EMPLOYEE ONBOARDING PACKET · EMPLOYEE ONBOARDING PACKET 1 | Page Simplify Business. Rev. 8/2016 PERSONAL INFORMATION Social Security Number Gender ale M Female Name Date of Birth

EMPLOYEE ONBOARDING PACKET

1 | P a g eSimplify Business. Rev. 8/2016

P E R S O N A L I N F O R M A T I O N

Social Security Number Gender Male Female

Name Date of Birth FIRST MIDDLE LAST

Physical Address STREET CITY STATE ZIP

Mailing Address (if different from above)

Phone Number(s) HOME CELL WORK

Email Address

E M E R G E N C Y C O N T A C T

Emergency Contact Name

Phone # Relationship

E E O - 1 V O L U N T A R Y S E L F I D E N T I F I C A T I O NAffirmative Action Information: We comply with government regulations including Affirmative Action obligations. In an effort to comply with requirements regarding government recordkeeping and other legal obligations, we ask that you complete this applicant data survey. Please be advised that your survey is considered confidential information that will not be used in any hiring decision. Your cooperation is appreciated.

Special Notice to Vietnam Veterans, Disabled Veterans and Individuals with Physical or Mental Handicaps or Disabilities: Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and qualified handicapped individuals. This information is used to satisfy the Affirmative Action requirement of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulations.

ARE YOU A VETERAN? An individual who served in the Army, Navy, Air Force, Marine corps or Coast Guard of the United States or in an auxiliary service of one of those branches. Yes No Decline to State

RACE/ETHNICITY: Please check one of the descriptions below corresponding to the ethnic group with which you identify. Asian Black or African American Hispanic or Latino American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Two or more races White Decline to State

T H I S S E C T I O N F O R E M P L O Y E R U S E O N L Y

Employee’s Date of Hire Employee’s Start Date with eESI

Employment Type Full Time Part Time Temporary Seasonal On-Call/PRN

Pay Rate $ per Hour Week Month Year Commission Other

Pay Status Exempt Non-Exempt Salaried Hourly Job Title

Pay Group (Pay Frequency) Weekly Bi-Weekly Semi-Monthly Monthly Other

Standard Hours per Week (example: 40) Company Name ______________________________

Location________________ Department _______


G E N E R A L A C K N O W L E D G E M E N T S

I acknowledge that eESI is a Professional Employer Organization, which handles human resources, risk management, employee benefits, payroll administration, technology and other matters for its clients. I understand that, whether I am an employee internal to eESI, who works directly for eESI delivering excellent PEO services, or an employee working at one of eESI’s client’s worksites, I will hold myself to the highest standards of professionalism. I understand that the term “Company” used in these documents refers to eESI and/or the eESI client company as applicable and appropriate.

I acknowledge that I have received a copy of The Company Employee Handbook. I understand that the Employee Handbook is not a contract of employment, and that the Company retains the right to review, amend, change or discontinue the policies and benefits discussed in the Handbook at any time, with or without notice.

I acknowledge understand and agree that my employment is on an "at-will" basis. This means that either the Company or I can terminate the employment relationship at any time for any reason not prohibited by law. I also understand that no exceptions to this policy will be recognized unless contained in a separate written agreement signed by an Officer of the Company and myself. Any oral representations to the contrary are invalid and will not be relied upon.

I authorize eESI to investigate my background and qualifications for purposes of evaluating whether I am qualified for the positions for which I am applying. I understand that eESI may utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of eESI’s choice and release eESI and any of its clients or outside firms of any liability arising out of such checks, including liability based on any theory of negligence. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

I have read and understand the legal terms and conditions. I agree to be bound by the legal terms and conditions.

Employee Signature:___________________________________________________Date:

E L E C T R O N I C W - 2 C O N S E N T

eESI provides employees with their W-2 form electronically via the Employee Portal. If the employee does not consent to receive it electronically, they will receive a paper Form W-2 postmarked on or before January 31st.

I consent to receive my Form W-2 in an electronic format via the Employee Portal. I acknowledge that this consent will remain in effect for this year’s W-2 and future years’ W-2s until I withdraw my consent by email to [email protected].



mailto:[email protected]


W A G E D E D U C T I O N A U T H O R I Z A T I O N

I understand and agree that the Company may deduct money from my pay from time to time for reasons that fall into the following categories:

1. my share of the premiums for the Company's group medical/dental plan;2. any contributions I may make into a retirement or pension Company-sponsored or controlled plan;3. installment payments on loans or wage advances given to me by the Company, and if there is a balance

remaining when I leave the Company, the balance of such loans or advances;4. installment payments on loans based upon store credit that I use for my own personal purchases, including

the value of merchandise or services that I purchase or have purchased for personal, non-business reasonsusing my employee charge account or credit card, an account or credit card assigned to another employee,or a general company account or credit card, regardless of whether such purchase was authorized, and ifthere is a balance remaining when I leave the Company, the balance of such store credit or charges;

