EMPLOYEE ENROLLMENT SIGNUP PACKET - OHIO

Transcription

1 EMPLOYEE ENROLLMENT SIGNUP PACKET - OHIO 8415 Pulsar Place, Suite 200 Columbus, Ohio HR Service Center

2 NEW EMPLOYEE DATA This information is to establish personnel and payroll records and for government required reporting. TO BE COMPLETED BY NEW EMPLOYEE (Please print your name legibly as it appears on your Social Security Card.) Position Information Job Title Supervisor s Name Start Date Full Name Last Name First Name Middle Name Personal Data Social Security Number - - Date of Birth (MM/DD/YYYY) / / Gender: Female Marital Status: Single Veteran Status: Veteran Male Married Disabled Veteran Ethnic Origin White Hispanic or Latino Black or African American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Address Number Street Name Apartment Number City State Zip County Phone Numbers Address(es) Home Work Cell ( ) ( ) ( ) Work Secondary Emergency Contact Information Contact Name Contact Relationship Contact Phone Number Contact Street Address City State Zip DEPENDENT INFORMATION Name Sex Date of Birth Name Sex Date of Birth Spouse DO NOT WRITE BELOW THIS LINE. TO BE COMPLETED BY AUTHORIZED STAFF MEMBER AT COMPANY WORKSITE. Company Name Worksite Location Department Workers Comp Code Job Title FLSA Classification Exempt Non-Exempt Employment Status Full Time (30 or more hrs/wk) Seasonal Employment Status Hourly Salary Other Part Time (less than 30 hrs/wk) Temporary Supervisor Responsibilities Yes No Pay Rate $ Per Hour or $ Average # of Hours Annually Per Pay Period Pay Frequency Weekly Bi-Weekly Semi-Monthly Monthly EEO Job Category Executive Officials & Managers Mid-level Officials & Professionals Technicians Sales Managers Administrative Support Craft Workers (skilled) Operatives (semi-skilled) Laborers Service Workers Revised7/10/

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23 IT 4 Rev. 5/07 Notice to Employee 1. For state purposes, an individual may claim only natural dependency exemptions. This includes the taxpayer, spouse and each dependent. Dependents are the same as defined in the Internal Revenue Code and as claimed in the taxpayer s federal income tax return for the taxable year for which the taxpayer would have been permitted to claim had the taxpayer filed such a return. 2. You may file a new certificate at any time if the number of your exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases because: (a) Your spouse for whom you have been claiming exemption is divorced or legally separated, or claims her (or his) own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is taken over by someone else. (c) You find that a dependent for whom you claimed exemption must be dropped for federal purposes. The death of a spouse or a dependent does not affect your withholding until the next year but requires the filing of a new certificate. If possible, file a new certificate by Dec. 1st of the year in which the death occurs. For further information, consult the Ohio Department of Taxation, Personal and School District Income Tax Division, or your employer. 3. If you expect to owe more Ohio income tax than will be withheld, you may claim a smaller number of exemptions; or under an agreement with your employer, you may have an additional amount withheld each pay period. 