TOWN OF HANOVER

PAYROLL & BENEFITS OFFICE

188 BROADWAY

HANOVER, MASSACHUSETTS 02339

(781) 878-0786

Website: www.hanover-ma.gov

Welcome to the Town of Hanover! The Payroll and Benefits Office for the Town of Hanover would like to congratulate and welcome you on your new

position. The staff is available and prepared to offer assistance in whatever you need.

Please complete all of the enclosed documents and contact Audrey Barresi at (781)878-0786 X 5009 to set up an

appointment to bring in and review your paperwork. It is VERY IMPORTANT you bring the required

documentation listed below with you to your appointment.

Conflict of Interest Law Summary and Training (must bring completed certificate with you

when you bring in your new hire paperwork.) Use this link to complete the required

training http://www.muniprog.eth.state.ma.us/

Voided check or bank authorization form for direct deposit.

Valid Driver’s License AND social security card OR birth certificate

OR a Valid U.S. Passport

Copy of your birth certificate (for all employees hired for 20+ hours per week)

Social Security numbers and birthdates for any dependents or beneficiaries you may be including

on health, life, or retirement documents.

Birth Certificates for any dependents you are adding to your health insurance.

Primary Care Physician (PCP) #’s for health insurance forms.

** You may NOT begin employment until all documents and proper identification needed

have been received.

All new employees are also required to review the following documents which can be found on our website at

http://www.hanover-ma.gov/payrollbenefits-office/pages/required-notices

Children’s Health Insurance Program (CHIP) Notice

HIPAA Notice of Privacy Practices

HIPAA Notice of Special Enrollment Rights

Creditable Coverage Disclosure Notice

Health Insurance Marketplace Information

Sexual Harassment Policy

For more information please feel free to contact the office with any questions or concerns at

781-878-0786.

Payroll/Benefits Supervisor Lisa Keefe Ext. 5007

Benefits Administrator: Audrey Barresi Ext. 5009

Payroll Assistant: Lisa Feeney Ext. 5008

------------------------------------------------------------------------------------------------------------------------------- Please sign below in acknowledgment that you have been notified of the required employee documents listed.

__________________________ _______________________ __________________

Employee signature Benefits Administrator Date

MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/12

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City. . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

FORMM-4

M

ASSACHUSETTS

DE

PAR

T

MENT OF REV

EN

UEE

NE

SP

ET

I TP

LA

C

IDA M

S V BLIB

ER

TAT

EO

IV

TE

EM

Employee:File this form or Form W-4 withyour employer. Otherwise,Massachusetts Income Taxeswill be withheld from yourwages without exemptions.

Employer:Keep this certificate with yourrecords. If the employee isbelieved to have claimedexcessive exemptions, theMassachusetts Departmentof Revenue should be soadvised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . . . . . . . . . .

2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will

be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Additional withholding per pay period under agreement with employer $ _____________________

A. Check if you will file as head of household on your tax return.

B. Check if you are blind. C. Check if spouse is blind and not subject to withholding.

D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual incomewill not exceed $8,000.

EMPLOYER: DO NOT withhold if Box D is checked.

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THIS FORM MAY BE REPRODUCED

THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE

IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

A. Number. If you claim more than the correct number of exemptions, civiland criminal penalties may be imposed. You may claim a smaller number ofexemptions. If you do not file a certificate, your employer must withhold onthe basis of no exemptions.

If you expect to owe more income tax than will be withheld, you may eitherclaim a smaller number of exemptions or enter into an agreement with youremployer to have additional amounts withheld.

You should claim the total number of exemptions to which you are entitled toprevent excessive overwithholding, unless you have a significant amount ofother income.

If you work for more than one employer at the same time, you mustnot claim any exemptions with employers other than your principalemployer.

If you are married and if your spouse is subject to withholding, each mayclaim a personal exemption.

B. Changes. You may file a new certificate at any time if the number ofexemptions increases. You must file a new certificate within 10 days if thenumber of exemptions previously claimed by you decreases. For example,if during the year your dependent son’s income indicates that you will notprovide over half of his support for the year, you must file a new certificate.