5. if I receive an overpayment of wages for any reason, repayment to the Company of such overpayments (thededuction for such a repayment will equal the entire amount of the overpayment, unless the Company and Iagree in writing to a series of smaller deductions in specified amounts);

6. the cost to the Company of personal long-distance calls I may make, or messages I may send, usingCompany phones (land lines or cell phones) or Company accounts, of personal faxes sent by me usingCompany equipment or Company accounts, or of non-work related access to the Internet or other computernetworks by me using Company equipment or Company accounts;

7. the cost of repairing or replacing any Company supplies, materials, equipment, money, or other propertythat I may damage (other than normal wear and tear), lose, fail to return, or take without appropriateauthorization from the Company during my employment (except in the case of misappropriation of moneyby me, I understand that no such deduction will take my pay below minimum wage, or, if I am a salariedexempt employee, reduce my salary below its predetermined amount);

8. the cost of Company uniforms and of cleaning the uniforms (the Company will deduct only the actual priceit pays for uniforms and cleaning costs);

9. the reasonable cost or fair value, whichever is less, of meals, lodging, and other facilities furnished to meby the Company in connection with my employment;

10. administrative fees in connection with court-ordered garnishments or legally-required wage attachments ofmy pay, limited in extent to the amount or amounts allowed under applicable laws;

11. if I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separatefrom the Company before accruing time to cover such advance leave, the value of such leave taken inadvance that is not so covered;

12. the value of any time off for absences to which paid leave is not applied (except in the case of those whoare paid a fixed salary for fluctuating workweeks, non-exempt salaried employees will have all such unpaidleave deducted from their salary, while exempt salaried employees will experience salary reductions only inunits of a full day or week at a time, depending upon the exact nature of the absence, unless partial-daydeductions are specifically allowed under federal law);

13. if my employer pays any insurance premiums or retirement system contributions ("payments") on mybehalf that I would normally make under the applicable Company benefit plan, the amount of suchpayments made by the Company, such payments being an advance of future wages payable to me;

14. the costs to Company for any positive drug test;15. any fees for professional licenses, dues or certifications that are paid on my behalf by Company; and16. reprints or reissuances of certain documents to an employee, including paychecks, W-2s, and paystubs.

I agree that the Company may deduct money from my pay under the above circumstances, or if any of the above situations occur. I further understand that the Company has stated its intention to abide by all applicable federal and state wage and hour laws and that if I believe that any such law has not been followed, I have the right to file a wage claim with appropriate state and federal agencies.


Employee Signature: __________________________________________________Date:


D R U G A N D / O R A L C O H O L T E S T I N G

C O N S E N T

I hereby agree, upon a request made under the drug/alcohol testing policy of the Company, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under Company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have the Company and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Company to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized Company officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities. I will hold harmless the Company, its company physician, and any testing laboratory the Company might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a Company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the Company, its company physician, and any testing laboratory the Company might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I UNDERSTAND THAT THE COMPANY WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST.




B I N D I N G A R B I T R A T I O N A G R E E M E N T

By your signature below, you accept the offer of employment (or your continued employment if applicable) with eESI, and, as applicable, employment with any of its PEO clients (collectively referred to herein as “Company”), subject to this Arbitration Agreement. You and the Company are hereby agreeing that any dispute that may arise that cannot be solved informally will be resolved finally and fully under this standalone binding arbitration policy, which shall be governed by the Federal Arbitration Act.

You should read this policy carefully, because it creates a binding agreement that affects all parties’ respective legal rights to bring a claim based on any aspect of the employment relationship or termination of that relationship, including a right to a trial by jury, which is being waived by all parties as a result of this agreement in the interest of resolving such disputes with the aid of a private arbitrator.

By signing below, you are agreeing that any past, present or future dispute that arises between you and the Company and/or its officers, employees, vendors, agents or clients regarding any aspect of your employment relationship, including its inception and termination as well as any post-termination events, will be submitted to binding arbitration before the American Arbitration Association (the “AAA”). Such binding arbitration will be administered under the AAA’s Employment Arbitration Rules. The venue for any such arbitration proceedings will be in San Antonio, Texas.

You agree that such arbitration will be the sole and exclusive remedy to redress any dispute, claim or controversy between you and the Company. The award of the arbitrator shall be final and binding on the parties.

You agree to bring any claim or dispute in arbitration on an individual basis only, and not as a class or collective action. You waive any right for a dispute or claim to be brought, heard, or decided as a class or collective action, and the arbitrator has no power or authority to preside over a class or collective action.