4. A married couple with both spouses working and filing a joint return will, in many cases, be required to file an individual estimated income tax form IT 1040ES even though Ohio income tax is being withheld from their wages. This result may occur because the tax on their combined income will be greater than the sum of the taxes withheld from the husband s wages and the wife s wages. This requirement to file an individual estimated income tax form IT 1040ES may also apply to an individual who has two jobs, both of which are subject to withholding. In lieu of filing the individual estimated income tax form IT 1040ES, the individual may provide for additional withholding with his employer by using line 5. please detach here Employee s Withholding Exemption Certificate IT 4 Rev. 5/07 Print full name Social Security number Home address and ZIP code Public school district of residence (See The Finder at tax.ohio.gov.) School district no. 1. Personal exemption for yourself, enter 1 if claimed If married, personal exemption for your spouse if not separately claimed (enter 1 if claimed) Exemptions for dependents Add the exemptions that you have claimed above and enter total Additional withholding per pay period under agreement with employer... $ Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled. Signature Date

24 School Districts With an Income Tax for 2015 Boldface indicates a newly enacted rate, a rate change for 2015 or a change in the tax type. Rev. 11/14 Decimal SD# School District Name (and Counties) Rate Percent Earned Income Only Tax Base School Districts 2301 Amanda-Clearcreek LSD (Fairfi eld) ½% 0502 Athens CSD (Athens) % 2801 Berkshire LSD (Geauga) % 2302 Berne-Union LSD (Fairfield, Hocking) % 5501 Bethel LSD (Miami) ¾% 7502 Botkins LSD (Auglaize, Shelby) ¼% 5901 Cardington-Lincoln LSD (Marion, Morrow) ¾% 5401 Celina CSD (Mercer) ¾% 8501 Chippewa LSD (Wayne) % 6501 Circleville CSD (Pickaway) ¾% 7001 Clear Fork Valley LSD (Knox, Richland) % 5204 Cloverleaf LSD (Medina) ¼% 7201 Clyde-Green Springs EVSD (Sandusky, Seneca) % 1704 Crestline EVSD (Crawford, Richland) ¼% 8702 Eastwood LSD (Wood) % 5101 Elgin LSD (Delaware, Hardin, Marion) ¾% 7203 Gibsonburg EVSD (Sandusky, Wood) ¾% 3603 Greenfi eld EVSD (Fayette, Highland, Ross) ¼% 0302 Hillsdale LSD (Ashland, Wayne) ¼% 7403 Hopewell-Loudon LSD (Seneca) ½% 7506 Jackson Center LSD (Auglaize, Logan, Shelby) ½% 4901 Jefferson LSD (Madison) % 4902 Jonathan Alder LSD (Franklin, Madison, Union) ¼% 2305 Lancaster CSD (Fairfi eld) ½% 2805 Ledgemont LSD (Ashtabula, Geauga) ¼% 6502 Logan Elm LSD (Hocking, Pickaway) % 5504 Miami East LSD (Champaign, Miami) ¾% 5505 Milton-Union EVSD (Miami) ¼% 3902 Monroeville LSD (Erie, Huron) ½% 8605 Montpelier EVSD (Williams) ¼% 8705 North Baltimore LSD (Hancock, Wood) ¼% 4508 North Fork LSD (Knox, Licking) % 7612 Northwest LSD (Stark, Summit, Wayne) % 1204 Northwestern LSD (Clark, Champaign) % 8706 Northwood LSD (Wood) ¼% 8504 Norwayne LSD (Medina, Wayne) ¾% 0908 Ross LSD (Butler) ¾% 5008 Sebring LSD (Mahoning) % 3118 Southwest LSD (Hamilton, Butler) ¾% 6503 Teays Valley LSD (Fairfi eld, Franklin, Pickaway) ½% 6806 Tri-County North LSD (Darke, Montgomery, Preble) % 8509 Triway LSD (Holmes, Wayne) ¾% 