Employment Application

Transcription

Employment Application
Information Form
To be considered for employment with Secured Staffing, please fill out the following application and
compliance documents completely and accurately.
NOTE: You will not be able to save the information within the form.
Please print a copy before submitting electronically and
keep a copy to retain for your records.
This packet consists of the following forms:
- Information Form
- Application for Employment
- Background Check Consent Form
- Substance Abuse Policy / Specimen Consent Form
- Harassment and Discrimination Policy
- Employee Medical History Questionnaire
- I9 Employment Eligibility Verification – Fill out Section 1 on page 4 only
- Form W4 Federal Withholdings
- Form K4 State Withholdings
- Direct Deposit Option / Disclosure
- Electronic Signature and Electronic Delivery of Disclosures and Notices
Complete all forms and return to Secured Staffing.
If you have a resume please include it in your submission.
You may return the forms by clicking the submit button at the end of the application or by sending
them by fax, mail or email.
Please don’t forget to send a copy of your drivers license or other form of identification as well as
documents that establish employment authorization. See page 5 of the I9 Employment Eligibility
Verification Form for a list of acceptable documents. Send these documents via mail, fax or email.
Please contact us with any questions or problems you may have with this application.
Send completed application to:
Fax: 2066007340
Email: Careers@SecuredStaffing.com
Mailing Address
Secured Staffing
P.O. Box 99291
Louisville, KY 40269
www.SecuredStaffing.com
Secured Staffing, LLC
An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT
Corporate Office
Secured Staffing
P.O. Box 99291
Phone: 502-744-3643
Fax: 2066007340
Filing Information
Date: ________________________
Time: _______________________
Rate: ________________________
Received By: _________________
Applicant: Do not write in this space.
PRINT IN INK OR TYPE. You must complete the entire application even if you have submitted a resume’. If questions are not applicable, enter
“N/A”. Be sure to sign the application when it is completed. Applications will be kept on active file for 60 days. Federal and State laws prohibit
discrimination on the basis of race, sex, creed, color, religion, national origin, age, handicap or veteran status. Secured Staffing, LLC is an equal
opportunity employer.
Last Name
First Name
Middle Initial
Social Security Number
Street Address
Home Phone
City
State
Date of birth
Alternate Phone
Email Address
Position(s) Desired
Date Available
Were you ever employed by
or are you currently
employed by our company?
 Yes
Zip

If Yes, When?
What Facility?
Pay Rate
Desired
What Capacity/Position?
Under What
Last Name?
No
Are you a US Citizen or an Alien Legally Authorized to work in the USA?
 Yes

No
Alien # if applicable: __________________________________________________________
Are you eligible to work in the US?
 Yes

No
Federal immigration laws require all job applicants to provide verification of authorization to work in the USA before they can be hired;
and, if hired, thereafter where necessary to demonstrate continued compliance with the immigration laws.
Have you ever pled guilty to or been convicted of any criminal offense?
(Do not disclose (1) minor traffic violations; or(2) convictions or arrests that have been sealed or expunged). Note:
A criminal conviction is not an automatic bar to employment. If yes, please explain:
 Yes

EDUCATION
Name & State of School
High School
# of Years Completed
Did You Graduate?
 Yes

No
 Yes

No
Post
Graduate
 Yes

No
Other
 Yes

No
College
Degree
No
EMPLOYMENT HISTORY
1.
2.
3.
4.
5.
6.
7.
Begin with your current or last position and work back to your first.
If other employment is pertinent to your qualification for this position, please list.
Specify any other names you may have worked under.
Employment record should include each position title, even those with the same employer.
Give a brief summary of the technical and, if appropriate, the managerial responsibilities of each position you held.
For supervisory/managerial positions, indicate the number of employees you supervised.
If more space is required, you may continue on a separate sheet of paper or copy additional pages of the following employment record.
You may attach a resume’, but application must be completed as well.
Employer
Position Title
Dates worked
Address