You acknowledge this Agreement does not prevent or discourage you from filing whatever claims, charges or other administrative complaints that you may file with any local, state or federal governmental agency, for example, claims with the Equal Employment Opportunity Commission, the National Labor Relations Board, the Department of Labor, workers’ compensation claims, or state unemployment claims.

Finally, there may be a situation where the Company feels it necessary to seek immediate injunctive relief (for example, if you were violating the terms of a non-compete agreement). In such a case, you agree that the Company may file such injunction proceedings in a court of competent jurisdiction located in San Antonio, Texas and thereafter transition those proceedings (and whatever injunctive relief was awarded) to AAA’s arbitral forum.

The employee, by his/her signature below, acknowledges having received and read the above Arbitration Policy and agreeing to be bound by its terms.



C O N F I D E N T I A L I T Y A G R E E M E N T

You and the Company (which includes any eESI PEO-client company, if applicable) know and agree that during the course of your employment with Company, you will be exposed to and otherwise have access to the Company’s confidential and proprietary information (e.g. hard copy documents, electronic files, and other documents) , including information concerning the identity of Company’s existing customers, as well as information concerning those customers’ internal procedures and confidential/proprietary information as well as the Company’s pricing, and other confidential and proprietary information, which could cause competitive harm to Company if disclosed to a third-party not authorized by the Company to have such information.

You and the Company agree that such confidential and proprietary information is a valuable, special and unique asset of Company’s business, which has been developed and which will be developed during the course of your employment by the Company through the expenditure by the Company of substantial time, money and effort.

You agree that you will not at any time or in any manner during or subsequent to your employment with Company either directly or indirectly use such information for your personal benefit or disclose such information to anyone outside of the Company.

You further agree that all records, documents, manuals, lists and other papers, or copies of same, given to you by Company and relating to the business and prospective business of the Company are and shall remain the exclusive property of the Company. You shall deliver same to Company upon demand and, in any event, upon termination of your employment with the Company.

You agree that Company will be entitled to those damages it sustains if you violate this Agreement (including attorneys’ fees and related expenses). You also realize that the obligations you are undertaking in this Agreement are in addition to and not in the place of those legal obligations that any employee owes by default to his or her employer, including a fiduciary duty to place the employer’s business interests ahead of the employee’s personal interests.

Employee Signature ___________________________________________________Date:


N O N - C O M P E T I T I O N & N O N - S O L I C I T A T I O N A G R E E M E N T

Whereas, the Company (which is a term including any PEO-client of ESI, if applicable) wishes to employ Employee under various terms and conditions, including those set forth below respecting non-competition and non-solicitation obligations, and the Employee wishes to accept such employment under such terms and conditions.

Whereas, Employee acknowledges that Employee has read and is fully familiar with the terms of this agreement, that Employee has had a reasonable opportunity to consider this Agreement and that Employee finds that the promises and considerations provided by Employee in this Agreement are not greater than necessary for the protection of the Company’s goodwill and legitimate business interests and do not create undue hardship for the Employee or the public.

Now therefore, for and in consideration of the above-stated premises, and the mutual promises and agreements set forth herein, the parties agree as follows:

1. Duties. Upon the effective date of this agreement, Employee (i) shall commence to perform theduties of the position to which he or she is assigned, and (ii) shall devote such time, ability, skillsand attention to the business of the Company as reasonably necessary to perform the assigned dutiesand performance targets, (ii) shall perform the duties in a reasonable, timely and professionalmanner, and (iv) shall comply with all applicable policies and rules of the Company as set forth inthe Employee Handbook as it now exists, and as it may exist in the future.

2. Business Interest & Obligations. The following are the parties’ agreements as to the legitimateprotectable business interests of the Company.

a. Trade Secrets. The Company will give access to and allow the Employee to become familiarwith the various trade secrets of the Company that are applicable to the Employee’s positionunder the Company’s normal policies and procedures. These trade secrets may include, withoutlimitation, compilations of market information, pricing guidelines, customer lists and contactinformation, advertising plans, and business plans of the Company. Employee agrees thatEmployee shall not disclose any of the trade secrets, directly or indirectly, nor use them in anyway, either during the Employee’s employment or at any time thereafter, except as required inthe ordinary course of Employees employment for the benefit of the Company.