5509 Troy CSD (Miami) ½% 2308 Walnut Township LSD (Fairfi eld) ¾% 3907 Willard CSD (Crawford, Huron) ¾% Traditional Tax Base School Districts 3301 Ada EVSD (Hancock, Hardin) ½% 7501 Anna LSD (Shelby) ¼% 1901 Ansonia LSD (Darke) ¾% Decimal SD# School District Name (and Counties) Rate Percent Traditional Tax Base School Districts (cont d.) 6301 Antwerp LSD (Paulding) ½% 3201 Arcadia LSD (Hancock, Seneca) % 1902 Arcanum-Butler LSD (Darke) ½% 3202 Arlington LSD (Hancock) ¼% 2001 Ayersville LSD (Defi ance) % 3901 Bellevue CSD (Erie, Huron, Sandusky, Seneca) ½% 2501 Bexley CSD (Franklin) ¾% 2101 Big Walnut LSD (Delaware) ¾% 2303 Bloom-Carroll LSD (Fairfi eld) ¼% 0203 Bluffton EVSD (Allen, Hancock) ½% 8701 Bowling Green CSD (Henry, Wood) ½% 5502 Bradford EVSD (Darke, Miami, Shelby) ¾% 8601 Bryan CSD (Williams) % 1701 Buckeye Central LSD (Crawford, Huron, Richland, Seneca) ½% 2102 Buckeye Valley LSD (Delaware, Marion, Morrow, Union) % 2502 Canal Winchester LSD (Fairfi eld, Franklin) ¾% 8801 Carey EVSD (Seneca, Wyandot) % 8301 Carlisle LSD (Montgomery, Warren) % 2902 Cedar Cliff LSD (Clark, Greene) ¼% 4201 Centerburg LSD (Delaware, Knox, Licking) ¾% 2002 Central LSD (Defi ance, Williams) ¾% 1303 Clermont-Northeastern LSD (Brown, Clermont) % 5402 Coldwater EVSD (Mercer) ½% 1703 Colonel Crawford LSD (Crawford) ¼% 1502 Columbiana EVSD (Columbiana, Mahoning) % 6901 Columbus Grove LSD (Allen, Putnam) % 6902 Continental LSD (Putnam) % 3203 Cory-Rawson LSD (Hancock) ¾% 5503 Covington EVSD (Miami) % 1503 Crestview LSD (Columbiana) % 8101 Crestview LSD (Van Wert) % 8502 Dalton LSD (Wayne) ¾% 4202 Danville LSD (Holmes, Knox) ¾% 2003 Defi ance CSD (Defi ance, Paulding) ½% 6803 Eaton CSD (Preble) ½% 8602 Edgerton LSD (Defi ance, Williams) % 8703 Elmwood LSD (Hancock, Wood) ¼% 2602 Evergreen LSD (Fulton, Lucas) % 8001 Fairbanks LSD (Madison, Union) % 2903 Fairborn CSD (Clark, Greene, Montgomery) ½% 2304 Fairfi eld Union LSD (Fairfi eld, Hocking, Perry) % 7503 Fairlawn LSD (Shelby) ¾% 7504 Fort Loramie LSD (Darke, Shelby) ½% 5406 Fort Recovery LSD (Darke, Mercer) ½% 1903 Franklin Monroe LSD (Darke, Miami) ¾% 7202 Fremont CSD (Sandusky) ¼% 2603 Gorham Fayette LSD (Fulton) % 1305 Goshen LSD (Clermont, Warren) % 2904 Greeneview LSD (Clinton, Fayette, Greene) % (continued on next page)

25 School Districts With an Income Tax for 2015 Rev. 11/14 Decimal SD# School District Name (and Counties) Rate Percent Decimal SD# School District Name (and Counties) Rate Percent Traditional Tax Base School Districts (cont d.) 1904 Greenville CSD (Darke) ½% 7505 Hardin-Houston LSD (Shelby) ¾% 3302 Hardin Northern LSD (Hancock, Hardin) ¾% 2004 Hicksville EVSD (Defi ance) ¾% 5902 Highland LSD (Delaware, Morrow) ½% 3604 Hillsboro CSD (Highland) % 3501 Holgate LSD (Henry) ½% 6903 Jennings LSD (Putnam) ¾% 4503 Johnstown-Monroe LSD (Delaware, Licking) % 6904 Kalida LSD (Putnam) % 3303 Kenton CSD (Hardin, Wyandot) ½% 7204 Lakota LSD (Sandusky, Seneca, Wood) ½% 6905 Leipsic LSD (Putnam) ¾% 3205 Liberty-Benton LSD (Hancock) ¾% 3502 Liberty Center LSD (Fulton, Henry) ¾% 2306 Liberty Union-Thurston LSD (Fairfi eld) ¾% 4506 Licking Valley LSD (Licking, Muskingum) % 4903 London CSD (Madison) % 0303 Loudonville-Perrysville EVSD (Ashland, Holmes, Knox, Richland) ¼% 