---------------------------------

TANGIPAHOA PARISH SCHOOL SYSTEM

If~~A~~~~~~~~~~~middotmiddotmiddotmiddotmiddot~middotmiddotmiddotmiddot~~~~~~~~~A~j~T~t~L~~~~~~~7~O~4~2~~~~~~~~~~~~~ SCH~gtJ-TEM rox) I 74K- - )3 bull Fe [9Wi I 7H-XiK7

iRIlt KULT CHRISI Prsjtnt 1

COHE f Iht B(laY~t

TO Substitute Applicants

FROM Ron Genco

Director of Human Resources

Please review the attached information in this packet All applicants must be

in-serviced BEFORE any paperwork will be accepted by our office The in-service can

be completed at any school Then complete the packet of information and bring it to

the Central Office (address is listed aboveJ where we will review your paperwork

review our electronic substitute system and set a date and time for your background

check The cost of the background check and fingerprint is $5750 and is paid directly

to the Tangipahoa Parish Sheriffs Office in the form of CASH or MONEY ORDER and

this amount WILL NOT be reimbursed If you have any questions please contact Erin Verberne at (985) 748-2505 or Gail Miller at (985J 748-2413

RGjehvjgjm

Attachments

Checklist of information to bring to the central office

Drivers License

Social Security Card

One of the following High School Diploma School or College Transcripts Verification of Degree or Teaching Certificate Completed Substitute Package

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer

2013middot2014PLEASE NOTE APPLICATION GOOD FOR ONE (1) SCHOOL YEAR

TANGIPAHOA PARISH SCHOOL SYSTEM SUBSTITUTE TEACHER APPLICATION

DATE________________ _

NAME____=-------~===_------~~~SS-------------------LAST FIRST MIDDLE

MAILING ADDRESS____________________ STREET IPO BOX

CITY STATE ZIP CODE

PHONE (You must be at least 21 years old) AGE_____ -A~R~E~A~C~O~D~E~-------------

HIGH SCHOOL ATTENDED____________________DIPLOMA___ YES NO

COLLEGEATTENDED_________________COLLEGEDEGREE__ YES NO

TEACHING CERTIFICATE TYPE AND NUMBER_____________________ (Provide ProofofExperience)

ARE YOU A RETIRED TEACHER FROM LOUISIANA - YES____ NO______ (Provide ProofofExperience)

ARE YOU RETIRED FROM ANOTHER STATE - YES NO______ ARE YOU A RETIRED PERSON (OTHER THAN A TEACHER) PLEASE INDICATE

WHAT TYPE OF RETIREMENT SYSTEM ____________

IMPORTANT Applicants must submit with this form a verification of degree if certified a copy of certificate and proof of teaching experience a copy of your High School Diploma Substitute Teacher Handbook Verification of In-Service Form (included in package) Drivers License and Social Security Card All Substitute Applicants will pay a $5750 fee (made payable to The Tangipahoa Parish Sheriffs Office) required for a background check Once the completed application is received the fingerprint process has to be scheduled at the Central Office 59656 Puleston Road Amite Louisiana The fingerprint fee WILL NOT be reimbursed

PLEASE MAIL TO Human ResourcesPersonnel Department Tangipahoa Parish School System 59656 Puleston Road Amite Louisiana 70422

The Tangipahoa Parish School system does not discriminate on the basis ofrace color national origin sex age disabilities or veteran status We are an equal opportunity employer

TANGIPAHOA PARISH SCHOOL SYSTEMANGIPAHO~ PARIS~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ -L~ I shy 59656 PULESTON ROADmiddot AMITE LOUISIANA 70422SCHOOL

~ SYSTEMJ TELEPHONE (985) 748-7153middot FAX (985) 748middot8587

MARK KOLWE CHRISTINA COHEA Superilltpoundldell President of the Board

Appendix B

Substitute Teacher Handbook Verification of Inservice Form

This is to verify that I have received a copy of the Tangipahoa Parish School

Systems Substitute Teacher Handbook and I have read andfully understand its

contents

Date____________

Applicant Name ________________Phone ________

Address__________________________________

(PO BoxStreet) City State Zip

School that issued applicant the handbook_____~____________

Applicant was inserviced at __________School

Principals Signature _______________

Applicants Signature _________________

Revised 1112

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer

Form W-4 (2013) Purpose Complete Form Wmiddot4 so that your employer ca~ withhold the cOltTect feoeral income tax from your pay Consider completing a new Form Wmiddot4 each year and when yOelr personal or financial situatio~ changes

Exemption from withholding If you are exempt complete only IinElS 1234 and 7 and sign the form to valdate it Your exemptIon for 2013 expires February 17 2014 See Pub 50S Tax Wtllholding and Estimated Tax

Note If another person can ciaire you as a dependent on hS or her tax return you canot clalfn exempfOfl from Withholding if yoU xome exceeds $1000 and i~cuoes more than $350 of unearned Income (tor example Interest a1d dlvide~ds)

Basic instructions if you are not exempt complete the Porsonal Allowances Worksheet below Tne worksheets on page 2 further adust your w~hholdin9 aJiowances based on Itenlzed deducliolS certain credits adjustments to income or two-earnersmultiple iobs srtuations

Complete ail worksheets that apply However you may clam fewer (or zero) allowances For reguiar wages withholding must be based on allowance$ you Claimed and may rot be a flat amount or percentage of wages

Head of househOld Generally you can claim head of household filing stalus On your tax retJrn only if you are unmarried and pay more t~an 50 of the costs of keeping up a home for yourself and your dependent(s) or other quallylOg ndividualS See PJb 501 Exemptio1S Standard Deduction and Filing Information for informatiOn

Tax credits You can lake prolected tax credits Into account in figuring your aliowaJble number of wllhholding allowances Cedlts for cnild or dependent care expenses and the child tax credit may be claimed using the Personal Allowanoos Worksheampt below See Pub 505 for Information on oonverting your other credits into wthholding allowances

N(gtnwage income It you have a large amount oj oowage income such as interest or dividends oonsgtder making eSTimaled tax payments uslng Form 104()-ES Estimaled Tax for Individuals Otherwise you may owe additional tax If you have pensjon or annuity

income see Pub 505 to find out if you ShOuld adjUst your withholding 011 Form W-4 or W-4P

Two earners or multiple jobs If you have a working spouse or more than one job fgure tne total number of aIgtowances you are enttled 10 claim on all joos usi9 warltsheets from only ana Form W-4 Your lnhoding usually wili 00 most accurate when all alowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the olhers See Pub 505 for details

Nonresident alien If yOu are a nonresident alien see Notice 1392 Supplemental For Wmiddot4 Instructor$ for No1resident Aliens before compleling thiS form

Check your withholding Mer your Form Wmiddot4 takes effect use Pb 505 to see how the anount you are having wllhheld oompares to your projected tolal tax for 2013 See Pub 505 especially if your earnings exceed $130000 (Single) or $180000 (Marred)

Future developments Information about any future developments affecting Form Wmiddot4 (such as legislation nacted atter we release il) will be posted at wwwlISgovlw4

Personal Allowances Worksheet (Keep for your records) A Enter 1 for yourself If no one else can claim you as a dependent A

bull You are single and have only one job or

B Enter 1 if bull You are married have only one jab and your spouse does nat work or B bull Your wages from a second jcb Or your spouses wages (or the total of both) are $1500 or less

C Enter 1 for your spouse But you may choose to enter -0- if you are married and have either a working spouse or more than one job (Entering -0- may help you avoid having too little tax withheld) C

o Enter nurnber ot dependents (other than your spouse or yoursell) you will claim on your tax return o E Enter 1 if yo~ will file as head of household on your tax retum (see conditions under Head of household above) E

F Enter 1 if yo~ have at least $1900 of child or dependent care expenses for which you plan to claim a credit F

(Note Do not include child support payrTens See PUb 503 Child and Dependent Care Expenses for details)

G Child Tax Credit (including additional child tax credit) See PUb 972 Child Tax Credit for more information bull If your total income will be less than $65000 ($95000 if married) enter 2 for each eligible child then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible chiidren

bull If your total income WIll be between $65000 ard $84000 ($95000 and $119000 if married) enter for each eligible child G

H Add lines A through G and enter total here (Note This may be different from the number of exemptions you claim on your tax return) H

IIf you plan to itemize or claim adjustments to Income and want to reduce your withholding see the Deductions

For accuracy and Adjustments Worksheet on page 2 complete all bull If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $40000 ($10000 if married) see the Two-EarnersMultiple Jobs Worksheet on page 2 to that apply avoid havu1g too little tax withheld

bull If neither of the above situations applies stop here and enter the number from line H on line 5 of Form W-4 below

bull-bullbullbullbullbullbullbullbullbullbullbull-- Separate here and give Form W-4 to your employer Keep the top part for your recordsbullbullbull--------bullbullbull -

Employees Withholding Allowance Certificate OMS No 1545-0074 Form W-4

Employees signature (This form is not valid unless you sign it) ~ Date ~

Whether you are entitled to claim a certain number of allowances or exemption from withholding Is liubjeet to review the IRS Your employer may be to send a copy of this fcmn to the lAS

name

4 If YOut laat name differs from that shown on your

check here You must call1-BOOmiddot772middot1213 for II

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount if any you want withheld from each paycheck