b. Confidential Information. Consistent with any Confidentiality Agreement separately enteredinto between us, the Company will provide employee confidential information, and/or access toconfidential information, that is applicable to the Employee’s position under the Company’snormal policies and procedures. The parties agree that, for purpose of this agreement,“Confidential Information” is information acquired by the Employee in the course and scope ofhis or her activities for the Company that is designated by the Company as “confidential” or thatthe Company indicates through its policies, procedures, or other instructions should not bedisclosed to anyone outside the Company except through controlled means. The controlleddisclosure of Confidential Information to customers or vendors for legitimate business purposesand the availability of the Confidential Information to others outside the Company throughindependent investigation status under this Agreement if the employee acquired theConfidential Information while employed with the Company. Employee agrees to use suchConfidential Information for the exclusive benefit of the Company, and Employee shall not,during employment with the Company or thereafter, directly or indirectly, use the ConfidentialInformation for any other purpose. Confidential information may also be protected as tradesecret under paragraph 4(a) above. Some examples of Confidential Information are internalfinancial statements and analysis, personnel files and evaluations, internal pricing and costinformation, customer lists and contacts information, salary and compensation information, andinformation concerning specific customer needs.

c. Goodwill. The Company may provide Employee with certain forms of compensation(including, for example, possible participation in bonus programs and/or stock option plans),


legitimate business expense reimbursements in accordance with Company policy, as well as contact with customers, contractors, vendors and co-workers in Employee’s position and pursuant to the Company’s normal policies and procedures. Employee agrees that he/she would not otherwise be entitled to participate in such bonus programs, stock option plans, or receive expense reimbursements and contact with customers to engender goodwill but for his/her promise not to appropriate such resulting goodwill for the benefit of someone other than the Company. Accordingly, Employee agrees to use the goodwill developed with the Company’s customers, contractors, vendors and co-workers for the exclusive benefit of the Company.

3. Protective Covenants. Employee agrees that the following covenants are reasonable and necessaryprotective covenants for the protection of the business interests described in Paragraph 2 above:

a. Definitions.

“Competing Business” means any business that offers goods or services of the kind Employeewas offering or performing while in the employ of Company that the Employee’s provision ofsuch goods or services on behalf of the Competing Business would displace businessopportunities or customers or customer prospects of the Company.

“Covered Customer” means those customer entities and/or persons who did business with theCompany and that Employee either (a) received Confidential Information about, or (b) hadcontact within the last 12-month-period Employee was employed with the Company.

b. Handling of Covered Items. All information and material covered by Paragraph 2(a)-(c) shallremain the exclusive property of the Company, and shall not be removed from the premises ofthe Company without the prior consent of the Company. If removed from the Companypremises by consent, such information and material will be used only for the benefit of theCompany in the ordinary course of business. All documents covered by Paragraphs 2(a)-(c) are,and shall continue to be, the property of the Company, and shall, together with all copies thereof,be returned and delivered to the Company by employee immediately without demand, upon thetermination of the employee’s employment with the Company, and shall be returned at any timeif the Company so demands.

c. Restrictions on Interfering With Co-Employees. Employee agrees that during employmentwith the Company, and for the period of twenty-four (24) complete calendar months followingthe termination of Employee’s employment with the Company, Employee will not, directly orindirectly, hire, call on, solicit, or take away, or attempt to call on, solicit or take away any of theemployees or officers of the Company to terminate their relationship with the Company, withoutprior written consent of the Company by a duly authorized Company representative.

d. Restriction on Interfering with Customer Relationships. Employee agrees that duringemployment with the Company, and for a period of twenty-four (24) complete calendar monthsfollowing the termination of employment with the Company, Employee will not, directly orindirectly, except in connection with the Employee’s employment with the Company, service,call on, solicit, or take away, or attempt to call on, solicit, or take away any of the CoveredCustomers of the Company without the prior written consent of the Company by a dulyauthorized Company representative.

e. Restrictions on Unfair Competition. Employee agrees that during employment with theCompany, employee will not actively participate in any way in a Competing Business.Employee also agrees that for the period of twenty-four (24) complete calendar monthsfollowing termination of employment with Company, Employee will not actively participate in aCompeting Business by providing services (whether as an employee, agent, consultant, advisor,independent contractor, or other capacity) to a Competing Business in a position that wouldinvolve the use or disclosure of Company Trade Secrets or Confidential Information, or that hassubstantially the same functions and/or responsibilities as a position Employee held with the


Company, and/or that involves supervision over substantially the same functions and/or responsibilities. For purpose of this paragraph “actively participate in” includes participating, directly or indirectly, either as an employee, consultant, partner, shareholder (other than through ownership of publicly-traded capital stock of a corporation that represents less than ten percent (10%) of the outstanding capital stock of such corporation), lender, corporate officer, director, or in any other capacity, in assisting a Competing Business if the participation would involve, in any way, influence or input into the Competing Business’s business decisions or relationships with Covered Customers. Employee agrees that competition in violation of these terms is intrinsically unfair to the Company because it would involve inevitable disclosures of Trade Secrets and Confidential Information, as well as conversion of the Company’s investment in goodwill and training and confusion over the Company’s brand and associations.