Full Time
City, State, Zip
Supervisors’ name & title
Phone Number
Salary / Compensation / Pay Rate

Part Time

Part Time

Part Time
Description of job duties & responsibilities
 Yes 
May we contact this employer?
Employer
Reason for leaving
No
Position Title
Dates worked
Address

Full Time
City, State, Zip
Phone Number
 Yes 
Employer
Reason for leaving
No
Position Title
Dates worked
Address

Full Time
City, State, Zip
Phone Number
 Yes 
Reason for leaving
No
MILITARY SERVICE RECORD
Are you a veteran of the US Military Services?
 Yes

No
If yes, branch of service ______________________________________ From ________________ To _________________
(Month/Year)
(Month/Year)
Present military affiliation:
None
Reserves (active)
Reserves (inactive)



EQUAL EMPLOYMENT OPPORTUNITY – AFFIRMATIVE ACTION DATA
The information you give in this section is optional. It is used by Secured Staffing to comply with Federal guidelines for
monitoring the equal employment opportunity efforts.
Ethnic Background (Check One):
Gender (Check One):







 Male
 Female
Native American
White, not of Hispanic origin
Hispanic
Black, not of Hispanic origin
Asian/Pacific Islander
Multi-racial
Other
PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS
Are you Currently?

Type
State Issued
Date
Number
Type
State Issued
Date
Number
Type
State Issued
Date
Number
Type
State Issued
Date
Number
Registered


Licensed
Have you ever had your Licenses, Registration or Certification Revoked, Suspended or put on
Probation? If Yes, please explain.
Certified
 Yes

