimination or harassment must immediately report it to their Manager and notify PEMCO s Human Resources Department at In order to obtain assistance in the resolution of such matters, I agree to allow PEMCO the opportunity to resolve any such claim or issue through mediation, arbitration, or government agency prior to seeking resolution through another means. SECTION 5: DRUG AND ALCOHOL FREE WORKPLACE PROGRAM AND TESTING CONSENT PEMCO and the WSE to which you are assigned (collectively referred to as the "Company") have established a drug and alcohol free workplace program. The Company's policy and program is set forth in the PEMCO Employee Handbook, receipt of which is acknowledged below. It is the policy of the Company that the unlawful/unauthorized possession, use, consumption, sale, purchase, distribution, or manufacture by any employee of alcohol or any illegal drugs or illegally obtained drugs in the workplace, on Company premises or within its facilities, or when operating Company vehicles on or off duty, or in the conduct of Company-related work off Company premises is strictly prohibited. The foregoing prohibitions apply at all times during the work day, including meal-times and break periods. The Company does not permit any employees to report to work or to perform his or her duties with the presence of illegal or illegally obtained drugs or alcohol in his or her body, or while impaired or under the influence of any illegal drug, or alcohol. For purposes of this policy, "impaired" or "under the influence" means testing positive pursuant to the cut-off levels applicable to the Company's testing program. The Company also does not permit any employee to report to work or to perform his or her duties while taking prescription or non-prescription medication which is adversely affecting the person's ability to safely and effectively perform his or her job functions. Employees are required to notify their supervisor in such instances, but need not disclose the medication being used or the medical condition involved. I understand that according to the Company's Drug and Alcohol Free Workplace Program, as a condition of employment with the Company, I may be required to submit a sample of my urine, blood, and/or other legally approved specimen, for chemical analysis. The purpose of this analysis is to determine the absence or presence of illegal drugs and/or alcohol. I consent and agree freely and voluntarily to provide a specimen upon the request of PEMCO or my on-site employer. I hereby release and hold harmless the Company from any liability whatsoever arising from any request to furnish my specimens and the testing of my specimens. I further consent to the release of the result(s) of any analysis to the Company and understand that in the event I refuse to be tested, refuse to provide this Consent, or test positive, I will be subject to disciplinary action up to and including termination of employment by the Company. I also understand that, in the event I was injured in the course and scope of my employment, and refuse to be tested or test positive, I may, in addition to the above, forfeit all my Workers' Compensation medical and indemnity benefits. I also consent, in the event of a confirmed positive test, to the release by the Company of such result(s) to any person(s) with a need to know in connection with any administrative proceeding, lawsuit or other legal action or proceeding where my test result(s) would be at issue or otherwise relevant to the outcome of the action/proceeding. Employee Signature **Employees under 18 years of age must have a parent or guardian sign this Consent. Date RECEIPT & ACKNOWLEDGMENT OF EMPLOYEE HANDBOOK I, the undersigned employee, acknowledge by my signature, that I have been informed that I am an assigned employee of PEMCO. I am aware that PEMCO has an employee handbook applicable to all assigned employees, that a copy of PEMCO s employee handbook is posted on PEMCO s website and that I have either been provided a copy of PEMCO s employee handbook or that I have obtained a copy of it from PEMCO s website. I understand and agree that it is my responsibility to read and comply with all policies and guidelines in PEMCO s employee handbook. I understand that PEMCO s employee handbook does not establish any contractual relationship and that its provisions may be changed at any time by management, and that this handbook is not a guarantee of employment. I further understand that my worksite employer may also establish additional policies and guidelines that relate to my employment, and it is my responsibility to ask questions to my Manager or to PEMCO regarding any policies and guidelines that I do not understand. Employee Signature Date

3 Form W-4 (2013) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2013 expires February 17, See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends). Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A B Enter 1 if: { You are single and have only one job; or You are married, have only one job and your spouse does not work; or... } Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit... F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($95,000 if married), enter 2 for each eligible child; then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible children. H If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter 1 for each eligible child... Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H { For accuracy, complete all worksheets that apply. Form W-4 Department of the Treasury Internal Revenue Service If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. G OMB No Your first name and middle initial Last name 2 Your social security number Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) 5 6 $ For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2013)