f. Survival of Covenants. Each of the restrictions set forth herein shall survive the termination ofEmployee’s employment with the Company. The existence of any claim or cause of action of theEmployee against the Company whether predicated on this Agreement or otherwise shall notconstitute a defense to the enforcement by the Company of said covenant. In the event anenforcement remedy is sought under Paragraph g., the time periods provided herein shall beextended by one day for each day employee failed to comply with the restriction at issue.

g. Remedies. Without waiving anything contained in any arbitration agreement signed separatelyby the parties, in the event of breach or threatened breach by Employee of any provision hereof,the Company shall be entitled to (i) injunctive relief by temporary restraining order, temporaryinjunction, and/or permanent injunction, (ii) recovery of all attorney fees and costs incurred bythe Company in obtaining such relief, and (iii) any other legal and equitable relief to which itmay be entitled, including any and all monetary damages that the Company may incur as a resultof said breach or threatened breach. An agreed amount for the bond to be posted if an injunctionis sought by the Company is $500.00. The Company may pursue any remedy available,including declaratory relief, concurrently or consecutively in any order as to any breach,violation, or threatened breach or violation, and pursuit of one such remedy at any time will notbe deemed an election of remedies or waiver of the right to pursue any other remedy. TheCompany has the right to pursue partial enforcement, and/or to seek declaratory relief regardingthe enforceable scope of this agreement without penalty and without waiving the Company’sright to pursue any other available remedy subsequent to declaratory relief.

h. Early Resolution Conference. This Agreement is understood to be clear and enforceable aswritten and is executed by both parties on that basis. Should, however, Employee later challengeany provision as unclear, unenforceable, or inapplicable to activity, the Employee will firstnotify the Company in writing and meet with the Company and a neutral mediator (if theCompany elects to retain one at its expense) to discuss resolution of any disputes informallybetween the parties. Employee will provide this notification at least fourteen (14) days beforethe Employee engages in any activity on behalf of a Competing Business, contacts any CoveredCustomer or engages in other activity that could foreseeably fall within a questioned restriction.The failure to comply with this requirement shall waive Employee’s right to challenge thereasonable scope, clarity, applicability, or enforceability of the Agreement and its restrictions ata later time. All rights of both parties will be preserved if the Early Resolution Conferencerequirement is complied with even if no agreement is reached in the conference.

i. Changes in Restrictions. The parties agree that the Company may change the scope,geography and/or time limitations that apply to the restrictions stated herein as a condition of areassignment, promotion, or other change in position, composition of a reassignment, promotion,or other change in position, compensation, or duties for the Employee. The agreements statedherein are independently sufficient to support this option provided to the Company. Such achange in the terms of this Agreement will be made in writing by a duly authorized officer of theCompany. The Company will give the Employee at least fourteen (14) days written notice of thechange in terms. An Employee who acts in continuing employment after the effective date willbe deemed to have accepted the change.


j. Ancillary Interest. The parties agree that one of the agreements in Paragraphs 2(a)-(c) standingalone, will be deemed an otherwise enforceable agreement at the time this Agreement wasmade, and gives rise to the need for the restrictions provided for herein.

4. Merger or Acquisition Disposition. In the event the Company should consolidate, or merge intoanother entity, or transfer all or substantially all of its assets to another entity, or divide its assetsamong a number of entities, this Agreement shall continue in full force and effect with regard to thesurviving entity.

5. Notices. All notices, requests, consents, and other communications under this Agreement shall be inwriting and shall be deemed to have been delivered on the date personally delivered or on the datedeposited in a receptacle maintained by the United States Postal Service for such purpose, postageprepaid, by certified mail, return receipt requested, addressed to the Company at its regular businessaddress and to the Employee at the address set forth below Employee’s signature on the signaturepage hereto. Either party hereto may designate a different address by providing written notice ofsuch new address to the other party hereto.

6. Severability. If any provision in this Agreement is determined to be void, illegal or unenforceable,in whole or in part, then the other provisions contained herein shall remain in full force and effect asif the provision that was determined to be void, illegal, or unenforceable had not been containedherein. If the restrictions herein are deemed unenforceable as written, the parties expressly authorizethe Court to revise, delete, or add to the restrictions contained herein to the extent necessary toenforce the intent of the parties and to provide the Company’s goodwill, confidential information,and other business interests with the most protection afforded under the law.