~copy13

7 I claim exemption from withholding for 2013 and I certify that I meet both of the following conditions for exemption

bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax If meet both conditions write here

declare that I have

a Empoyes name and address (Employer Complete lines 8 and 10 only if send ng to the IRS) 9 Office code (optional) 10 Employer IdentifICation numbet (EIN)

Tan I ahoa Parish School S stern 0053 126001372 For PrivaCY Act and Paperwork Reduction Act Notice see page 2 Cat No 102200 Form W~4 (2013)

2013middot2014PLEASE NOTE APPLICATION GOOD FOR ONE (1) SCHOOL YEAR

TANGIPAHOA PARISH SCHOOL SYSTEM SUBSTITUTE TEACHER APPLICATION

DATE________________ _

NAME____=-------~===_------~~~SS-------------------LAST FIRST MIDDLE

MAILING ADDRESS____________________ STREET IPO BOX

CITY STATE ZIP CODE

PHONE (You must be at least 21 years old) AGE_____ -A~R~E~A~C~O~D~E~-------------

HIGH SCHOOL ATTENDED____________________DIPLOMA___ YES NO

COLLEGEATTENDED_________________COLLEGEDEGREE__ YES NO

TEACHING CERTIFICATE TYPE AND NUMBER_____________________ (Provide ProofofExperience)

ARE YOU A RETIRED TEACHER FROM LOUISIANA - YES____ NO______ (Provide ProofofExperience)

ARE YOU RETIRED FROM ANOTHER STATE - YES NO______ ARE YOU A RETIRED PERSON (OTHER THAN A TEACHER) PLEASE INDICATE

WHAT TYPE OF RETIREMENT SYSTEM ____________

IMPORTANT Applicants must submit with this form a verification of degree if certified a copy of certificate and proof of teaching experience a copy of your High School Diploma Substitute Teacher Handbook Verification of In-Service Form (included in package) Drivers License and Social Security Card All Substitute Applicants will pay a $5750 fee (made payable to The Tangipahoa Parish Sheriffs Office) required for a background check Once the completed application is received the fingerprint process has to be scheduled at the Central Office 59656 Puleston Road Amite Louisiana The fingerprint fee WILL NOT be reimbursed

PLEASE MAIL TO Human ResourcesPersonnel Department Tangipahoa Parish School System 59656 Puleston Road Amite Louisiana 70422

The Tangipahoa Parish School system does not discriminate on the basis ofrace color national origin sex age disabilities or veteran status We are an equal opportunity employer

TANGIPAHOA PARISH SCHOOL SYSTEMANGIPAHO~ PARIS~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ -L~ I shy 59656 PULESTON ROADmiddot AMITE LOUISIANA 70422SCHOOL

~ SYSTEMJ TELEPHONE (985) 748-7153middot FAX (985) 748middot8587

MARK KOLWE CHRISTINA COHEA Superilltpoundldell President of the Board

Appendix B

Substitute Teacher Handbook Verification of Inservice Form

This is to verify that I have received a copy of the Tangipahoa Parish School

Systems Substitute Teacher Handbook and I have read andfully understand its

contents

Date____________

Applicant Name ________________Phone ________

Address__________________________________

(PO BoxStreet) City State Zip

School that issued applicant the handbook_____~____________

Applicant was inserviced at __________School

Principals Signature _______________

Applicants Signature _________________

Revised 1112

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer

Form W-4 (2013) Purpose Complete Form Wmiddot4 so that your employer ca~ withhold the cOltTect feoeral income tax from your pay Consider completing a new Form Wmiddot4 each year and when yOelr personal or financial situatio~ changes

Exemption from withholding If you are exempt complete only IinElS 1234 and 7 and sign the form to valdate it Your exemptIon for 2013 expires February 17 2014 See Pub 50S Tax Wtllholding and Estimated Tax

Note If another person can ciaire you as a dependent on hS or her tax return you canot clalfn exempfOfl from Withholding if yoU xome exceeds $1000 and i~cuoes more than $350 of unearned Income (tor example Interest a1d dlvide~ds)

Basic instructions if you are not exempt complete the Porsonal Allowances Worksheet below Tne worksheets on page 2 further adust your w~hholdin9 aJiowances based on Itenlzed deducliolS certain credits adjustments to income or two-earnersmultiple iobs srtuations

Complete ail worksheets that apply However you may clam fewer (or zero) allowances For reguiar wages withholding must be based on allowance$ you Claimed and may rot be a flat amount or percentage of wages

Head of househOld Generally you can claim head of household filing stalus On your tax retJrn only if you are unmarried and pay more t~an 50 of the costs of keeping up a home for yourself and your dependent(s) or other quallylOg ndividualS See PJb 501 Exemptio1S Standard Deduction and Filing Information for informatiOn

Tax credits You can lake prolected tax credits Into account in figuring your aliowaJble number of wllhholding allowances Cedlts for cnild or dependent care expenses and the child tax credit may be claimed using the Personal Allowanoos Worksheampt below See Pub 505 for Information on oonverting your other credits into wthholding allowances

N(gtnwage income It you have a large amount oj oowage income such as interest or dividends oonsgtder making eSTimaled tax payments uslng Form 104()-ES Estimaled Tax for Individuals Otherwise you may owe additional tax If you have pensjon or annuity

income see Pub 505 to find out if you ShOuld adjUst your withholding 011 Form W-4 or W-4P

Two earners or multiple jobs If you have a working spouse or more than one job fgure tne total number of aIgtowances you are enttled 10 claim on all joos usi9 warltsheets from only ana Form W-4 Your lnhoding usually wili 00 most accurate when all alowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the olhers See Pub 505 for details

Nonresident alien If yOu are a nonresident alien see Notice 1392 Supplemental For Wmiddot4 Instructor$ for No1resident Aliens before compleling thiS form

Check your withholding Mer your Form Wmiddot4 takes effect use Pb 505 to see how the anount you are having wllhheld oompares to your projected tolal tax for 2013 See Pub 505 especially if your earnings exceed $130000 (Single) or $180000 (Marred)

Future developments Information about any future developments affecting Form Wmiddot4 (such as legislation nacted atter we release il) will be posted at wwwlISgovlw4

Personal Allowances Worksheet (Keep for your records) A Enter 1 for yourself If no one else can claim you as a dependent A

bull You are single and have only one job or

B Enter 1 if bull You are married have only one jab and your spouse does nat work or B bull Your wages from a second jcb Or your spouses wages (or the total of both) are $1500 or less

C Enter 1 for your spouse But you may choose to enter -0- if you are married and have either a working spouse or more than one job (Entering -0- may help you avoid having too little tax withheld) C

o Enter nurnber ot dependents (other than your spouse or yoursell) you will claim on your tax return o E Enter 1 if yo~ will file as head of household on your tax retum (see conditions under Head of household above) E

F Enter 1 if yo~ have at least $1900 of child or dependent care expenses for which you plan to claim a credit F

(Note Do not include child support payrTens See PUb 503 Child and Dependent Care Expenses for details)

G Child Tax Credit (including additional child tax credit) See PUb 972 Child Tax Credit for more information bull If your total income will be less than $65000 ($95000 if married) enter 2 for each eligible child then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible chiidren

bull If your total income WIll be between $65000 ard $84000 ($95000 and $119000 if married) enter for each eligible child G

H Add lines A through G and enter total here (Note This may be different from the number of exemptions you claim on your tax return) H

IIf you plan to itemize or claim adjustments to Income and want to reduce your withholding see the Deductions

For accuracy and Adjustments Worksheet on page 2 complete all bull If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $40000 ($10000 if married) see the Two-EarnersMultiple Jobs Worksheet on page 2 to that apply avoid havu1g too little tax withheld

bull If neither of the above situations applies stop here and enter the number from line H on line 5 of Form W-4 below

bull-bullbullbullbullbullbullbullbullbullbullbull-- Separate here and give Form W-4 to your employer Keep the top part for your recordsbullbullbull--------bullbullbull -

Employees Withholding Allowance Certificate OMS No 1545-0074 Form W-4

Employees signature (This form is not valid unless you sign it) ~ Date ~

Whether you are entitled to claim a certain number of allowances or exemption from withholding Is liubjeet to review the IRS Your employer may be to send a copy of this fcmn to the lAS

name

4 If YOut laat name differs from that shown on your

check here You must call1-BOOmiddot772middot1213 for II

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount if any you want withheld from each paycheck

~copy13

7 I claim exemption from withholding for 2013 and I certify that I meet both of the following conditions for exemption

bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax If meet both conditions write here

declare that I have

a Empoyes name and address (Employer Complete lines 8 and 10 only if send ng to the IRS) 9 Office code (optional) 10 Employer IdentifICation numbet (EIN)

Tan I ahoa Parish School S stern 0053 126001372 For PrivaCY Act and Paperwork Reduction Act Notice see page 2 Cat No 102200 Form W~4 (2013)

TANGIPAHOA PARISH SCHOOL SYSTEMANGIPAHO~ PARIS~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ -L~ I shy 59656 PULESTON ROADmiddot AMITE LOUISIANA 70422SCHOOL