C. Spouse. If your spouse is not working or if she or he is working but notclaiming the personal exemption or the age 65 or over exemption, general-ly you may claim those exemptions in line 2. However, if you are planning tofile separate annual tax returns, you should not claim withholding exemp-tions for your spouse or for any dependents that will not be claimed on yourannual tax return.

If claiming a wife or husband, write “4” in line 2. Using “4” is the withholdingsystem adjustment for the $4,400 exemption for a spouse.

D. Dependent(s). You may claim an exemption in line 3 for each individualwho qualifies as a dependent under the Federal Income Tax Law. In addition,if one or more of your dependents will be under age 12 at year end, add “1”to your dependents total for line 3.

You are not allowed to claim “federal withholding deductions andadjustments” under the Massachusetts withholding system.

If you have income not subject to withholding, you are urged to haveadditional amounts withheld to cover your tax liability on such income.See line 5.

TOWN OF HANOVER PAYROLL & BENEFITS OFFICE

188 BROADWAY

HANOVER, MASSACHUSETTS 02339 (781) 878-0786

Website: www.hanover-ma.gov

DIRECT DEPOSIT

The Town of Hanover offers the use of direct deposit for all employees. This benefit allows you to have your paycheck deposited

electronically to any bank account(s) YOU specify. There are no restrictions on your choice of financial institutions.

Direct deposit will benefit you in many ways. There is no need to stand in line at the bank and there will be no hold on your money

until your payroll check clears. Your money is available for immediate use each Thursday at 12:01 a.m. To sign up for direct deposit,

please complete the information requested below. If your funds will be deposited into a checking account please attach a voided check

and return it to the Payroll/Benefits Department.

** A voided check or a bank authorization form is required for all direct deposits.

Employee Name: _____________________________ Department: School Town

Primary Direct Deposit-

(Full Net Amount of Check to be deposited)

Financial Institution: ______________________________________ NEW CHANGE

Routing Number ____________________________ Account Number ____________________

Checking Account Savings account

PLEASE STOP THIS DIRECT DEPOSIT:_______________

DATE

If you wish to deposit funds into additional accounts such as Savings Account, Christmas Club or an

additional Checking Account please complete below and specify amount

Financial Institution 2: ______________________________________

Checking Account Savings account

Routing Number ____________________________ Account Number ______________________

Amount $ __________ PLEASE STOP THIS DEDUCTION:_______________

DATE

Financial Institution 3: ______________________________________

Checking Account Savings account

Routing Number ____________________________ Account Number ______________________

Amount $ _________ PLEASE STOP THIS DEDUCTION:_______________

DATE

I hereby authorize the Town of Hanover to electronically deposit my paycheck to the financial institutions noted above.

Signature__________________________________________ Date____________________________

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

EMERGENCY CONTACT FORM

TOWN OF HANOVER

PAYROLL & BENEFITS OFFICE

188 BROADWAY

HANOVER, MA 02339

(781)878-0876 X23

EMPLOYEE EMERGENCY CONTACT INFORMATION FORM

EMPLOYEE PERSONAL INFORMATION

LAST NAME: FIRST NAME: MIDDLE INITIAL:

ADDRESS:

CITY: STATE: ZIP CODE:

CELL PHONE: HOME PHONE:

PERSONAL E-MAIL ADDRESS:

TOWN INFORMATION

WORK PHONE: E-MAIL ADDRESS:

PRIMARY EMERGENCY CONTACT INFORMATION (emergency contacts should be local)

LAST NAME: FIRST NAME:

CELL PHONE # HOME PHONE #:

SECONDARY EMERGENCY CONTACT INFORMATION

LAST NAME: FIRST NAME:

CELL PHONE # HOME PHONE #:

I CHOOSE NOT TO PROVIDE PERSONAL CONTACT INFORMATION.

ACKNOWLEDGE THAT BY NOT DOING SO THERE MAY BE CRITICAL INFORMATION NOT ABLE TO BE SENT TO ME IN A TIMELY FASHION.