0905 Madison LSD (Butler) ½% 3206 McComb LSD (Hancock, Putnam, Wood) ½% 1102 Mechanicsburg EVSD (Champaign, Madison) ½% 8604 Millcreek-West Unity LSD (Williams) % 6906 Miller City-New Cleveland LSD (Putnam) ¼% 0601 Minster LSD (Auglaize, Darke, Mercer Shelby) % 1905 Mississinawa Valley LSD (Darke) ¾% 8802 Mohawk LSD (Crawford, Seneca, Wyandot) % 5903 Mount Gilead EVSD (Morrow) ¾% 6802 National Trail LSD (Darke, Preble) ¾% 0602 New Bremen LSD (Auglaize, Mercer, Shelby) % 0603 New Knoxville LSD (Auglaize, Shelby) ¼% 5708 New Lebanon LSD (Montgomery) ¼% 3903 New London LSD (Ashland, Huron, Lorain) % 0907 New Miami LSD (Butler) % 7404 New Riegel LSD (Seneca) ½% 4507 Newark CSD (Licking) % 5506 Newton LSD (Darke, Miami) ¾% 8003 North Union LSD (Delaware, Union) % 5904 Northmor LSD (Marion, Morrow, Richland) % 8505 Northwestern LSD (Ashland, Wayne) ¼% 3904 Norwalk CSD (Huron) ½% 4712 Oberlin CSD (Lorain) % 7405 Old Fort LSD (Sandusky, Seneca) % 8707 Otsego LSD (Henry, Lucas, Wood) % 6907 Ottawa-Glandorf LSD (Putnam) ½% 6908 Ottoville LSD (Paulding, Putnam) ¾% 6909 Pandora-Gilboa LSD (Allen, Putnam) ¾% 5405 Parkway LSD (Auglaize, Mercer, Van Wert) % Traditional Tax Base School Districts (cont d.) 3504 Patrick Henry LSD (Henry, Putnam, Wood) ¾% 6302 Paulding EVSD (Paulding, Putnam) % 8708 Perrysburg EVSD (Wood) ½% 2604 Pettisville LSD (Fulton, Henry) % 2307 Pickerington LSD (Fairfi eld, Franklin) % 5507 Piqua CSD (Miami) ¼% 7007 Plymouth-Shiloh LSD (Crawford, Huron, Richland) % 6804 Preble Shawnee LSD (Butler, Montgomery, Preble) ¾% 2509 Reynoldsburg CSD (Fairfi eld, Franklin, Licking) ½% 3304 Ridgemont LSD (Hardin, Logan) ¾% 3305 Riverdale LSD (Hancock, Hardin, Wyandot) % 4604 Riverside LSD (Logan, Shelby) ¾% 7507 Russia LSD (Darke, Shelby) ¾% 7406 Seneca East LSD (Huron, Seneca) % 7008 Shelby CSD (Richland) % 3905 South Central LSD (Huron, Richland) ¼% 1205 Southeastern LSD (Clark, Greene) % 4510 Southwest Licking LSD (Fairfi eld, Licking) ¾% 0209 Spencerville LSD (Allen, Auglaize, Van Wert) % 5010 Springfi eld LSD (Mahoning) % 8607 Stryker LSD (Williams) ½% 2606 Swanton LSD (Fulton, Lucas) ¾% 0909 Talawanda CSD (Butler, Preble) % 1103 Triad LSD (Champaign, Logan, Union) ½% 1906 Tri-Village LSD (Darke) ½% 6805 Twin Valley Community LSD (Preble) ½% 7106 Union-Scioto LSD (Ross) ½% 1510 United LSD (Columbiana) ½% 8803 Upper Sandusky EVSD (Crawford, Marion, Wyandot) ¼% 3306 Upper Scioto Valley LSD (Auglaize, Hardin, Logan) ½% 5713 Valley View LSD (Montgomery, Preble) ¼% 8104 Van Wert CSD (Van Wert) % 3208 Vanlue LSD (Hancock, Seneca, Wyandot) % 1907 Versailles EVSD (Darke, Shelby) % 0605 Wapakoneta CSD (Auglaize) ¾% 6303 Wayne Trace LSD (Paulding, Putnam, Van Wert) ¼% 0606 Waynesfi eld-goshen LSD (Allen, Auglaize, Logan) % 4715 Wellington EVSD (Huron, Lorain) % 1105 West Liberty-Salem LSD (Champaign, Logan) ¾% 3906 Western Reserve LSD (Erie, Huron) ¼% 1404 Wilmington CSD (Clinton, Greene) % 3122 Wyoming CSD (Hamilton) ¼% 2906 Xenia Community CSD (Greene, Warren) ½% 2907 Yellow Springs EVSD (Clark, Greene) % - 4 -