No
SKILLS AND QUALIFICATIONS
List below all skills and qualifications you may have.
If the job you are applying for requires the driving of a motor vehicle while on duty, please provide the following information:
DRIVER’S LICENSE NO.:_______________________________________
STATE: _____________
Are you willing to travel?
Yes
No
CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW
I hereby affirm that the information on this application (and accompanying resume’, if any) is true and complete. I understand that any false or
misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for
employment and may result in discharge even if discovered at a later date.
I understand that employment may be conditioned upon successfully passing a medical examination and that I am required to satisfactorily
complete a drug screening as a condition of employment. Refusal to submit to such test(s) may result in immediate dismissal.
I understand that as part of the application process, information and references may be sought regarding my prior employment and other history,
and that a criminal background check may be conducted, and I hereby authorize persons, schools, my current employer (if applicable) and
previous employers and other organizations to provide this facility and its affiliates with any requested information related to the providing of or
use of such information.
I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or
without notice, and that the company has the same right. I understand that no one has the authority to enter into any agreement contrary to the
preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.
Include a copy of your drivers license or other picture identification with this application along with
copies of any certifications/licenses held.
Signature: __________________________________________________
Date: __________________
BACKGROUND CHECK POLICY
INFORMED CONSENT AGREEMENT TO REQUEST A
BACKGROUND CHECK
I, ________________________________ (please print your name) hereby
give my informed consent to the designated Secured Staffing
Representative and/or its partner companies, to conduct a full background
check.
I understand that refusal to submit to a background check may disqualify
me from consideration for employment or if employed, subject me to
immediate disciplinary action up to, and including immediate DISCHARGE.
Signature: ___________________________ Date: ___________
Date of Birth: ___________________
Social security #:__________________________
Physical Address: _________________________________________
_________________________________________
SUBSTANCE ABUSE POLICY
INFORMED CONSENT AGREEMENT TO REQUEST A BIOLOGICAL SPECIMEN
I, ________________________________________________ (please print your name)
freely and voluntarily agree to submit to this request for a urinalysis and/or blood test (drug
screen). I understand that the chemical analysis will be conducted by a qualified laboratory
and Medical Review Officer, with the results forwarded to the appropriate company
representative. I understand that my agreement to this request is in fulfillment of Secured
Staffing’s Substance Abuse Policy. The purpose of this analysis is to determine the absence
or presence of drugs or alcohol.
I hereby give my informed consent to the designated Secured Staffing representative
and/or their collection agents, to collect the requested specimen, forward it to a laboratory for
analysis and have the findings reported back to the appropriate company representative.
I understand that refusal to submit to the drug screen, failure to qualify according to the
minimum standards established by the company for this screen or the substituting or
tampering with a biological specimen may disqualify me from consideration for employment
or if employed, subject me to immediate disciplinary action up to and including immediate
DISCHARGE.
I CONSENT freely and voluntarily to the Company’s request for urine and/or blood
specimens. I hereby release and hold harmless the Company and its employees and agents
from any liability whatsoever arising from this request to furnish my specimens and the
testing of my specimens.
I am taking the following medications:
(Reporting of birth control medication and doctor’s diagnoses are not required.)
Name of medication
Name of doctor Issuing prescription
________________________________
_______________________________
________________________________
_______________________________
I am submitting to these tests of my own free will.
Signature: __________________________________________
Social Security No.: ___________________________________
Date: ____________
SECURED STAFFING LLC
HARASSMENT & EMPLOYMENT DISCRIMINATION POLICY
HARASSMENT POLICY
SECURED STAFFING LLC believes that every employee has the right to a work
environment free of unwelcome verbal or physical conduct which harasses, disrupts, or
interferes with the individual's work performance or creates an intimidating, offensive, or
hostile environment. Secured Staffing LLC does not tolerate any employees engaging in
this type of behavior. Any employee participating in such negative conduct will be
subject to appropriate corrective action which may include termination.
EMPLOYEE HARASSMENT is any unwelcome conduct that illegally discriminates
against you or another employee, unreasonably interferes with an individual's work
performance, or creates an intimidating, hostile, or offensive work environment. This
would include harassment based upon an individual's race, color, religion, sexual
orientation, marital status, gender, family status, age, creed, physical or mental disability,
or other protected classifications.
SEXUAL HARASSMENT is defined as unwelcome sexual advances, requests for
sexual favors, or other verbal or physical conduct of a sexual nature where submission to
such conduct is made either explicitly or implicitly a term or condition of an individual's
employment; or submission to or rejection of such conduct is used or threatened to be