~ SYSTEMJ TELEPHONE (985) 748-7153middot FAX (985) 748middot8587

MARK KOLWE CHRISTINA COHEA Superilltpoundldell President of the Board

Appendix B

Substitute Teacher Handbook Verification of Inservice Form

This is to verify that I have received a copy of the Tangipahoa Parish School

Systems Substitute Teacher Handbook and I have read andfully understand its

contents

Date____________

Applicant Name ________________Phone ________

Address__________________________________

(PO BoxStreet) City State Zip

School that issued applicant the handbook_____~____________

Applicant was inserviced at __________School

Principals Signature _______________

Applicants Signature _________________

Revised 1112

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer

Form W-4 (2013) Purpose Complete Form Wmiddot4 so that your employer ca~ withhold the cOltTect feoeral income tax from your pay Consider completing a new Form Wmiddot4 each year and when yOelr personal or financial situatio~ changes

Exemption from withholding If you are exempt complete only IinElS 1234 and 7 and sign the form to valdate it Your exemptIon for 2013 expires February 17 2014 See Pub 50S Tax Wtllholding and Estimated Tax

Note If another person can ciaire you as a dependent on hS or her tax return you canot clalfn exempfOfl from Withholding if yoU xome exceeds $1000 and i~cuoes more than $350 of unearned Income (tor example Interest a1d dlvide~ds)

Basic instructions if you are not exempt complete the Porsonal Allowances Worksheet below Tne worksheets on page 2 further adust your w~hholdin9 aJiowances based on Itenlzed deducliolS certain credits adjustments to income or two-earnersmultiple iobs srtuations

Complete ail worksheets that apply However you may clam fewer (or zero) allowances For reguiar wages withholding must be based on allowance$ you Claimed and may rot be a flat amount or percentage of wages

Head of househOld Generally you can claim head of household filing stalus On your tax retJrn only if you are unmarried and pay more t~an 50 of the costs of keeping up a home for yourself and your dependent(s) or other quallylOg ndividualS See PJb 501 Exemptio1S Standard Deduction and Filing Information for informatiOn

Tax credits You can lake prolected tax credits Into account in figuring your aliowaJble number of wllhholding allowances Cedlts for cnild or dependent care expenses and the child tax credit may be claimed using the Personal Allowanoos Worksheampt below See Pub 505 for Information on oonverting your other credits into wthholding allowances

N(gtnwage income It you have a large amount oj oowage income such as interest or dividends oonsgtder making eSTimaled tax payments uslng Form 104()-ES Estimaled Tax for Individuals Otherwise you may owe additional tax If you have pensjon or annuity

income see Pub 505 to find out if you ShOuld adjUst your withholding 011 Form W-4 or W-4P

Two earners or multiple jobs If you have a working spouse or more than one job fgure tne total number of aIgtowances you are enttled 10 claim on all joos usi9 warltsheets from only ana Form W-4 Your lnhoding usually wili 00 most accurate when all alowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the olhers See Pub 505 for details

Nonresident alien If yOu are a nonresident alien see Notice 1392 Supplemental For Wmiddot4 Instructor$ for No1resident Aliens before compleling thiS form

Check your withholding Mer your Form Wmiddot4 takes effect use Pb 505 to see how the anount you are having wllhheld oompares to your projected tolal tax for 2013 See Pub 505 especially if your earnings exceed $130000 (Single) or $180000 (Marred)

Future developments Information about any future developments affecting Form Wmiddot4 (such as legislation nacted atter we release il) will be posted at wwwlISgovlw4

Personal Allowances Worksheet (Keep for your records) A Enter 1 for yourself If no one else can claim you as a dependent A

bull You are single and have only one job or

B Enter 1 if bull You are married have only one jab and your spouse does nat work or B bull Your wages from a second jcb Or your spouses wages (or the total of both) are $1500 or less

C Enter 1 for your spouse But you may choose to enter -0- if you are married and have either a working spouse or more than one job (Entering -0- may help you avoid having too little tax withheld) C

o Enter nurnber ot dependents (other than your spouse or yoursell) you will claim on your tax return o E Enter 1 if yo~ will file as head of household on your tax retum (see conditions under Head of household above) E

F Enter 1 if yo~ have at least $1900 of child or dependent care expenses for which you plan to claim a credit F

(Note Do not include child support payrTens See PUb 503 Child and Dependent Care Expenses for details)

G Child Tax Credit (including additional child tax credit) See PUb 972 Child Tax Credit for more information bull If your total income will be less than $65000 ($95000 if married) enter 2 for each eligible child then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible chiidren

bull If your total income WIll be between $65000 ard $84000 ($95000 and $119000 if married) enter for each eligible child G

H Add lines A through G and enter total here (Note This may be different from the number of exemptions you claim on your tax return) H

IIf you plan to itemize or claim adjustments to Income and want to reduce your withholding see the Deductions

For accuracy and Adjustments Worksheet on page 2 complete all bull If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $40000 ($10000 if married) see the Two-EarnersMultiple Jobs Worksheet on page 2 to that apply avoid havu1g too little tax withheld

bull If neither of the above situations applies stop here and enter the number from line H on line 5 of Form W-4 below

bull-bullbullbullbullbullbullbullbullbullbullbull-- Separate here and give Form W-4 to your employer Keep the top part for your recordsbullbullbull--------bullbullbull -

Employees Withholding Allowance Certificate OMS No 1545-0074 Form W-4

Employees signature (This form is not valid unless you sign it) ~ Date ~

Whether you are entitled to claim a certain number of allowances or exemption from withholding Is liubjeet to review the IRS Your employer may be to send a copy of this fcmn to the lAS

name

4 If YOut laat name differs from that shown on your

check here You must call1-BOOmiddot772middot1213 for II

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount if any you want withheld from each paycheck

~copy13

7 I claim exemption from withholding for 2013 and I certify that I meet both of the following conditions for exemption

bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax If meet both conditions write here

declare that I have

a Empoyes name and address (Employer Complete lines 8 and 10 only if send ng to the IRS) 9 Office code (optional) 10 Employer IdentifICation numbet (EIN)

Tan I ahoa Parish School S stern 0053 126001372 For PrivaCY Act and Paperwork Reduction Act Notice see page 2 Cat No 102200 Form W~4 (2013)

Form W-4 (2013) Purpose Complete Form Wmiddot4 so that your employer ca~ withhold the cOltTect feoeral income tax from your pay Consider completing a new Form Wmiddot4 each year and when yOelr personal or financial situatio~ changes

Exemption from withholding If you are exempt complete only IinElS 1234 and 7 and sign the form to valdate it Your exemptIon for 2013 expires February 17 2014 See Pub 50S Tax Wtllholding and Estimated Tax

Note If another person can ciaire you as a dependent on hS or her tax return you canot clalfn exempfOfl from Withholding if yoU xome exceeds $1000 and i~cuoes more than $350 of unearned Income (tor example Interest a1d dlvide~ds)

Basic instructions if you are not exempt complete the Porsonal Allowances Worksheet below Tne worksheets on page 2 further adust your w~hholdin9 aJiowances based on Itenlzed deducliolS certain credits adjustments to income or two-earnersmultiple iobs srtuations

Complete ail worksheets that apply However you may clam fewer (or zero) allowances For reguiar wages withholding must be based on allowance$ you Claimed and may rot be a flat amount or percentage of wages

Head of househOld Generally you can claim head of household filing stalus On your tax retJrn only if you are unmarried and pay more t~an 50 of the costs of keeping up a home for yourself and your dependent(s) or other quallylOg ndividualS See PJb 501 Exemptio1S Standard Deduction and Filing Information for informatiOn

Tax credits You can lake prolected tax credits Into account in figuring your aliowaJble number of wllhholding allowances Cedlts for cnild or dependent care expenses and the child tax credit may be claimed using the Personal Allowanoos Worksheampt below See Pub 505 for Information on oonverting your other credits into wthholding allowances

N(gtnwage income It you have a large amount oj oowage income such as interest or dividends oonsgtder making eSTimaled tax payments uslng Form 104()-ES Estimaled Tax for Individuals Otherwise you may owe additional tax If you have pensjon or annuity

income see Pub 505 to find out if you ShOuld adjUst your withholding 011 Form W-4 or W-4P

Two earners or multiple jobs If you have a working spouse or more than one job fgure tne total number of aIgtowances you are enttled 10 claim on all joos usi9 warltsheets from only ana Form W-4 Your lnhoding usually wili 00 most accurate when all alowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the olhers See Pub 505 for details

Nonresident alien If yOu are a nonresident alien see Notice 1392 Supplemental For Wmiddot4 Instructor$ for No1resident Aliens before compleling thiS form

Check your withholding Mer your Form Wmiddot4 takes effect use Pb 505 to see how the anount you are having wllhheld oompares to your projected tolal tax for 2013 See Pub 505 especially if your earnings exceed $130000 (Single) or $180000 (Marred)

Future developments Information about any future developments affecting Form Wmiddot4 (such as legislation nacted atter we release il) will be posted at wwwlISgovlw4

Personal Allowances Worksheet (Keep for your records) A Enter 1 for yourself If no one else can claim you as a dependent A

bull You are single and have only one job or

B Enter 1 if bull You are married have only one jab and your spouse does nat work or B bull Your wages from a second jcb Or your spouses wages (or the total of both) are $1500 or less

C Enter 1 for your spouse But you may choose to enter -0- if you are married and have either a working spouse or more than one job (Entering -0- may help you avoid having too little tax withheld) C

o Enter nurnber ot dependents (other than your spouse or yoursell) you will claim on your tax return o E Enter 1 if yo~ will file as head of household on your tax retum (see conditions under Head of household above) E

F Enter 1 if yo~ have at least $1900 of child or dependent care expenses for which you plan to claim a credit F