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS

Criminal Offender Record Information (CORI)  Acknowledgement Form 

To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes. 

_______________________________________________________________________________ is registered under the  (Organization) 

provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees,  subcontractors,  volunteers,  license  applicants,  current  licensees,  and  applicants  for  the  rental  or  lease  of  housing.  

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to __________________________________________________________   

(Organization) to submit a CORI check  for my  information  to  the DCJIS. This authorization  is valid  for one year  from  the date of my signature. I may withdraw this authorization at any time by providing 

with written notice of my intent to withdraw consent to a CORI check.  

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: 

The _______________________________________________________________________________ may conduct (Organization) 

subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that _______________________________________________________________________________, must first provide me  

(Organization) with written notice of this check.  

By  signing below,  I provide my  consent  to a CORI  check and affirm  that  the  information provided on Page 2 of  this Acknowledgement Form is true and accurate. 

 ___________________________________________________________  _________________________________ Signature of CORI Subject  Date  

IMPORTANT - Please complete below

SCHOOL or BUILDING__________________________________

POSITION (Please circle one):

Employee Contractor Volunteer Student Teacher/Observer Other(Please Specify)______________

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS

2 

SUBJECT INFORMATION 

Please complete this section using the information of the person whose CORI you are requesting.  The fields marked with an asterisk (*) are required fields. 

* First Name: ________________________________________________________  Middle Initial:  _________________

* Last Name:_________________________________________________________  Suffix (Jr., Sr., etc.):  _____________

Former Last Name 1:  _______________________________________________________________________________

Former Last Name 2:  _______________________________________________________________________________

Former Last Name 3:  _______________________________________________________________________________

Former Last Name 4:  _______________________________________________________________________________

* Date of Birth (MM/DD/YYYY):  ___________________  Place of Birth: ________________________________________

* Last SIX digits of Social Security Number:  ___ ___ ‐‐ ___ ___ ___ ___  ☐ No Social Security Number

Sex:  _________________ Height:  _____ ft. _____ in.  Eye Color: _______________  Race: ______________________

Driver’s License or ID Number: ______________________________________  State of Issue: ____________________

Father’s Full Name:  ________________________________________________________________________________

Mother’s Full Name:  _______________________________________________________________________________

Current Address 

* Street Address: ____________________________________________________________________________________

Apt. # or Suite:  _____________  *City: __________________________  *State:  ________  *Zip:  _______________

DO NOT WRITE BELOW THIS LINE - For Internal Purposes Only

The above information was verified by reviewing the following form(s) of government‐issued identification:  _______________________________________________________________________________________________

_______________________________________________________________________________________________ _________________________________________________________________________________________________

Verified by:

_________________________________________________________

Print Name of Person Verifying information

 __________________________________________________________Signature 

_________________________________ Date

**

Hanover Public Schools

Matthew A. Ferron

Superintendent of Schools

Deborah St. Ives

Assistant Superintendent

Thomas R. Raab, Ed.D.

Business Manager

Keith Guyette

Director of Student Services

188 Broadway, Hanover, MA 02339 ● www.hanoverschools.org ● Telephone 781-878-0786 ● Facsimile 781-871-3374

The mission of the Hanover Public Schools is to guide every student to thrive in a global society.

To: Newly Hired Hanover Public School Employees

From: Lisa Keefe, Payroll & Benefits Office

Subject: Fingerprinting Requirements for Public School Employees

Date: October 15, 2018

Overview:

Effective July 1, 2013, all school employees are required to submit fingerprints for a state and national

criminal records check. Under this law, all newly hired school employees are required to submit their

fingerprints for state and national criminal history background checks prior to beginning their active

employment. Fingerprinting is a one-time process, unlike CORI’s, which we will continue to process

every three years.

The Vendor:

The vendor selected to process school employee fingerprints in the state of Massachusetts is Morpho

Trust USA. They operate IdentoGo Centers throughout the state of Massachusetts. Please refer to their

website https://www.identogo.com/locations/massachusetts for center locations, directions, and additional

information.