4 Form W-4 (2013) Page 2 Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2013 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions $ $12,200 if married filing jointly or surviving spouse 2 Enter: { $8,950 if head of household } $ $6,100 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2013 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2013 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2013 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $3,900 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 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 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet Note. If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 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 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above If wages from LOWEST paying job are Enter on line 2 above If wages from HIGHEST paying job are Enter on line 7 above If wages from HIGHEST paying job are Enter on line 7 above $0 - $5,000 0 $0 - $8,000 0 $0 - $72,000 $590 $0 - $37,000 $590 5,001-13, ,001-16, , , ,001-80, ,001-24, ,001-25, , ,000 1,090 80, ,000 1,090 24,001-26, ,001-30, , ,000 1, , ,000 1,290 26,001-30, ,001-40, , ,000 1, ,001 and over 1,540 30,001-42, ,001-50, ,001 and over 1,540 42,001-48, ,001-70, ,001-55, ,001-80, ,001-65, ,001-95, ,001-75, , , ,001-85, ,001 and over 10 85,001-97, , , , , , , ,001 and over 15 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

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14 Form 8850 (Rev. January 2013) Department of the Treasury Internal Revenue Service Employer # Pre-Screening Notice and Certification Request for the Work Opportunity Credit Information about Form 8850 and its separate instructions is at Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side. OMB No Your name Social security number Street address where you live City or town, state, and ZIP code County Telephone number If you are under age 40, enter your date of birth (month, day, year) 1 Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit. 2 Check here if any of the following statements apply to you. I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. I am at least age 18 but not age 40 or older and I am a member of a family that: a Received SNAP benefits (food stamps) for the past 6 months, or b Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. During the past year, I was convicted of a felony or released from prison for a felony. I received supplemental security income (SSI) benefits for any month ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year. 3 Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year. 4 Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year. 5 Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year. 6 Check here if you are a member of a family that: Received TANF payments for at least the past 18 months, or Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years, or Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made. Signature All Applicants Must Sign Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete. Job applicant s signature For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No L Form 8850 (Rev ) Date

15 Form 8850 (Rev ) Page 2 For Employer s Use Only Employer s name: Progressive Employer Management Company Telephone no. (888) EIN Street address: 6407 Parkland Drive City or town, state, and ZIP code: Sarasota, FL Person to contact, if different from above HK Payroll Services, Inc. Telephone no Street address P.O. Box 3310; 2345 JFK Rd City or town, state, and ZIP code Dubuque, IA If, based on the individual s age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6) Date applicant: Gave information Was offered job Was hired Started job Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group. Employer s signature Title Date Privacy Act and Paperwork Reduction Act Notice Section references are to the Internal Revenue Code. Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer s federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for administration of the Internal Revenue laws, to the Department of Justice for civil and criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping.. 6 hr., 27 min. Learning about the law or the form min. Preparing and sending this form to the SWA min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526, Washington, DC Do not send this form to this address. Instead, see When and Where To File in the separate instructions. Form 8850 (Rev )

16 U.S. Department Labor Employment and Training Administration OMB No Expiration Date: June 30, Control No. (For Agency use only) Individual Characteristics Form (ICF) Work Opportunity Tax Credit APPLICANT INFORMATION (See instructions on reverse) 2.Date Received (For Agency Use only) 3. Employer Name Progressive Employer Management Company, Inc. EMPLOYER INFORMATION 4. Employer Address and Telephone 6407 Parkland Drive Sarasota, FL (888) Employer Federal ID Number (EIN) APPLICANT INFORMATION 6. Applicant Name (Last, First, MI) 7. Social Security Number 8. Have you worked for this employer before? Yes No If YES, enter last date of employment: APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date 10. Starting Wage 11. Position 12. Are you at least age 16, but under age 40? Yes No If YES, enter your date of birth 13. Are you a Veteran of the U.S. Armed Forces? Yes _ No If NO, go to Box 14. If YES, are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Yes No If YES, enter name of primary recipient _ and city and state where benefits were received. OR, are you a veteran entitled to compensation for a service-connected disability? Yes No If YES, were you discharged or released from active duty within a year before you were hired? Yes No OR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes No 14. Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes No _ OR, received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them? Yes No_ If YES to either question, enter name of primary recipient and city and state where benefits were received. 15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? Yes No OR, by an Employment Network under the Ticket to Work Program? Yes No_ OR, by the Department of Veterans Affairs? Yes No 1 ETA Form 9061 (Rev. July 2013) 50431