used as the basis for employment decisions affecting such individual; or such
unreasonable conduct interferes with an individual's work performance or creates an
intimidating, hostile, or offensive work environment.
GUIDELINES: If you become aware of a situation involving unwelcome and
inappropriate behavior directed toward you or another employee, report it immediately to
your supervisor. If for any reason you do not feel that you can speak to your supervisor
about the situation, please report to April Ravenscroft. Upon receipt of a complaint
under this policy, Secured Staffing LLC will initiate an investigation of the situation and
document the responses of all individuals involved.
DISCIPLINARY ACTION: Any disciplinary action taken in response to the findings of
a harassment complaint will be based on the individual circumstances of each
situation. Disciplinary actions may include, but are not limited to written warnings,
suspension without pay, or termination. In addition, if it is determined that a person has
falsely and intentionally accused someone of harassment, appropriate disciplinary action
may be taken, which may include termination.
Page 1 of 2
EMPLOYMENT DISCRIMINATION & EQUAL OPPORTUNITY POLICY
SECURED STAFFING LLC strives to provide equal employment opportunities for all
employees and job applicants without regard to race, color, religion, sexual orientation,
marital status, gender, family status, age, creed, physical or mental disability, or other
protected classifications, in compliance with federal, state, and local laws governing
nondiscrimination in employment.
By signing below, I acknowledge I have read and understand the SECURED
STAFFING LLC Harassment Policy and Employment Discrimination/Equal
Opportunity Policy.
Signature
Date
Page 2 of 2
Employee Medical History Questionnaire Letter
NOTICE:
All questions must be answered. If the answer is “no” or “none,” please indicate. All responses must be
complete. If a response requires explanation, please provide one. If there is not enough space on the form for a
complete response, please complete your response on the back of the form.
The information obtained from the questionnaire will be kept CONFIDENTIAL and will not be made a part of
your personnel file. As you complete the attached questionnaire, you should be aware that:
FAILURE TO ANSWER TRUTHFULLY MAY RESULT IN FORFEITURE OF YOUR WORKERS’
COMPENSATION BENEFITS
QUESTIONNAIRE:
Please answer the following questions by selecting either YES or NO.
1. Have you ever had a disease or disability arising from your occupation? YES NO
If YES, please explain:
________________________________________________________________________________________
2. Have you ever received workers’ compensation benefits for an injury that occurred at work? YES NO
If YES, when?
________________________________________________________________________________________
How long were you on compensation?
________________________________________________________________________________________
Name of employer:
________________________________________________________________________________________
Nature of injury:
________________________________________________________________________________________
3. Have you ever been rejected for employment, insurance, or military service because of your health? YES NO
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Have you ever had back trouble or injury to your back, head or neck? YES NO
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Do you have any restrictions or limitations upon your physical activities? YES NO
______________________________________________________________________________________________
______________________________________________________________________________________________
Page 1 of 2
6. What operations, accidents, broken bones, strains or serious illnesses have you had?
______________________________________________________________________________________________
______________________________________________________________________________________________
7. Have you had any of the following? Put an “X” in the box for YES. Leave blank for NO.
 Amputation
(foot, leg, arm, hand or total loss
thereof)
 Ankylosis of Joints
 Arteriosclerosis
 Arthritis
 Asthma
 Back/Neck Problem
 Brain Damage
 Bronchitis
 Cancer
 Cardiac Disease
 Carpal Tunnel Syndrome
 Cerebral Vascular Accident
 Chronic Headaches
 Chronic Osteomyelitis
 Communicable Disease
 Compressed Air Sequelae
 Diabetes
 Dizziness
 Double Vision (Blurred Sight)
 Emphysema
 Epilepsy
 Head Injury
 Heart Condition
 Heavy Metal Poisoning
 Hemophilia
 High/Low Blood Pressure
 Hodgkin’s Disease
 Hyperinsulinism
 Hypertension
 Ionizing Radiation Injury
 Kidney Disorder
 Loss of Hearing (more than 75%)
 Loss of Sight (of one or both eyes or a
partial loss of uncorrected vision)
 Loss of Use of Limbs
 Mental Disorders
 Mental Retardation
 Multiple Sclerosis
 Muscle, Ligament or Tendon Injury
 Muscular Dystrophy
 Nervous Disorders
 Numbness of Extremities
 Parkinson’s Disease
 Psychoneurotic Disability (following
treatment in a recognized institution)
 Refl ex Sympathetic Dystrophy
 Repetitive Motion Injury
 Residual Disability from Polio
 Rheumatism
 Rotator Cuff Injury
 Ruptured Intervertebral Disc
 Silicosis
 Spinal Fusion
 Stroke
 Sugar in Urine
 Surgical Removal of Intervertebral Disc
 Thrombophlebitis
 Thorasic Oulet
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
8. Do you have any other long-term health problems or adverse physical conditions? YES NO
_____________________________________________________________________________________________
______________________________________________________________________________________________
I have read the foregoing notice and have completed the questionnaire to the best of my
knowledge, information and belief.
Signature: ____________________________________________ Date: _______________
Printed Name: _________________________________________