Registration Process:

There are two ways to register. You can register on-line at the IdentoGo website

https://www.identogo.com/locations/massachusetts or you can call 866-349-8130 to set up an

appointment. You must make an actual appointment to be fingerprinted. IdentoGo does not allow walk-

in appointments.

Prior to registering, please review the materials provided under the Massachusetts: Forms and Links

section on the IdentoGo website. This is where you can find a list of acceptable forms of identification

(everyone must bring one valid current form of ID to their fingerprinting session), the Registration Guide

for the ESE fingerprinting process and other important information.

The registration process takes about 5 minutes and most of the information requested is of a personal

nature, however, there is specific school district information that is required and that information is

provided below:

Agency/Sector: Pre-K-12th

Grade Education (ESE)

Fingerprinting Information

Continued

Page 2

Provider ID: Location Code

Cedar Elementary 01220004

Center Elementary 01220005

Sylvester 01220015

Hanover Middle 01220305

Hanover High 01220505

Hanover 01220000 (Districtwide/ Salmond employees)

Applicant Employer Information: Hanover Public Schools

188 Broadway

Hanover, MA 02339

(781)878-0786

Employer Contact Name: Lisa Feeney, Payroll & Benefits Office

When you complete your registration, you will receive a confirmation number. You must bring your

confirmation number and a verifiable and unexpired form of ID (as listed on the website) to your

appointment.

Fees:

Each individual is responsible for the cost of their fingerprinting. There is a fee of $35.00 for the non-

licensed employees and a $55.00 fee for DESE licensed professionals (including those with pending

applications/ licenses). Payment can be made on-line with a credit card at the time of your registration or

you can pay with a personal check at your IdentoGo center.

Substitutes:

Under the new law, substitutes are school employees so they must adhere to the new fingerprinting

guidelines. Substitutes may, however provide up to 10 district Provided ID codes on their registration.

In order to do this, you will need to contact each district and ask for their code so you can process all of

them at the same time. This will help control the cost and time associated with the process for those

substitutes working in more than one district. Like all other employees, if a substitute teacher is licensed,

the fee is $55.00 and if they are not licensed, the fee is $35.00.

Fingerprinting session:

It only takes about 5 minutes to be fingerprinted. Please make sure you bring your confirmation number

and a valid ID with you to your appointment. When your fingerprints have been processed, you will

receive a SAFIS Fingerprinting Receipt which looks like a credit card slip. You MUST provide a copy

of this to Lisa Feeney, Payroll & Benefits Office, Salmond School, before you can begin your

employment. This is our confirmation that your fingerprints have been processed.

We MUST receive your fingerprinting results before you can begin work.

If you have any questions, please contact Lisa Feeney at lfeeney@hanoverschools.org or call (781)878-

0786 X5008

GWRS FENRAP 3121 ][07/21/15)( 98966-02 ADD NUPART][ADMIN FORMAT

][GP22)(/][401370563)(

Page 1 of 2

Participant EnrollmentGovernmental 457(b) Plan

Massachusetts Deferred Compensation SMART Plan - MandatoryOBRA

98966-02

Participant Information

Last Name First Name MI Social Security Number

Address - Number & Street E-Mail Address

Married Unmarried Female MaleCity State Zip Code

Mo Day Year Mo Day Year

( ) ( )Home Phone Work Phone Date of Birth Date of Hire

Check box if you prefer to receive quarterly accountstatements in Spanish.

Do you have a retirement savings account with a previousemployer or an IRA? Yes or No

Important Notice: Employees participating in the Massachusetts Deferred Compensation SMART Plan - OBRA Mandatory Plan (thePlan) must complete Social Security Form SSA-1945. The Plan has been designated as an alternative retirement system for part timeemployees not covered by their employers retirement system. The SSA-1945 explains the potential effects of the Windfall EliminationProvision and Government Pension Offset Provision under the Social Security law which may reduce the amount of your Social Securityretirement or disability benefits, and/or benefits received by you as a spouse or an ex-spouse. If you have any questions regardingSSA-1945 or if you have not completed SSA-1945, please contact your employer.