(Note Do not include child support payrTens See PUb 503 Child and Dependent Care Expenses for details)

G Child Tax Credit (including additional child tax credit) See PUb 972 Child Tax Credit for more information bull If your total income will be less than $65000 ($95000 if married) enter 2 for each eligible child then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible chiidren

bull If your total income WIll be between $65000 ard $84000 ($95000 and $119000 if married) enter for each eligible child G

H Add lines A through G and enter total here (Note This may be different from the number of exemptions you claim on your tax return) H

IIf you plan to itemize or claim adjustments to Income and want to reduce your withholding see the Deductions

For accuracy and Adjustments Worksheet on page 2 complete all bull If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $40000 ($10000 if married) see the Two-EarnersMultiple Jobs Worksheet on page 2 to that apply avoid havu1g too little tax withheld

bull If neither of the above situations applies stop here and enter the number from line H on line 5 of Form W-4 below

bull-bullbullbullbullbullbullbullbullbullbullbull-- Separate here and give Form W-4 to your employer Keep the top part for your recordsbullbullbull--------bullbullbull -

Employees Withholding Allowance Certificate OMS No 1545-0074 Form W-4

Employees signature (This form is not valid unless you sign it) ~ Date ~

Whether you are entitled to claim a certain number of allowances or exemption from withholding Is liubjeet to review the IRS Your employer may be to send a copy of this fcmn to the lAS

name

4 If YOut laat name differs from that shown on your

check here You must call1-BOOmiddot772middot1213 for II

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount if any you want withheld from each paycheck

~copy13

7 I claim exemption from withholding for 2013 and I certify that I meet both of the following conditions for exemption

bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax If meet both conditions write here

declare that I have

a Empoyes name and address (Employer Complete lines 8 and 10 only if send ng to the IRS) 9 Office code (optional) 10 Employer IdentifICation numbet (EIN)

Tan I ahoa Parish School S stern 0053 126001372 For PrivaCY Act and Paperwork Reduction Act Notice see page 2 Cat No 102200 Form W~4 (2013)

---------------------------------------

R-~300 (4101) State of LouiSiana

===-=_==--~-==

Department of Revenue

Employee Withholding Exemption Certificate (L-4)

~--=-~== middotmiddotmiddotmiddot7===~_c==middotmiddot_~~- -~ Purpose Complee form L-4 so that your employer can withhold the correct amount of state income tax from your salary

Basic Instructions Employees who are subject to state withholding should complete the personal allowances worKsheet below Do not claim more than your correct withholaing personal exemptions and the correct number of withholding dependency credits Do not claim additional withholding exemptions if you qualify as head-at-household In such cases only the withholding personal exemption applicable to single individua[s is allowable You must file a new certificate within 10 days if the number of your exemptions decreaSeS except where the change occurs as the result of death ot a spouse or a dependent You may file a new certificate at any time the number of your exemptions increases Penalties are imposed for willfully supplying false information or willful failure to supply information that would reduce the withholding exemption This foim must be filed with your employer Otherwise he must withhold Louisiana income tal( from your wages without tlxellption

Note to Employer Keep this certificate with your records If the employee is believed to have claimed too many exemptions or dependency credits the Secretary of Revenue should be so advised by forwardirg a copy of the employees signed L-4 form to the Department

Personal Allowances Worksheet

A In Block A enter 0 if you claim neither yourself nor your spouse or

In Block A ellter1 it you claim yourself prollided you do not claim this exemption in connection with cther employment or your spouse has not claimed your exemption or

In 8 lock A enter 2 if you claim yourself and your spouse You may choose to enter 0 If you are married and have either 3 working spouse or more than one job (ThiS may help you avoid having too little tax withheld)

s In BlOCk B enter the number of dependents (other than your spouse or yourself) whom you will I

claim on your tax return If no credits are claimed enler 0 LB-_______

- Cut here and gille the bottom portion of certificate to your omployer Keep the top portion for your records - ~

Form L-4 Employees Withholding Allowance

Louisiana Department of Certificate Revenue

1 Type or pMrlt first name and middle Initial Last name

2 Social Seeurigt Number 3 0 No exemptions or dependents claimed o Married

4 Home addreSii (number and street or rural route)

5 State ZIP

6 number of exemptions you lire claiming (from Bloc( A above)

7 Total number dependents you are claiming (from Block B

s pay period

rdeclare unBer the penalties imposed-for mini false reports thai (h-enumber 6r exemptions and dependency credrts claimed on this certificate do not exceed the number to which 1am entitled

5mployees signature Date f1

The following Is to be completed by employer

9 Employers name and address )10 Employers state Withholding account number

OMB No 1615middot0047 Expircs0813112

Form 1-9 Employment Department of Homelalld Security US Citi2enship and Immigration Services Eligibility Verification

Read instructions carefully before completing this (orm The instructions must be available during completion of this form

ANTI-DISCRIMINAnON NOTICE It is illegal to discriminate against work-authorized individuals Employers CANNOT specify which document(s) tbey will accept from an employee The refusal to hire an individual because the documeDts have a future expiration date may also constitute illegal discrimination

Section L Employee Information and Verification (To be completed and Signed by employee at the time employment begins) Print Name Last First Middle Illilial Maiden Name

Address (Srreel Name and Number) ApU Dale of Birth (montMkrylyear)

City Stale ZipCooe Social Socurity

I am aware that federal law provides ror imprisonment andor fines for false statements or use of false documents in connection with the completion of this rorm

I altest under penalty of perjury that I am (check one of the following)

o A citizen of the Uniled States

o A noncitizen national oflhe United States (see instructions)

o A lawful permanent resident (Aliell ~)

An allen authorized to work (Alien I or Aemission~) _______

until (expiration date if appicable - monthldaytyear)

Employees SgnatlrC Date (monrrdaylyear)

Preparer andor Translator Certification (To be rompered and signed ifSeccion I is prepared by a person other than the employee) I atcur lInaer penalty ofperjury that I have (Usgt_ in the comp(etiol ofthis form and rholo rhe beesc ofmy knowledge the injimnatlon is true and correct

PreparersTranslators Signature Print Name

Address (Streel Name and Number Cil) ampale Zip Code Dale (moncMJaylyear)

Section 2 Employer Review and Verification (To be completed and signed by employer Examine one document from List A OR examine one document from Lis B and one from List C as listed on the reverse ofhis form and record the title number and expiration dale ifany ofthe document(s))

List A OR ListB ListC

Document title

Issuing authority

Document

Expiration Date (ifany)

Document

Expil1luon Dale (ifany)

CERTIFlCAnON I attest under penalty ofpnjury that I have examined the documents) presented by the above-named employee that the above-listed documenl(s) appear to be genuine and to relate to the employee named that the employee began employment on (monhdaylycar) and that to the best of my knowledge the employee is authorized to work in the United Slates (Slate employment agendes may omit the date the employee began employment)

Signature of EmpJoyer or Authorivd Representative Print Name Title

Business or OrganizatIOn Name aod Address (Stree Name and Number Ciry SiaJe Zip Code) Date (monl 1year

Section 3 Updating and Reverification (To be completed and signed by employer) A New Name (if applicable) B Date of Rehire (mOlrhldaylyear) (ifapplicable)

C Ifemployees previous gran of work authorization has expired provide the information below for the document that establishes current employment authorization

Document Title Document Expiration Date (if any)

I attest UDder penalty of perjury that to tbe~t of my kuwlelge Ihis employee is authorized to work in Ihe Upilltd Slates and if the employee prestlttI doegtlJlept(s)lbe document(s) I han examined appltar 10 be genuine and 10 Niate to tbe individual Signalure of Employer or Authorized Representative Date (lnonthldaylyear)

form )middot9 (Rev 08071(9) Y Page 4

t

The Premier Plan lVllclJmerica (~lljIIL~ril ~1lljmiddotnh1j1 ~fJhillqho- tl~1 Eligible FIIII-TIIIC ParI-Time SltasOl1al and Temporary Empolees

~ i EaS~ Man StrE~ Suite 00 la~eand Fl 3)a0 1

SOcil SClriIy Aliemalin Rellremenf Plan OC430 7995 bull Fax 863 S86 S727 WI m O(HTleHC2O

Acknowledgement nnd Designation of Bcnelieiary Form Employer __Ia3I~cPahObJ~H-=~r-=I~-~-ch(gt()c1_$v=Sf=e_tY1--___ 0 New Enrollment 0 Address Change 0 Beneficiary Change

o Name Change - Please insert former name here and lill in new name below You mu~t provide documentation of proof of name change (ie Copy of Marriage Certificate Social Security Card etc)

Participant I n formation (pleaampe prim legibl)) Social Security ________ Date of MaleiFemale__

Address-_---_______~____~__---------_=___o_--------------ISlcel 10 30lt (ApI iCily Siale ZIp)

Daytime Phone(_-L-________ Evening Phone(_1________

Beginning (Hire Date) I will participate in the (Employer) iPS S Deferred Compensation Plan IRC Section 457 and hereby forego my rights 0 receive compensation equal to of my gross annual compensation in return for the benefits provided thereunder I Wish this contribution to be invested in an annuity contract with American United Life I understand that my total amount of deferred compensaTion shall not exceed the lesser of the Section 4 J5 dollar limit or 100 of the participants includable compensation or such other sum as is permissible pursuant to the provision of Section 457 of Ihe Code in any calendar year I ul1derstand that my participating in this Plan is a condition of employment required by IRC Section 3 J21 bl(7) OBRA 1990 I further understand that payment(s) will be based on the value of the individual account(s) I acknowledge that a copy of the Deferred OJrnpensalion Plan Document is available to me for my review and llndcntanding The terms conditions and provisions of the Plan Document are hereby incorporated into this agreement