Page 2 of 2
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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 2011
expires February 16, 2012. 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 $950 and includes more than $300 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 may 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. 919,
How Do I Adjust My Tax Withholding, 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. 919 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.
919 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. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2011. See Pub. 919,
especially if your earnings exceed $130,000
(Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• 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.
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
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
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.)
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 $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . .
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
• If 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
• If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
worksheets
$40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
{
B
C
D
E
F
G
H
}
{
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
2011
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Type or print your first name and middle initial.
Last name
2 Your social security number
Home address (number and street or rural route)
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.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
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 . . . . . . . . . . . . . .
I claim exemption from withholding for 2011, 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 . . . . . . . . . . . . . . . ▶ 7
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.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2011)
Page 2
Form W-4 (2011)
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
2
3
4
5
6
7
8
9
10
Enter an estimate of your 2011 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 . . . . . . . . . . . . . . . . . . . . . . . . .
$11,600 if married filing jointly or qualifying widow(er)
Enter:
$8,500 if head of household
. . . . . . . . . . .
$5,800 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)
. . . . . . . . . . .
{
}
Enter an estimate of your 2011 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
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
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
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.
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” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
1
2
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 . . . . . . . . .
3
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
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . .
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
6
7
8
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
Married Filing Jointly
Enter on
line 2 above
$0 - $5,000 0
$0 - $8,000 0
1
8,001 - 15,000 1
5,001 - 12,000 2
15,001 - 25,000 2
12,001 - 22,000 3
25,001 - 30,000 3
22,001 - 25,000 4
30,001 - 40,000 4
25,001 - 30,000 5
40,001 - 50,000 5
30,001 - 40,000 6
50,001 - 65,000 6
40,001 - 48,000 7
65,001 - 80,000 7
48,001 - 55,000 8
80,001 - 95,000 8
55,001 - 65,000 9
95,001 -120,000 9
65,001 - 72,000 10
120,001 and over
10
72,001 - 85,000 11
85,001 - 97,000 12
97,001 -110,000 13
110,001 -120,000 14
120,001 -135,000 15
135,001 and over
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.
If wages from HIGHEST
paying job are—
$0
65,001
125,001
185,001
335,001
- $65,000
- 125,000
- 185,000
- 335,000
and over
Enter on
line 7 above
$560
930
1,040
1,220
1,300
All Others
If wages from HIGHEST
paying job are—
$0
35,001
90,001
165,001
370,001
- $35,000
- 90,000
- 165,000
- 370,000
and over
Enter on
line 7 above
$560
930
1,040
1,220
1,300
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 6103.
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.
Revenue Form K-4
42A804 (11-09)
KENTUCKY DEPARTMENT OF REVENUE
EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
Print Full Name ________________________________________________________________________
Payroll No. __________________________
Social Security No. ___________________________
Print Home Address ____________________________________________________________________________________________________________________
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
I certify that I am not subject 1. If SINGLE, and you claim an exemption, enter “1,” if you do not, enter “0” ............................................................... ________
to Kentucky withholding 2. If MARRIED, one exemption each for you and spouse if not claimed on another certificate.
under the Military Spouses
(a) If you claim both of these exemptions, enter “2”
Residency Relief Act. See
(b) If you claim one of these exemptions, enter “1” ................................................................................................ ________
(c) If you claim neither of these exemptions, enter “0”
instructions on the back of
Form K-4 before checking 3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents):
(a) If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption,
this box.........................
enter “2”; if both will be 65 or older, and you claim both of these exemptions, enter “4” .................................. ________
(b) If you or your spouse are blind, and you claim this exemption, enter “2”; if both are blind, and you claim
both of these exemptions, enter “4” ......................................................................................................................... ________
EMPLOYER:
4. If you claim exemptions for one or more dependents, enter the number of such exemptions ................................ ________
5. National Guard exemption (see instruction 1) ............................................................................................................... ________
Keep this certificate with 6. Exemptions for Excess Itemized Deductions (Form K-4A) ............................................................................................ ________
your records.
7. Add the number of exemptions which you have claimed above and enter the total .................................................
8. Additional withholding per pay period under agreement with employer. See instruction 1 ...........................$ _____________
}