7. Waiver, Opportunity to Cure, Modification, and Integration. The waiver by any party hereto ofbreach of any provision of this Agreement shall not operate or be constructed as a viewer of anysubsequent breach by any party; provided, however that if Employee becomes aware of any breachof any material term of this Agreement by the Company, Employee will give the Company writtennotice of the alleged breach within seven (7) days and give the Company thirty (30) days to curesuch alleged breach. Employee’s failure to provide this notice and opportunity to cure will waiveany right of Employee to assert that alleged breach at a later time. This instrument contains theentire agreement of the parties on the non-competition and non-solicitation issues covered herein.This agreement may not be modified, altered or amended except by written agreement of all theparties hereto, except as provided specifically herein.

8. Binding Effect. This Agreement shall be binding effective upon the Company and its successorsand permitted assigns, and upon Employee, employee’s heirs and representatives.

9. Governing Laws. It is the intention of the parties that the laws of the State of Texas should governthe validity of this Agreement, the construction of its terms, and the interpretation of the rights andduties of the parties hereto. The agreed venue and jurisdiction for any claims or disputes under thisagreement is Texas.

10. Representation of Employee. Employee hereby represents and warrants to the Company thatEmployee has not previously assumed any obligation inconsistent with those contained in thisAgreement, and will not use, disclose or otherwise rely upon any Confidential Information or TradeSecrets derived from any previous employment if employee has any in the performance of his dutieson behalf of the Company.



Direct Deposit Authorization

I (we) hereby authorize eEmployers Solutions, Inc., hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our) account indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.

Check this box if this is a change to your current direct deposit information

Account 1

Bank Name: ___________________________________________________________

Account Name: ________________________________________________________

Address: ______________________________________________________________

City, State: ____________________________________________________________

Account #: ____________________________________________________________

Routing/Transit #: ______________________________________________________

Type of account: Checking Savings (Attach voided check)

Amount: $ _________ or % ________

Account 2

Bank Name: ___________________________________________________________

Account Name: ________________________________________________________

Address: ______________________________________________________________

City, State: ____________________________________________________________

Account #: ____________________________________________________________

Routing/Transit #: ______________________________________________________

Type of account: Checking Savings (Attach voided check)

Amount: $ _________ or % ________

This authority is to remain in effect until eEmployers Solutions, Inc. and _____________________ Bank Name

have received written notification from me (or either of us) of its termination. Sufficient

advance notification will be provided to eEmployers Solutions, Inc. and ______________________ Bank Name

to allow for proper processing of all accounts pending.

AUTHORIZED SIGNATURE: ______________________________ DATE: __________________

AUTHORIZED SIGNATURE: ______________________________ DATE: __________________

BRINK’S PAYCARD ACCOUNT OWNER INFORMATION (Please print)

Yes! I want Brink’s Paycard

First Name _________________________________________ MI _____

Last Name__________________________________________________

Social Security ______________________________________________

Address (No PO Box) _________________________________Apt #______

City _______________________________________________________

State __________________________ Zip Code ____________________

Home Phone _______________________________________________

Date of Birth (mm/dd/yyyy) __/__/____

I am requesting a:

Full deposit Partial deposit

(Amount per payday) $ ______________________________________

Brink’s Paycard Cardholder Agreement Please read and sign before submitting.

By signing below you: (1) acknowledge and agree that you have chosen the Brink’s Money Program and that

you were given an opportunity to review the Cardholder Agreement, Privacy Policy, and Fee Schedule in

advance; (2) authorize BofI Federal Bank to establish your Brink’s Money Account and issue your Brink’s

Money Card; (3) authorize your employer to: (a) transmit the information that you have provided to Skylight

and BofI Federal Bank, and (b) deposit your wages into your Brink’s Money Account, all subject to the

Cardholder Agreement and Fee Schedule.

Employee Signature __________________________ Date: ____________

Very Important eESI Employees

Please fax to 210-495-1244 or

e-mail: [email protected]

The Brink’s Money Prepaid MasterCard is issued by BofI Federal Bank, pursuant to a license by MasterCard International Incorporated. Funds

loaded to Brink’s Money Card accounts are held at BofI Federal Bank, Member FDIC.

MasterCard is a registered trademark of MasterCard International Incorporated. The Brink’s Money and Design mark is a registered trademark of

Brink’s Network, Incorporated. All other trademarks and service marks are the property of their respective owners.

2

3

1 ACTIVATE IT WELCOME TO

BRINK’S MONEY

PAYCARD!THE MORE

CONVENIENT WAY

TO GET PAID!

Once you get your card activate it online at

www.BrinksMoney.com or call the number

on the back of your card.

GET PAID Get your paycheck direct deposited to

your card.

USE IT Anywhere Debit MasterCard is accepted,

online for paying bills, Allpoint ATMs

Network or MasterCard Member Banks.

PAYCARD FEATURESFee Free Signature and PIN POS

TransactionsUse anywhere Debit MasterCard is

accepted.