BfPefl~clarv De~Hgnalions Jt you nee d more fpace I han provl ed be ow pi ease areach an a tiona page

Primaa Name -- Social Security Date of Birth

Address Relationship Percent

Contin2~nt Name Social Security - Date of Birth Address Relationship Percent

A SO75 monthly fee will be applied to inactive participant account balances Inactive participants are those participants who have not made a contribution to the plan for one year are no longer employed with this Employer and who could at any time request a distribution of their account balance

Statement Concerning Your Employment in a Job Not Covered by Social Security Your W11ings from this job are not oover~d under Social Security When you retire Qf if you become disabled JOIi may ~ccentjve a ~ion based on earnings from this job If you do and you arc alw entitled to a benefit from Social Security based on either your own work or the wor of your husband or wife or former hU$band or wift your pemion may Aff~c th (lIl1O1n1 otthe Social Security helltltll you receive Your Medicate hen~tils hOwever willl10t tx affcct~d Undr the Social Security law Ihere are two ways your Social S~curi1) benet It amoulll may be afteclcd Windral Elhnlnallon Provision Under th~ Windfall Elimination Provision your Social Security retirement or disability bendil is figured using a IWdifled formula when you are also entitled to a pension from 11

job where you did not pay Social Security tax As a result you will receiw a lower Social Security benefit than jfyou were lOt emitted to a pension from Ibi job For e~ample if )01 ilTe age 62 in 2005 the maimum monthly reduction in your Social Security benefit as a result of this provision is $31350 This amoWlt is updated annually This provision redultes but docs not totally eliminate your Social Security benefit For aaditional information please retir to Social Security Publication Windfall Elimination Poision Govenmcpl Pension Oifsel Provision Under the Govemment Pension Offsel Provision any Social Sccurlly spouse or widow(cr) benefit to which you bewme tnlitled will be olfse ifyou also receive a Federal State or local government pension based on wor where you did not pay Social Security lax The offset reduces the amount of your Social Security spouse or ydow(er) benefit by two-thirds oftne amount of your penSion For example if you get a monthly pension of $600 bagted on earnings that are nOI covered under Social SeCllrity Von-Ihirds of Iliat amount S400 is used to offset your Social Security spouse ()( widow(er) benefit If you are eligible for a SSOO widow(er) bltndit you will receive SIOO per month from Social $ccurity ($500-$4()()=s 00) Even ifyour pension is hi)h enough 10 totally offset Jour spouse or widow(erl Social Security benefil you are ~til eligible for Medicare at age 65 For additional informntion please refer to Social Security PublicalJo~ Government Pension OffSet For Mofl Informalion SOCial Security Publication and additional information including information aboul exceptions 10 each provision are available at Ww)nQinlsecurilygpv You may also call 011 ftee j middot800-772-1213 or for the deaf or hard of hearing call the TrY number 1-800-325-0178 or contact your local Social Security office Copies of the SSA-1945 are available oolne at the SOCial Sccuflly webSite W sclaISeCl[It golfofml945 Paper copies can be requested by email atllmoorl1l rqt o[d~iil~ssectgO or by fal at 410middot 965middot2037 form SSAmiddot1945( 1220(4)

Employee Signature Print Name Date Submit completed form to

MidAmerica Administrative amp Retirement Solutions Inc 211 E Main Street Suite 100 Lakeland FL 33amp01

OMB No 1615middot0047 Expircs0813112

Form 1-9 Employment Department of Homelalld Security US Citi2enship and Immigration Services Eligibility Verification

Read instructions carefully before completing this (orm The instructions must be available during completion of this form

ANTI-DISCRIMINAnON NOTICE It is illegal to discriminate against work-authorized individuals Employers CANNOT specify which document(s) tbey will accept from an employee The refusal to hire an individual because the documeDts have a future expiration date may also constitute illegal discrimination

Section L Employee Information and Verification (To be completed and Signed by employee at the time employment begins) Print Name Last First Middle Illilial Maiden Name

Address (Srreel Name and Number) ApU Dale of Birth (montMkrylyear)

City Stale ZipCooe Social Socurity

I am aware that federal law provides ror imprisonment andor fines for false statements or use of false documents in connection with the completion of this rorm

I altest under penalty of perjury that I am (check one of the following)

o A citizen of the Uniled States

o A noncitizen national oflhe United States (see instructions)

o A lawful permanent resident (Aliell ~)

An allen authorized to work (Alien I or Aemission~) _______

until (expiration date if appicable - monthldaytyear)

Employees SgnatlrC Date (monrrdaylyear)

Preparer andor Translator Certification (To be rompered and signed ifSeccion I is prepared by a person other than the employee) I atcur lInaer penalty ofperjury that I have (Usgt_ in the comp(etiol ofthis form and rholo rhe beesc ofmy knowledge the injimnatlon is true and correct

PreparersTranslators Signature Print Name

Address (Streel Name and Number Cil) ampale Zip Code Dale (moncMJaylyear)

Section 2 Employer Review and Verification (To be completed and signed by employer Examine one document from List A OR examine one document from Lis B and one from List C as listed on the reverse ofhis form and record the title number and expiration dale ifany ofthe document(s))

List A OR ListB ListC

Document title

Issuing authority

Document

Expiration Date (ifany)

Document

Expil1luon Dale (ifany)

CERTIFlCAnON I attest under penalty ofpnjury that I have examined the documents) presented by the above-named employee that the above-listed documenl(s) appear to be genuine and to relate to the employee named that the employee began employment on (monhdaylycar) and that to the best of my knowledge the employee is authorized to work in the United Slates (Slate employment agendes may omit the date the employee began employment)

Signature of EmpJoyer or Authorivd Representative Print Name Title

Business or OrganizatIOn Name aod Address (Stree Name and Number Ciry SiaJe Zip Code) Date (monl 1year

Section 3 Updating and Reverification (To be completed and signed by employer) A New Name (if applicable) B Date of Rehire (mOlrhldaylyear) (ifapplicable)

C Ifemployees previous gran of work authorization has expired provide the information below for the document that establishes current employment authorization

Document Title Document Expiration Date (if any)

I attest UDder penalty of perjury that to tbe~t of my kuwlelge Ihis employee is authorized to work in Ihe Upilltd Slates and if the employee prestlttI doegtlJlept(s)lbe document(s) I han examined appltar 10 be genuine and 10 Niate to tbe individual Signalure of Employer or Authorized Representative Date (lnonthldaylyear)

form )middot9 (Rev 08071(9) Y Page 4

t

The Premier Plan lVllclJmerica (~lljIIL~ril ~1lljmiddotnh1j1 ~fJhillqho- tl~1 Eligible FIIII-TIIIC ParI-Time SltasOl1al and Temporary Empolees

~ i EaS~ Man StrE~ Suite 00 la~eand Fl 3)a0 1

SOcil SClriIy Aliemalin Rellremenf Plan OC430 7995 bull Fax 863 S86 S727 WI m O(HTleHC2O

Acknowledgement nnd Designation of Bcnelieiary Form Employer __Ia3I~cPahObJ~H-=~r-=I~-~-ch(gt()c1_$v=Sf=e_tY1--___ 0 New Enrollment 0 Address Change 0 Beneficiary Change

o Name Change - Please insert former name here and lill in new name below You mu~t provide documentation of proof of name change (ie Copy of Marriage Certificate Social Security Card etc)

Participant I n formation (pleaampe prim legibl)) Social Security ________ Date of MaleiFemale__

Address-_---_______~____~__---------_=___o_--------------ISlcel 10 30lt (ApI iCily Siale ZIp)

Daytime Phone(_-L-________ Evening Phone(_1________

Beginning (Hire Date) I will participate in the (Employer) iPS S Deferred Compensation Plan IRC Section 457 and hereby forego my rights 0 receive compensation equal to of my gross annual compensation in return for the benefits provided thereunder I Wish this contribution to be invested in an annuity contract with American United Life I understand that my total amount of deferred compensaTion shall not exceed the lesser of the Section 4 J5 dollar limit or 100 of the participants includable compensation or such other sum as is permissible pursuant to the provision of Section 457 of Ihe Code in any calendar year I ul1derstand that my participating in this Plan is a condition of employment required by IRC Section 3 J21 bl(7) OBRA 1990 I further understand that payment(s) will be based on the value of the individual account(s) I acknowledge that a copy of the Deferred OJrnpensalion Plan Document is available to me for my review and llndcntanding The terms conditions and provisions of the Plan Document are hereby incorporated into this agreement

BfPefl~clarv De~Hgnalions Jt you nee d more fpace I han provl ed be ow pi ease areach an a tiona page

Primaa Name -- Social Security Date of Birth

Address Relationship Percent

Contin2~nt Name Social Security - Date of Birth Address Relationship Percent

A SO75 monthly fee will be applied to inactive participant account balances Inactive participants are those participants who have not made a contribution to the plan for one year are no longer employed with this Employer and who could at any time request a distribution of their account balance