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date _________________________________
Signed___________________________________________________________________________________
INSTRUCTIONS
1. NUMBER OF EXEMPTIONS—Do not claim more than the correct
number of exemptions. However, if you have unusually large amounts
of itemized deductions, you may claim additional exemptions to avoid
excess withholding. You may also claim an additional exemption if you
will be a member of the Kentucky National Guard at the end of the year.
If you expect to owe more income tax for the year than will be withheld,
you may increase the withholding by claiming a smaller number of
exemptions or you may enter into an agreement with your employer to
have additional amounts withheld. If you claim more than 10 exemptions
this information is sent to the Department of Revenue.
2. CHANGES IN EXEMPTIONS—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 for any of the
following reasons.
(a) You are divorced or legally separated from your spouse for
whom you have been claiming an exemption or your spouse claims his
or her own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption
is taken over by someone else, so that you no longer expect to furnish
more than half the support for the year.
(c) Your itemized deductions substantially decrease and a Form
K-4A has previously been filed.
OTHER DECREASES in exemption, such as the death of a spouse
or a dependent, do not affect your withholding until the next year, but
require the filing of a new certificate by December 1 of the year in which
they occur.
3. DEPENDENTS—To qualify as your dependent (line 4 on reverse), a person
(a) must receive more than one-half of his or her support from you for the year,
and (b) must not be claimed as an exemption by such person’s spouse, and (c)
must be a citizen of the United States, or a resident of the United States, Canada,
or Mexico, or (d) must have lived with you for the entire year as a member of
your household or be related to you as follows:
your child, stepchild, legally adopted child, foster child (if he lived in your
home as a member of the family for the entire year), grandchild, son-in-law,
or daughter-in-law;
your father, mother, or ancestor of either, stepfather, stepmother, father-inlaw, or mother-in-law;
your brother, sister, stepbrother, stepsister, brother-in-law, or sister-in-law;
your uncle, aunt, nephew, or niece (but only if related by blood).
4. MILITARY SPOUSE—Under the Military Spouses Residency Relief Act, you
may be exempt from Kentucky tax on your wages if (a) your spouse is a member
of the armed forces present in Kentucky in compliance with military orders; (b)
you are present in Kentucky solely to be with your spouse; and (c) you maintain
your domicile in another state. If you claim this exemption, please check the box
on the front of the K-4 and attach a copy of your spousal military identification
card.
5. PENALTIES—Penalties are imposed for willfully supplying false information
or willful failure to supply information which would reduce the withholding
exemption.
•
•
•
•
www.revenue.ky.gov
Request and Authorization for Direct Deposit Option
You have the option of choosing to have your paycheck directly deposited into
your bank account. There is a convenience charge for this service of $1.25 per
direct deposit which will be deducted from the gross amount of your paycheck.
If you wish to decline this service, please disregard this form.
This authorizes Secured Staffing, LLC to send credit entries (and appropriate debit
and adjustment entries), electronically or by any other commercially accepted
method, to my account indicated below and to other accounts I may identify in the
future. This authorizes the financial institution holding my account to post all such
entries.
Bank Account Information
Note: You may attach a voided check in lieu of filling out this information.
Account Type (select one):
CHECKING
SAVINGS
Bank Name: _______________________________________________________
Routing Number: ___________________________________________________
Account Number: ___________________________________________________
This authorization will be in effect until Secured Staffing receives a written
termination notice from myself and has a reasonable opportunity to act on it.
By signing below I confirm I am requesting direct deposit service and agree to the
$1.25 convenience fee per transaction.
_______________________________________
___________________
Signature
Date
_______________________________________
Printed Name
_______________________________________
SSN#
P.O. Box 99291
Louisville, Kentucky 40269
Phone: 502-744-3643
Fax: 502-263-7256
www.SecuredStaffing.com
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and electronic signatures rather than paper documents for the forms provided on this web site. Those forms include:

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Application for Employment
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Substance Abuse Policy / Specimen Consent Form
Harassment and Discrimination Policy
Employee Medical History Questionnaire
I9 Employment Eligibility Verification
Form W4 Federal Withholdings
Form K4 State Withholdings
Direct Deposit Option / Disclosure
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P.O. Box 99291
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