17 16. Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired? Yes_ No _ OR, are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired? Yes No OR, did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made? Yes No If NO, are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired? Yes_ No If YES, to any question, enter name of primary recipient and the city and state where benefits were received 17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired? Yes _No_ If YES, enter date of conviction and date of release. Was this a Federal or a State conviction _? (Check one) 18. Do you live in a Rural Renewal County or Empowerment Zone? Yes No 19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date? Yes No 20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? Yes No 21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes No 22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired? Yes No 23. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. SWAs: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made.) _. I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. 24(a). Signature: (See instructions in Box 24.(b) for who signs this signature block) 24. (b) Signatory Options: Indicate with a mark who signed this form: Employer, Consultant, SWA, Participating Agency, Applicant, or Parent/Guardian (if applicant is a minor) 25. Date: 2 ETA Form 9061 (Rev. July 2013)

18 New Health Insurance Marketplace Coverage Options and Your Health Care Part A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as Jan. 1, Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5 percent of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. (An employer-sponsored health plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.) Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution as well as your employee contribution to employer-offered coverage is often excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, if applicable, please check your summary plan description or contact your employer directly. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. You can contact PEMCO s preferred Marketplace vendor, Health Aviator at or by telephone at (877)

19 PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. address Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: All employees. Some employees. Eligible employees are: With respect to dependents: We do offer coverage. Eligible dependents are: We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

20 Employee Name: (Please print) Employee Benefit Information SSN: Worksite Employer Name: All employees must read, sign and return this form to PEMCO. Benefits such as the prescription drug program (not insurance), entertainment discounts, and credit union membership are available to all employees. Other employee-paid benefits such as dental, vision, life, disability, dependent and medical flexible spending accounts, may be available to you if you work 25 hours or more per week. If you choose to enroll, you must do so within your eligibility period. To review information about voluntary employee paid benefits, please place a check mark in the following box: ( ). By checking the box, a packet of benefits information will be sent to you through your worksite employer. If you are not interested in employee benefits, simply read, sign and return this form to PEMCO without checking the box. If you do not check the above box, you will not receive a packet detailing PEMCO s voluntary employee paid benefits unless a phone call is placed requesting one. I understand this is not an enrollment form, that PEMCO has a Section 125 pretax program, and that I must meet certain eligibility requirements to be covered. I understand that no coverage or insurance exists until I complete an enrollment form, it is accepted by PEMCO and the carrier (as applicable), becomes effective, and payroll deductions begin. I understand that generally, I cannot change my benefit decisions until the next annual open enrollment period unless I experience a "change in status", such as: 1) an event that changes my legal marital status, including marriage, death of a spouse, divorce, legal separation, or annulment; 2) an event that changes the number of my dependents including birth, adoption, placement for adoption or death of a dependent; 3) a change in my employment status or that of my spouse or dependent resulting from a termination or commencement of employment, strike or a walkout, a commencement of or return from an unpaid leave of absence, or a change in worksite, as well as any other change to my employment status or that of my spouse or dependent resulting in any such individual's becoming (or ceasing to be) eligible under a cafeteria plan or other employee benefit plan sponsored by such individual's employer; 4) an event that causes my dependent to satisfy or cease to satisfy eligibility requirements for coverage due to the attainment of age, student status, or any similar circumstance; or 5) there is a change in my place of residence or the place of residence of my spouse or dependent. I understand that if I have a change in status, I must notify PEMCO in writing within 30 days of such event. Employee s Signature Today s Date

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