Statement Concerning Your Employment in a Job Not Covered by Social Security Your W11ings from this job are not oover~d under Social Security When you retire Qf if you become disabled JOIi may ~ccentjve a ~ion based on earnings from this job If you do and you arc alw entitled to a benefit from Social Security based on either your own work or the wor of your husband or wife or former hU$band or wift your pemion may Aff~c th (lIl1O1n1 otthe Social Security helltltll you receive Your Medicate hen~tils hOwever willl10t tx affcct~d Undr the Social Security law Ihere are two ways your Social S~curi1) benet It amoulll may be afteclcd Windral Elhnlnallon Provision Under th~ Windfall Elimination Provision your Social Security retirement or disability bendil is figured using a IWdifled formula when you are also entitled to a pension from 11

job where you did not pay Social Security tax As a result you will receiw a lower Social Security benefit than jfyou were lOt emitted to a pension from Ibi job For e~ample if )01 ilTe age 62 in 2005 the maimum monthly reduction in your Social Security benefit as a result of this provision is $31350 This amoWlt is updated annually This provision redultes but docs not totally eliminate your Social Security benefit For aaditional information please retir to Social Security Publication Windfall Elimination Poision Govenmcpl Pension Oifsel Provision Under the Govemment Pension Offsel Provision any Social Sccurlly spouse or widow(cr) benefit to which you bewme tnlitled will be olfse ifyou also receive a Federal State or local government pension based on wor where you did not pay Social Security lax The offset reduces the amount of your Social Security spouse or ydow(er) benefit by two-thirds oftne amount of your penSion For example if you get a monthly pension of $600 bagted on earnings that are nOI covered under Social SeCllrity Von-Ihirds of Iliat amount S400 is used to offset your Social Security spouse ()( widow(er) benefit If you are eligible for a SSOO widow(er) bltndit you will receive SIOO per month from Social $ccurity ($500-$4()()=s 00) Even ifyour pension is hi)h enough 10 totally offset Jour spouse or widow(erl Social Security benefil you are ~til eligible for Medicare at age 65 For additional informntion please refer to Social Security PublicalJo~ Government Pension OffSet For Mofl Informalion SOCial Security Publication and additional information including information aboul exceptions 10 each provision are available at Ww)nQinlsecurilygpv You may also call 011 ftee j middot800-772-1213 or for the deaf or hard of hearing call the TrY number 1-800-325-0178 or contact your local Social Security office Copies of the SSA-1945 are available oolne at the SOCial Sccuflly webSite W sclaISeCl[It golfofml945 Paper copies can be requested by email atllmoorl1l rqt o[d~iil~ssectgO or by fal at 410middot 965middot2037 form SSAmiddot1945( 1220(4)

Employee Signature Print Name Date Submit completed form to

MidAmerica Administrative amp Retirement Solutions Inc 211 E Main Street Suite 100 Lakeland FL 33amp01

t

The Premier Plan lVllclJmerica (~lljIIL~ril ~1lljmiddotnh1j1 ~fJhillqho- tl~1 Eligible FIIII-TIIIC ParI-Time SltasOl1al and Temporary Empolees

~ i EaS~ Man StrE~ Suite 00 la~eand Fl 3)a0 1

SOcil SClriIy Aliemalin Rellremenf Plan OC430 7995 bull Fax 863 S86 S727 WI m O(HTleHC2O

Acknowledgement nnd Designation of Bcnelieiary Form Employer __Ia3I~cPahObJ~H-=~r-=I~-~-ch(gt()c1_$v=Sf=e_tY1--___ 0 New Enrollment 0 Address Change 0 Beneficiary Change

o Name Change - Please insert former name here and lill in new name below You mu~t provide documentation of proof of name change (ie Copy of Marriage Certificate Social Security Card etc)

Participant I n formation (pleaampe prim legibl)) Social Security ________ Date of MaleiFemale__

Address-_---_______~____~__---------_=___o_--------------ISlcel 10 30lt (ApI iCily Siale ZIp)

Daytime Phone(_-L-________ Evening Phone(_1________

Beginning (Hire Date) I will participate in the (Employer) iPS S Deferred Compensation Plan IRC Section 457 and hereby forego my rights 0 receive compensation equal to of my gross annual compensation in return for the benefits provided thereunder I Wish this contribution to be invested in an annuity contract with American United Life I understand that my total amount of deferred compensaTion shall not exceed the lesser of the Section 4 J5 dollar limit or 100 of the participants includable compensation or such other sum as is permissible pursuant to the provision of Section 457 of Ihe Code in any calendar year I ul1derstand that my participating in this Plan is a condition of employment required by IRC Section 3 J21 bl(7) OBRA 1990 I further understand that payment(s) will be based on the value of the individual account(s) I acknowledge that a copy of the Deferred OJrnpensalion Plan Document is available to me for my review and llndcntanding The terms conditions and provisions of the Plan Document are hereby incorporated into this agreement

BfPefl~clarv De~Hgnalions Jt you nee d more fpace I han provl ed be ow pi ease areach an a tiona page

Primaa Name -- Social Security Date of Birth

Address Relationship Percent

Contin2~nt Name Social Security - Date of Birth Address Relationship Percent

A SO75 monthly fee will be applied to inactive participant account balances Inactive participants are those participants who have not made a contribution to the plan for one year are no longer employed with this Employer and who could at any time request a distribution of their account balance

Statement Concerning Your Employment in a Job Not Covered by Social Security Your W11ings from this job are not oover~d under Social Security When you retire Qf if you become disabled JOIi may ~ccentjve a ~ion based on earnings from this job If you do and you arc alw entitled to a benefit from Social Security based on either your own work or the wor of your husband or wife or former hU$band or wift your pemion may Aff~c th (lIl1O1n1 otthe Social Security helltltll you receive Your Medicate hen~tils hOwever willl10t tx affcct~d Undr the Social Security law Ihere are two ways your Social S~curi1) benet It amoulll may be afteclcd Windral Elhnlnallon Provision Under th~ Windfall Elimination Provision your Social Security retirement or disability bendil is figured using a IWdifled formula when you are also entitled to a pension from 11

job where you did not pay Social Security tax As a result you will receiw a lower Social Security benefit than jfyou were lOt emitted to a pension from Ibi job For e~ample if )01 ilTe age 62 in 2005 the maimum monthly reduction in your Social Security benefit as a result of this provision is $31350 This amoWlt is updated annually This provision redultes but docs not totally eliminate your Social Security benefit For aaditional information please retir to Social Security Publication Windfall Elimination Poision Govenmcpl Pension Oifsel Provision Under the Govemment Pension Offsel Provision any Social Sccurlly spouse or widow(cr) benefit to which you bewme tnlitled will be olfse ifyou also receive a Federal State or local government pension based on wor where you did not pay Social Security lax The offset reduces the amount of your Social Security spouse or ydow(er) benefit by two-thirds oftne amount of your penSion For example if you get a monthly pension of $600 bagted on earnings that are nOI covered under Social SeCllrity Von-Ihirds of Iliat amount S400 is used to offset your Social Security spouse ()( widow(er) benefit If you are eligible for a SSOO widow(er) bltndit you will receive SIOO per month from Social $ccurity ($500-$4()()=s 00) Even ifyour pension is hi)h enough 10 totally offset Jour spouse or widow(erl Social Security benefil you are ~til eligible for Medicare at age 65 For additional informntion please refer to Social Security PublicalJo~ Government Pension OffSet For Mofl Informalion SOCial Security Publication and additional information including information aboul exceptions 10 each provision are available at Ww)nQinlsecurilygpv You may also call 011 ftee j middot800-772-1213 or for the deaf or hard of hearing call the TrY number 1-800-325-0178 or contact your local Social Security office Copies of the SSA-1945 are available oolne at the SOCial Sccuflly webSite W sclaISeCl[It golfofml945 Paper copies can be requested by email atllmoorl1l rqt o[d~iil~ssectgO or by fal at 410middot 965middot2037 form SSAmiddot1945( 1220(4)

Employee Signature Print Name Date Submit completed form to

MidAmerica Administrative amp Retirement Solutions Inc 211 E Main Street Suite 100 Lakeland FL 33amp01

----------------------

---------- ---------------- -----

----------

I CRIMINAL BACKGROUND CHECKLIST II

Nan1e ____________________________ _______________________________________ Last First Middle

Address ____________________________________________________________________ StreetlP 0 Box

City State Zip

Position Applied

Social Security No ____________________________ Date of Birth

State of Birth Driver s LicenseIdentification No Slale

Sex F ___~1 Height _______ Weight Hair Color

Eye Color _ ______ Race =Black White llispanic =Asian lOther _________________

Please check from one of the follo ing

Complexion Build

D Dark EmaciatedThin

D Light Heavy

C Medium Light

C Fair Medium

D Freckled Obese

D Albino

D Olive

Pimpled

C Pock ~larked

Yellow

Salim

Ruddy

Fingerprinting is available onl) on -=-====- or Thursdav from 800AM - 1OOPM Central Time

D Tuesday ____________________ D Thursday ________________ Date Date

Tangipahoa Parish School System

TO All Employees

FROM The Payroll Department

Tangipahoa Parish School System

The Payroll Department has made it mandatory that all employees

be paid either by PAY CARD or DIRECT DEPOSIT We ask that you

choose only one method of pay

Thank you for your cooperation

bull bull bull bull bullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbull T T bullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbull ~