Fee Free Allpoint ATMsUse at any Allpoint ATM with no fee.

Download the Allpoint App¹ today to find

the closest Allpoint ATM.

SkyLight ChecksGet 100% of your account balance by

cashing the Skylight Check at U.S. Bank

branch locations, and participating

Walmart and ACE Cash Express

locations.

Payback Rewards℠Earn rewards on select purchases and

you’ll get paid back on your prepaid

card².

1 There is no charge for this service, but your wireless carrier may charge for messages or data.

2 By activating and using a Brink's Money Card, your participation in the rewards program is automatically activated. You may opt-out at any time by visiting your Rewards Summary Page at your Online

Account Center. The reward offers we choose and send to you are based on your shopping habits. We will not share any personal information about you with the merchants who sponsor offers. When

you activate an offer and make a purchase with the card, the merchant will not know you are a rewards program customer, but you will become their customer. For more details about how and when

you get rewarded, see the program FAQs, terms and conditions in your Account Center. Cash back rewards are credited to your Card Account and are not available in the form of a check or other direct

payment method. Program sponsor: Skylight Financial. BofI Federal Bank is not affiliated in any way with the program and neither endorses nor sponsors it.

The Brink’s Money™ Prepaid MasterCard® is issued by BofI Federal Bank pursuant to a license by MasterCard International Incorporated. BofI Federal Bank, Member FDIC. Skylight Financial, Inc., a

TSYS® Company, is a registered agent of BofI Federal Bank. Certain products and services may be licensed under U.S. Patent Nos. 6,000,608 and 6,189,787. MasterCard and the MasterCard Brand Mark

are registered trademarks of MasterCard International Incorporated. Use of the Card Account is subject to funds availability and ID verification. Transaction fees, terms, and conditions apply to the use

and reloading of the Card Account. See the Cardholder Agreement for details. © 2016 Total System Services, Inc.® All rights reserved.

MasterCard Member BanksPresent your card to the teller at any

MasterCard Member Bank to receive up to

100% of your available balance!

Anytime Alerts™Get a text message or email the instant

your money is available, plus other

activity updates¹.

Online Account CenterView transaction history, pay bills, send

money, create a budget and track your

spending.

Transaction Fee⁴ Description

Maintenance Fee – Primary/Secondary No Charge

Signature Debit Purchase No Charge At Participating MasterCard Merchants

MasterCard (OTC) Over the Counter Cash withdraw No Charge Available at any MasterCard Member banks, down to the penny.

POS PIN Purchase – with or without cash back No Charge At Participating MasterCard Merchants

SkyLight Checks¹ No Charge Cashed at Wal-Mart, ACE Cash Express, and US Bank Branches

Allpoint ATM Withdrawals No Charge

Non-Allpoint ATM Withdrawals $1.75 ATM owner may charge a surcharge fee

Balance Inquiry/Transaction Denials $1.25 Free inquiry through IVR, Text Alerts, Online account center³

Card Replacement $7.00 One free per year, delivered regular mail. Some card replacement may require

exception handling and additional fees may apply. OverDraft Fee² $25.00 For any overdraft transaction Brink’s Money chooses to pay; fee is per

transaction. Up to 5 fees per month, cardholder opt-in required

ACH Return Fee No Charge Each time a scheduled or recurring fee ACH debit transaction (e.g. merchant bill

payments) is returned for insufficient funds.

Stop Payment Fee No Charge To stop payment on a pre-authorized ACH debit from the account or to stop

payment of a Disbursement Check or Skylight Check.

Monthly Electronic or Paper Statements No Charge Paper statements are opt-in.

Inactivity Fee $5.00 Per month. Assessed after 90 days of continuous inactivity. For former

employees/ported cards only. Live Customer Support No Charge Balance history via live customer support agent - $0.50.

Have your check ready and call 1-800-414-9010 for

step by step instructions

Write the date on the check

Write your name in the “Pay to the order of” line

Write the amount of money in your Skylight account

Write the Cardholder Approval Number you received

during your call in the appropriate boxes

Check your account balance by one of the 3 methods:

1. Log in to your account at www.brinksmoney.com

2. Text “BAL” to 22622 if you are registered for

Anytime Alerts³

3. Call the number on the back of your card and use

the automated phone service

SkyLight Checks

Cash ThemWrite Them

Hand your check to the teller. Ask them to call the

number beneath the “Authorization Number” section of

the check.

You may be asked to verify your Social Security number to

the Brink’s Money Representative.

Take your check to any U.S. Bank branch locations, or

participating Walmart and ACE Cash Express locations.

Pro Tip: It is never a bad idea to take with you the detailed

instructions attached to your Skylight checks.