26 AUTOMATIC DEPOSIT/DEBIT AUTHORIZATION AGREEMENT I authorize Sequent to initiate Credit entries to my personal Checking/Savings account(s) as indicated below. I also authorize Sequent to Debit the account(s) I ve listed below for payroll correction purposes only. This authorization is to remain in effect until Sequent has received written notification from me of a change or termination with sufficient time to allow Sequent a reasonable timeframe to make the appropriate changes. Sequent may discontinue Automatic Deposits/Debits at any time, with or without notice Acct. 1 Checking Savings Change Cancel Bank, Credit Union, or Savings Institution Name Bank Routing Number Account Number Deposit Amount Dollar Percentage Acct. 2 Checking Savings Change Cancel Bank, Credit Union, or Savings Institution Name Bank Routing Number Account Number Deposit Amount Dollar Percentage Remainder Acct. 3 Checking Savings Change Cancel Bank, Credit Union, or Savings Institution Name Bank Routing Number Account Number Deposit Amount Remainder Decline This is to acknowledge that I have been offered direct deposit; however, I wish to decline at this time. If you are a new employee, your Automatic Deposit will begin on your first pay date, unless otherwise indicated by Sequent. If you are already an employee and are signing up for Automatic Deposit or making a change to an existing Automatic Deposit request, please provide this completed form at least five full business days before your next pay date to make the changes effective with your next pay. Your Name: Social Security #: (Please Print) Company Name: Location: Your Signature: Date: THE FOLLOWING DOCUMENTATION IS REQUIRED TO SET UP AN AUTOMATIC DEPOSIT ACCOUNT. Please attach a voided check or a bank letter for Checking Accounts Or Bank Verification for Savings Accounts Deposit slips for Checking or Savings Accounts are not valid verification for setting up Automatic Deposits. Auto Deposit Auth, Rev.10/22/09

27 EMPLOYEE ACKNOWLEDGEMENT Sequent provides a comprehensive benefit package to all eligible employees. If you are a full time employee (over 30 hours per week), you are eligible to participate in any of the Sequent sponsored group health, dental or vision plans, effective the first of the month following 30 days of service. In addition, you may participate in the Section 125 Cafeteria Based Plan sponsored by Sequent. Under the Cafeteria Plan, you may use pre-tax dollars to help pay for some personal expenses such as dependent care expenses, medical and dental un-reimbursed expenses, and medical and dental premiums. I have received information on the Sequent Benefit Program, and I understand that I must enroll for these programs prior to the date that benefits would be effective. I have also received a copy of the Sequent Employee Handbook. The Employee Handbook contains policies and regulations that apply to me. The contents of the Employee Handbook are not presented as a contract or an agreement to provide any certain benefit. It is for information only. I agree to read the Employee Handbook and follow it during my employment with this Company. I understand that it may be amended at any time, with or without prior notice. In that case, changes will be communicated to me as quickly as possible. My signature below attests to the fact that I have read, understand, and agree to be legally bound to all of the above terms. Employee Signature Date Printed Name Revised 04/11/