DIERECT DEPOSIT Form Complete and Attach Void Check

PAY CARD Form Cornplete requested information on the form up to the Signature ofCardholder

Copy ofDrivers LicenseIdentification and Social Security Card is required

--

TANGIPAHOA PARISH SCHOOL SYSTEM SIMPLEXES RElOADABlE CARD REGISTRATION FORM

EMPLOYEE INFORMATIONPlease provide two forms of identlflcation along with registration Names MUST match on both

identification forms and cannot be expired u

Cardholders First Name Physical Address

Cardholders Last Name IMailing Address

I

I Cardholders SSN City

Cardholders Phone Number With Area Code State Zip

Cardholders Date of Birth Cardholders Drivers licenseState Issued 10 Number

Cardholders OLIO Issue Date Cardholders Drivers licenseState Issued 10 Exp Date

The card is a prepaId card The card allows you to access funds loaded or deposited to your Card account by yol) Your fund WIll never expire

regardless of the expiration date on the front of your Card In order for the Card to accept reloads the USA PATRIOT ACT a federal law requires

all financial intuitions to obtain verify and record information that identifies each person who has a Card We will ask your name address date

of birth social security number and other information that will enable us to reasonably identify you We may also ask to see your drivers

license or other Identifying documents Upon successful Identification verification you may load and reload funds to your card

Please review your Prepaid Mastercard Reloadable Cardholder Agreement for complete terms conditions and important Information

concerning using your Card obtaining a PIN loading and reloading your Card and other Important terms and definitions

MONTHLY FEE RELOAD FEE YOI) will be assessed a Monthly maintenance fee of $300 If you are You will be asse$Sed a fee ranging from $000 to $495 each time you enrolled in direct deposit and have deposits made monthly your reload your Card This Fee is also waved as long as you are enrolled in Maiotenall(e Fee will be waived for each month you are enrolled in direct deposit direct deposit

FOR ONLINE RELOADS REPLACEMENT CARD FEE An Online Reload Fee of up to $3000 will be applied to your Card used If your card Is lost or Stolen there is a $500 Fee to replace it to reload based on the amount of Funds loaded

ATM INTERNAnONAL TRANSACTION FEE The domestic ATM withdrawal fee is $150 The international ATM You will be assessed an International Transaction Fee of 3 of the withdrawal fee is $300 To get your balance using an ATM you will be domestic dollar amount of the transaction for purchases made outside assessed a $050 fee ~ to call the number on back of card to obtain the United States of America balance There is a maximum of $500003 times a day for a total of $150000

POSPOIPOP PIN OVER THE COUNTER CASH ADVANCE To use your PIN at the point of saletransactionpurchase you will not To obtain cash over the counter you will be assessed a fee of $500 be assessed a fee No purchase fee on signature purchases There is a maKimum of $50000 3 times a day for a total of $150000 BY SIGNING BELOW I UNDERSTAND AND AGREE THAT middotThe information I provided is correct and complete bull I am requesting Tangipahoa Parish School System to issue a MasterCard prepaid Card on my behalf bull I will receive the Terms and Conditions associated with my Card CIt the same time I receive the Card If I choose to use the Card I have agreed to the terms and conditions SIGNATURE OF CARDHOLDER DATE

SIGNATURE OF PROVIDERS

-ANGIPAHOA

p~ SCHOOL ~ SYSTEM DIRECT DEPOSIT ENROLLMENT FORM

PLEASE COMPLETE THIS FORM (PLEASE PRINT) AND RETURN TO

ROSA DUPUY PA YROLL COORDINATOR BY MAIL (59656 PULESTON ROAD AMITE LA 70422)

EMAIL (rosadupuytanqischoolsorq) OR FAX (985-748-2504

EMPLOYEE INFORMATION

EMPLOYEES NAME_______________ EMPLOYEE NUMBER_________

MAILING ADDRESS______________________________

FINANCIAL INSTITUTION (BANK SAVINGS amp LOAN CREDIT UNION) INFORMATION

NAME_________________________________________

ADDRESS__________________________________________

TYPE OF ACCOUNT (CHECK ONE) __CHECKING __SAVINGS

ACCOUNT NUMBER__________________________

ROUTING OR ABA NUMBER _____________________

My signature below indicates that I have read and understand the following information bull Direct deposit will remain in effect until canceled by the employee or when the employee terminates employment with

the TangipahoaParish School System bull If the employee wishes to change to a different financial institution he or she will be required to complete a new

Direct Deposit Enrollment Form The employee should maintain an account at both financial institutions until after the new finincial institution receives the employees Direct Deposit payment

bull Direct deposit will apply to monthly payroll checks and stipends bull A voided personsectll check must be submitted with this form

I hereby authorize the Tangipahoa Parish School System Payroll Department to forward my payroll checks andor

stipends to the financial insittution listed above

EMPlOYEES SIGNATURE__________________________ DATE_____________

TO All Employees

FROM The Payroll Department

Tangipahoa Parish School System

The Payroll Department has made it mandatory that all employees

be paid either by PAY CARD or DIRECT DEPOSIT We ask that you

choose only one method of pay

Thank you for your cooperation

bull bull bull bull bullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbull T T bullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbull ~

DIERECT DEPOSIT Form Complete and Attach Void Check

PAY CARD Form Cornplete requested information on the form up to the Signature ofCardholder

Copy ofDrivers LicenseIdentification and Social Security Card is required

--

TANGIPAHOA PARISH SCHOOL SYSTEM SIMPLEXES RElOADABlE CARD REGISTRATION FORM

EMPLOYEE INFORMATIONPlease provide two forms of identlflcation along with registration Names MUST match on both

identification forms and cannot be expired u

Cardholders First Name Physical Address

Cardholders Last Name IMailing Address

I

I Cardholders SSN City

Cardholders Phone Number With Area Code State Zip

Cardholders Date of Birth Cardholders Drivers licenseState Issued 10 Number

Cardholders OLIO Issue Date Cardholders Drivers licenseState Issued 10 Exp Date

The card is a prepaId card The card allows you to access funds loaded or deposited to your Card account by yol) Your fund WIll never expire

regardless of the expiration date on the front of your Card In order for the Card to accept reloads the USA PATRIOT ACT a federal law requires

all financial intuitions to obtain verify and record information that identifies each person who has a Card We will ask your name address date

of birth social security number and other information that will enable us to reasonably identify you We may also ask to see your drivers

license or other Identifying documents Upon successful Identification verification you may load and reload funds to your card

Please review your Prepaid Mastercard Reloadable Cardholder Agreement for complete terms conditions and important Information

concerning using your Card obtaining a PIN loading and reloading your Card and other Important terms and definitions

MONTHLY FEE RELOAD FEE YOI) will be assessed a Monthly maintenance fee of $300 If you are You will be asse$Sed a fee ranging from $000 to $495 each time you enrolled in direct deposit and have deposits made monthly your reload your Card This Fee is also waved as long as you are enrolled in Maiotenall(e Fee will be waived for each month you are enrolled in direct deposit direct deposit

FOR ONLINE RELOADS REPLACEMENT CARD FEE An Online Reload Fee of up to $3000 will be applied to your Card used If your card Is lost or Stolen there is a $500 Fee to replace it to reload based on the amount of Funds loaded

ATM INTERNAnONAL TRANSACTION FEE The domestic ATM withdrawal fee is $150 The international ATM You will be assessed an International Transaction Fee of 3 of the withdrawal fee is $300 To get your balance using an ATM you will be domestic dollar amount of the transaction for purchases made outside assessed a $050 fee ~ to call the number on back of card to obtain the United States of America balance There is a maximum of $500003 times a day for a total of $150000

POSPOIPOP PIN OVER THE COUNTER CASH ADVANCE To use your PIN at the point of saletransactionpurchase you will not To obtain cash over the counter you will be assessed a fee of $500 be assessed a fee No purchase fee on signature purchases There is a maKimum of $50000 3 times a day for a total of $150000 BY SIGNING BELOW I UNDERSTAND AND AGREE THAT middotThe information I provided is correct and complete bull I am requesting Tangipahoa Parish School System to issue a MasterCard prepaid Card on my behalf bull I will receive the Terms and Conditions associated with my Card CIt the same time I receive the Card If I choose to use the Card I have agreed to the terms and conditions SIGNATURE OF CARDHOLDER DATE

SIGNATURE OF PROVIDERS

-ANGIPAHOA

p~ SCHOOL ~ SYSTEM DIRECT DEPOSIT ENROLLMENT FORM

PLEASE COMPLETE THIS FORM (PLEASE PRINT) AND RETURN TO

ROSA DUPUY PA YROLL COORDINATOR BY MAIL (59656 PULESTON ROAD AMITE LA 70422)

EMAIL (rosadupuytanqischoolsorq) OR FAX (985-748-2504

EMPLOYEE INFORMATION

EMPLOYEES NAME_______________ EMPLOYEE NUMBER_________

MAILING ADDRESS______________________________

FINANCIAL INSTITUTION (BANK SAVINGS amp LOAN CREDIT UNION) INFORMATION

NAME_________________________________________

ADDRESS__________________________________________

TYPE OF ACCOUNT (CHECK ONE) __CHECKING __SAVINGS

ACCOUNT NUMBER__________________________

ROUTING OR ABA NUMBER _____________________

My signature below indicates that I have read and understand the following information bull Direct deposit will remain in effect until canceled by the employee or when the employee terminates employment with

the TangipahoaParish School System bull If the employee wishes to change to a different financial institution he or she will be required to complete a new