1 You can cash Skylight Checks free of charge at all U.S. Bank branch locations, at participating Walmart locations and at participating ACE Cash Express locations. Other check cashers set their own policies regarding

check acceptance and may charge you a fee to cash Skylight Checks. See the Skylight Checks for step-by-step instructions.

2 See your cardholder agreement for more information.

3 Skylight does not charge for this service, but your wireless carrier may charge for messages or data.

4 Fees are void where prohibited. Some fees may be different for certain cardholders due to differences in state wage and hour laws. Some services are not available in all states.

Please wait... If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document. You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download. For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader. Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

Form W-4 (2018)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.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. You may claim exemption from withholding for 2018 if both of the following apply.• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. 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 might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re 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.

OMB No. 1545-0074

20181 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2018, 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.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

Form W-4 (2018) Page 2

your wages and other income, including income earned by a spouse, during the year.Line G. Other credits. You might be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as the earned income tax credit and tax credits for education and child care expenses. If you do so, your paycheck will be larger but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account.

Deductions, Adjustments, and Additional Income WorksheetComplete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income, such as interest or dividends.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Two-Earners/Multiple Jobs WorksheetComplete this worksheet if you have more

than one job at a time or are married filing jointly and have a working spouse. If you don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate.Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

Instructions for EmployerEmployees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary.New hire reporting. Employers are

required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9, and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/programs/css/employers.

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date.Box 10. Enter the employer’s employer identification number (EIN).

Form W-4 (2018) Page 3Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . BC Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C

D Enter “1” if: { • You’re single, or married filing separately, and have only one job; or• You’re married filing jointly, have only one job, and your spouse doesn’t work; or• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} D

E Child tax credit. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “4” for each eligible child. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “2” for each eligible child.

• If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter “1” for each eligible child.

• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . EF Credit for other dependents.

• If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “1” for each eligible dependent. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).

• If your total income will be higher than $175,550 ($339,000 if married filing jointly), enter “-0-” . . . . . . . FG Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here . . GH Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.

• If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $52,000 ($24,000 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 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 above.

Deductions, Adjustments, and Additional Income WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage

income.

1

Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $24,000 if you’re married filing jointly or qualifying widow(er)$18,000 if you’re head of household$12,000 if you’re single or married filing separately

} . . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or

blindness (see Pub. 505 for information about these items) . . . . . . . . . . . . . . . . 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2018 nonwage income (such as dividends or interest) . . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7 $8 Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H above . . . . . . . . . . 9

10

Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 . . . . . . . . . . . . . . . . . . . . . . . . . 10

Form W-4 (2018) Page 4 Two-Earners/Multiple Jobs Worksheet

Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

1 Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . . . . . . 2

3 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 Enter the number from line 2 of this worksheet . . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8 $

9

Divide line 8 by the number of pay periods remaining in 2018. For example, divide by 18 if you’re paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2018. 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 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $5,000 05,001 - 9,500 19,501 - 19,000 2

19,001 - 26,500 326,501 - 37,000 437,001 - 43,500 543,501 - 55,000 655,001 - 60,000 760,001 - 70,000 870,001 - 75,000 975,001 - 85,000 1085,001 - 95,000 1195,001 - 130,000 12

130,001 - 150,000 13150,001 - 160,000 14160,001 - 170,000 15170,001 - 180,000 16180,001 - 190,000 17190,001 - 200,000 18200,001 and over 19

All Others

If wages from LOWEST paying job are—


$0 - $7,000 07,001 - 12,500 1

12,501 - 24,500 224,501 - 31,500 331,501 - 39,000 439,001 - 55,000 555,001 - 70,000 670,001 - 85,000 785,001 - 90,000 890,001 - 100,000 9

100,001 - 105,000 10105,001 - 115,000 11115,001 - 120,000 12120,001 - 130,000 13130,001 - 145,000 14145,001 - 155,000 15155,001 - 185,000 16185,001 and over 17

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $24,375 $42024,376 - 82,725 50082,726 - 170,325 910

170,326 - 320,325 1,000320,326 - 405,325 1,330405,326 - 605,325 1,450605,326 and over 1,540

All Others

If wages from HIGHEST paying job are—


$0 - $7,000 $4207,001 - 36,175 500

36,176 - 79,975 91079,976 - 154,975 1,000

154,976 - 197,475 1,330197,476 - 497,475 1,450497,476 and over 1,540

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 aren’t required to provide the information requested on a form that’s 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.

Documents

EMPLOYEE ONBOARDING PACKET · EMPLOYEE ONBOARDING PACKET 1 | Page Simplify Business. Rev. 8/2016 PERSONAL INFORMATION Social Security Number Gender ale M Female Name Date of Birth