Statement Delivery - Participant quarterly statements are sent regular mail via the U.S. Postal Service. If you prefer an environmentallyfriendly alternative, please visit www.mass-smart.com for fast and easy enrollment in our Online File Cabinet service.

Payroll Information

To be completed byRepresentative:

Division Name Division Number

Investment Option Information (applies to all contributions) - Please refer to your communication materials for informationregarding each investment option.

I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the periodstated in the fund's prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for moreinformation.

INVESTMENT OPTION NAMEINVESTMENTOPTION CODE

(Internal Use Only)

MUST INDICATE WHOLE PERCENTAGES = 100%

INVESTMENT OPTION NAMEINVESTMENTOPTION CODE

(Internal Use Only)SMART Capital Preservation Fund...................................... MELINC.......................................100%

98966-02Last Name First Name M.I. Social Security Number Number

GWRS FENRAP ][07/21/15)( 98966-02 ADD NUPART ][GP22)(/][401370563)(

Page 2 of 2

Plan Beneficiary DesignationThis designation is effective upon execution and delivery to Service Provider at the address below. I have the right to change thebeneficiary. If any information is missing, additional information may be required prior to recording my beneficiary designation. If myprimary and contingent beneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid pursuant to the terms ofthe Plan Document or applicable law.

You may only designate one primary and one contingent beneficiary on this form. However, the number of primary or contingentbeneficiaries you name is not limited. If you wish to designate more than one primary and/or contingent beneficiary, do notcomplete the section below. Instead, complete and forward the Beneficiary Designation form.

Primary Beneficiary100.00%

% of Account Balance Social Security Number Primary Beneficiary Name Relationship Date of BirthContingent Beneficiary

100.00%% of Account Balance Social Security Number Contingent Beneficiary Name Relationship Date of Birth

Participation AgreementWithdrawal Restrictions - I understand that the Internal Revenue Code (the "Code") and/or my employer's Plan Document may imposerestrictions on transfers and/or distributions. I understand that I must contact the Plan Administrator/Trustee to determine when and/orunder what circumstances I am eligible to receive distributions or make transfers.

Compliance With Plan Document and/or the Code - Participation in this Plan is mandatory. A deduction will be taken from yourwages and invested on your behalf based on your employer's Plan Document. I agree that my employer or Plan Administrator/Trusteemay take any action that may be necessary to ensure that my participation in the Plan is in compliance with any applicable requirement ofthe Plan Document and/or the Code. I understand that the maximum annual limit on contributions is determined under the Plan Documentand/or the Code. I understand that it is my responsibility to monitor my total annual contributions to ensure that I do not exceed theamount permitted. If I exceed the contribution limit, I assume sole liability for any tax, penalty, or costs that may be incurred.

Incomplete Forms - I understand that in the event my Participant Enrollment form is incomplete or is not received by Service Providerat the address below prior to the receipt of any deposits, I specifically consent to Service Provider retaining all monies received andallocating them to the default investment option.

Account Corrections - I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies orerrors. Corrections will be made only for errors which I communicate within 90 calendar days of the last calendar quarter. After this 90days, account information shall be deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days, thecorrection will only be processed from the date of notification forward and not on a retroactive basis.

Signature(s) and Consent

Participant Consent

I have completed, understand and agree to all pages of this Participant Enrollment form. I understand that Service Provider is requiredto comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As aresult, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a speciallydesignated national or blocked person. For more information, please access the OFAC Web site at:http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.Deferral agreements must be entered into prior to the first day of the month that the deferral will be made.

Participant Signature Date

Participant forward to Service Provider at:Great-West Retirement Services®

P.O. Box 173764Denver, CO 80217-3764Phone #: 1-877-457-1900Fax #: 1-866-745-5766Web site: www.mass-smart.com

Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers.GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company.Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A),Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY; andtheir subsidiaries and affiliates. All trademarks, logos, service marks, and design elements used are owned by their respective owners and are used bypermission.