Direct Deposit Enrollment Form The employee should maintain an account at both financial institutions until after the new finincial institution receives the employees Direct Deposit payment

bull Direct deposit will apply to monthly payroll checks and stipends bull A voided personsectll check must be submitted with this form

I hereby authorize the Tangipahoa Parish School System Payroll Department to forward my payroll checks andor

stipends to the financial insittution listed above

EMPlOYEES SIGNATURE__________________________ DATE_____________

--

TANGIPAHOA PARISH SCHOOL SYSTEM SIMPLEXES RElOADABlE CARD REGISTRATION FORM

EMPLOYEE INFORMATIONPlease provide two forms of identlflcation along with registration Names MUST match on both

identification forms and cannot be expired u

Cardholders First Name Physical Address

Cardholders Last Name IMailing Address

I

I Cardholders SSN City

Cardholders Phone Number With Area Code State Zip

Cardholders Date of Birth Cardholders Drivers licenseState Issued 10 Number

Cardholders OLIO Issue Date Cardholders Drivers licenseState Issued 10 Exp Date

The card is a prepaId card The card allows you to access funds loaded or deposited to your Card account by yol) Your fund WIll never expire

regardless of the expiration date on the front of your Card In order for the Card to accept reloads the USA PATRIOT ACT a federal law requires

all financial intuitions to obtain verify and record information that identifies each person who has a Card We will ask your name address date

of birth social security number and other information that will enable us to reasonably identify you We may also ask to see your drivers

license or other Identifying documents Upon successful Identification verification you may load and reload funds to your card

Please review your Prepaid Mastercard Reloadable Cardholder Agreement for complete terms conditions and important Information

concerning using your Card obtaining a PIN loading and reloading your Card and other Important terms and definitions

MONTHLY FEE RELOAD FEE YOI) will be assessed a Monthly maintenance fee of $300 If you are You will be asse$Sed a fee ranging from $000 to $495 each time you enrolled in direct deposit and have deposits made monthly your reload your Card This Fee is also waved as long as you are enrolled in Maiotenall(e Fee will be waived for each month you are enrolled in direct deposit direct deposit

FOR ONLINE RELOADS REPLACEMENT CARD FEE An Online Reload Fee of up to $3000 will be applied to your Card used If your card Is lost or Stolen there is a $500 Fee to replace it to reload based on the amount of Funds loaded

ATM INTERNAnONAL TRANSACTION FEE The domestic ATM withdrawal fee is $150 The international ATM You will be assessed an International Transaction Fee of 3 of the withdrawal fee is $300 To get your balance using an ATM you will be domestic dollar amount of the transaction for purchases made outside assessed a $050 fee ~ to call the number on back of card to obtain the United States of America balance There is a maximum of $500003 times a day for a total of $150000

POSPOIPOP PIN OVER THE COUNTER CASH ADVANCE To use your PIN at the point of saletransactionpurchase you will not To obtain cash over the counter you will be assessed a fee of $500 be assessed a fee No purchase fee on signature purchases There is a maKimum of $50000 3 times a day for a total of $150000 BY SIGNING BELOW I UNDERSTAND AND AGREE THAT middotThe information I provided is correct and complete bull I am requesting Tangipahoa Parish School System to issue a MasterCard prepaid Card on my behalf bull I will receive the Terms and Conditions associated with my Card CIt the same time I receive the Card If I choose to use the Card I have agreed to the terms and conditions SIGNATURE OF CARDHOLDER DATE

SIGNATURE OF PROVIDERS

-ANGIPAHOA

p~ SCHOOL ~ SYSTEM DIRECT DEPOSIT ENROLLMENT FORM

PLEASE COMPLETE THIS FORM (PLEASE PRINT) AND RETURN TO

ROSA DUPUY PA YROLL COORDINATOR BY MAIL (59656 PULESTON ROAD AMITE LA 70422)

EMAIL (rosadupuytanqischoolsorq) OR FAX (985-748-2504

EMPLOYEE INFORMATION

EMPLOYEES NAME_______________ EMPLOYEE NUMBER_________

MAILING ADDRESS______________________________

FINANCIAL INSTITUTION (BANK SAVINGS amp LOAN CREDIT UNION) INFORMATION

NAME_________________________________________

ADDRESS__________________________________________

TYPE OF ACCOUNT (CHECK ONE) __CHECKING __SAVINGS

ACCOUNT NUMBER__________________________

ROUTING OR ABA NUMBER _____________________

My signature below indicates that I have read and understand the following information bull Direct deposit will remain in effect until canceled by the employee or when the employee terminates employment with

the TangipahoaParish School System bull If the employee wishes to change to a different financial institution he or she will be required to complete a new

Direct Deposit Enrollment Form The employee should maintain an account at both financial institutions until after the new finincial institution receives the employees Direct Deposit payment

bull Direct deposit will apply to monthly payroll checks and stipends bull A voided personsectll check must be submitted with this form

I hereby authorize the Tangipahoa Parish School System Payroll Department to forward my payroll checks andor

stipends to the financial insittution listed above

EMPlOYEES SIGNATURE__________________________ DATE_____________

-ANGIPAHOA

p~ SCHOOL ~ SYSTEM DIRECT DEPOSIT ENROLLMENT FORM

PLEASE COMPLETE THIS FORM (PLEASE PRINT) AND RETURN TO

ROSA DUPUY PA YROLL COORDINATOR BY MAIL (59656 PULESTON ROAD AMITE LA 70422)

EMAIL (rosadupuytanqischoolsorq) OR FAX (985-748-2504

EMPLOYEE INFORMATION

EMPLOYEES NAME_______________ EMPLOYEE NUMBER_________

MAILING ADDRESS______________________________

FINANCIAL INSTITUTION (BANK SAVINGS amp LOAN CREDIT UNION) INFORMATION

NAME_________________________________________

ADDRESS__________________________________________

TYPE OF ACCOUNT (CHECK ONE) __CHECKING __SAVINGS

ACCOUNT NUMBER__________________________

ROUTING OR ABA NUMBER _____________________

My signature below indicates that I have read and understand the following information bull Direct deposit will remain in effect until canceled by the employee or when the employee terminates employment with

the TangipahoaParish School System bull If the employee wishes to change to a different financial institution he or she will be required to complete a new

Direct Deposit Enrollment Form The employee should maintain an account at both financial institutions until after the new finincial institution receives the employees Direct Deposit payment

bull Direct deposit will apply to monthly payroll checks and stipends bull A voided personsectll check must be submitted with this form

I hereby authorize the Tangipahoa Parish School System Payroll Department to forward my payroll checks andor

stipends to the financial insittution listed above

EMPlOYEES SIGNATURE__________________________ DATE_____________

TANGIPAHOA PARISH SCHOOL SYSTEM

Sexual Misconduct Disclosure Statement

As required by Louisiana Revised Statue 17819 (Act 723) the applicant authorizes all previous employers to disclose any and all information in the applicants personnel file related to instances of sexual misconduct with students committed by the applicant The applicant releases previous and current employees from liability for providing the requested information to the Tangipahoa Parish School System

I have read and understand the statement above bull I understand that I cannot be considered for employment in the Tangipahoa Parish School

System unless this form is signed bull Once this form has been signed the applicant may be hired on a conditional basis pending the

review of any information obtained bull I agree that a copy of this form will be sent to each of my previous employers bull Each completed form received will be placed in my personnel file

Please check the appropriate box

o I have formerly worked in (a) school district(s) in the StateofLouisiana

o I have never worked in (a) school district(s) in the State of Louisiana

PRINT FULL NAME DATE

SIGNATURE OF EMPLOYEE SOCIAL SECURITY NUMBER

This section to be completed by previous employer

Name of School system ___________________________

o There is no information in this employeeS file indicating sexual misconduct

o [have attached documentation regarding sexual misconduct

Previous employer(s) shouldcomplete this fonn and return it within twenty (20) business days to the following address~

Tangipahoa parish School System Human Resource Department

59656 Puleston Road Amite Louisiana 70422

Print Name Authorized HR Employee Date

Signature of Authorized IIR

As part of your background check this completed form must accompany your

application All fingerprintbackground checks are scheduled with the Tangipahoa Parish

Sheriffs Office

Please answer the following question accurately

)gt Have you ever been convicted of a crime Yes NO____

Jgt If your answer is Yes please state the charges for which you were convicted

The facts set forth above in my application for employment are true and complete I

understand that if employed false statements within this application shall be considered

sufficient cause for dismissal You are hereby authorized to make any investigation of my

personal history and financial and credit records through any investigative or credit agencies or

bureaus of your determination

SIGNATURE OF APPLICANT DATE

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer

As part of your background check this completed form must accompany your

application All fingerprintbackground checks are scheduled with the Tangipahoa Parish

Sheriffs Office

Please answer the following question accurately

)gt Have you ever been convicted of a crime Yes NO____

Jgt If your answer is Yes please state the charges for which you were convicted

The facts set forth above in my application for employment are true and complete I

understand that if employed false statements within this application shall be considered

sufficient cause for dismissal You are hereby authorized to make any investigation of my

personal history and financial and credit records through any investigative or credit agencies or

bureaus of your determination

SIGNATURE OF APPLICANT DATE

The Tangipahoa Parish School System does not discriminate on the basis of race color national origin sex age disabilities or veteran status We are an equal opportunity employer