university of massachusetts boston non-benefited

Rev.4.27.2017 04.27.2017

HR use only

Employee ID Empl Class

ePAF # (if applicable)

LAST NAME

Department of Human Resources

UNIVERSITY OF MASSACHUSETTS BOSTON

NON-BENEFITED PRE-EMPLOYMENT PAPERWORK CHECKLIST

Completed by appointee 1) Personal Data Questionnaire (PDQ) 2) State Tax Form (M-4) 3) Federal Tax Form (W-4)

4) Employment Eligibility Verification Form (I-9)

5) Self-Identification Form (Completion of this form or any part of this form is strictly voluntary, but will enable the University to accurately report the diversity of its faculty and staff and to monitor the effectiveness of its affirmative action approach.)

6) Retirement Savings Plan (Massachusetts Deferred Compensation SMART Plan)

7) Direct Deposit Form

8) Conflict of Interest Law Requirements

Received by appointee (Pre-employment packet will not be accepted unless boxes below are checked off by employee to acknowledge receipt.)

Federal Affordable Care Act (ACA) notification/information

Guide to the Conflict of Interest Law

Guide to Political Activity (Public Employees and Fundraising) Sexual Harassment Policy Drug-Free Workplace Policy

University Policy on Fraudulent Financial Activities

University of Massachusetts Principals of Employee Conduct

I have received and understand the information listed under “Received by appointee.” I also understand that my name will not be added to the University’s payroll until all of the appropriate paperwork is completed.

Signature Date

http://cdn.umb.edu/images/hr/ACA_notification_info.pdf

Rev. 04.27.17


UNIVERSITY OF MASSACHUSETTS BOSTON

NON-BENEFITED PRE-EMPLOYMENT PAPERWORK

All new employees appointed to the University must complete Pre-Employment paperwork in order to be placed on the University’s payroll system.

Completed by appointee

1. Personal Data Questionnaire (PDQ) The appointee must complete, sign and date the bottom of the form.

2. State Tax Form (M-4) The appointee must complete, sign and date the bottom of the form. Note: The appointee can change his/her tax exemptions as often as he/she needs.

3. Federal Tax Form (W-4) Same instructions as above. The majority of the form is really a worksheet for determining the appropriate number of exemptions. Only the bottom half of the front page needs to be completed. **Federal law mandates that Non-Resident Aliens adhere to specific requirements when completing the W-4 and/or Form 8233 (Tax treaties), please contact Human Resources for additional information.

4. Form I-9, Employment Eligibility Verification***Please read instructions thoroughly *** An appointee must provide documents within three days of employment that will verify identity as well as employment eligibility when completing the I-9 Form. Any one document that establishes both identity and employment eligibility (List A: e.g., U.S. Passport, Permanent Resident Card) would satisfy the requirements for I-9 identity and Employment Eligibility. Otherwise, a combination of documents is required. One type of document needs to establish identity (List B: e.g., Driver’s license, School ID card with a photograph, voter’s registration card) while the other needs to establish employment eligibility (List C: e.g., U.S. social security card, original birth certificate, un-expired employment authorization document issued by the Department of Homeland Security).

5. University of Massachusetts Boston, Self Identification Form It is the policy of the University of Massachusetts to collect, maintain, and report certain ethnicity, race, disability, and Vietnam Era Veteran status information as required by the Office of Federal Contract Compliance Programs (OFCCP), the Equal Employment Commission (EEOC), the Institute of Educational Sciences, United States Department of Education (DOE), and other required Federal and state entities. Any data collected as part of this process will not be used to make employment-related decisions. For a complete copy of the University’s policy on the collection, maintenance, and reporting of ethnicity, race, disability, and Veteran status information, please contact the Office of Diversity and Inclusion at 617- 287-4818 or visit: www.umb.edu/odi ***Completion of this form or any part of this form is strictly voluntary, but will enable the University to accurately report the diversity of its faculty and staff and to monitor the effectiveness of its affirmative action programs.

http://www.umb.edu/odi

Rev. 04.27.17

6. Retirement Savings Plan: Massachusetts Deferred Compensation SMART Plan The federal government requires that every employee contribute to some form of retirement savings plan. Types of Employees who are NOT required to contribute to the SMART Plan are: participating members of the State Board of Retirement; employees retired from State service; employees age 70 or older who have elected to stop contributions to the State Retirement System; and active UMass Boston students enrolled in and regularly attending six or more credit courses. **Employees who participate in the Massachusetts Teachers’ Retirement System are NOT exempt from paying into this plan.

7. Mandatory Direct Deposit Your payroll check will be deposited directly into your account: checking, savings, credit union, etc. The University now offers the ability to have your check deposited into a combination of up to four accounts. On the bottom of your personnel check, to the left side, you will locate a nine-digit Bank ID number (transit routing number) alongside these series of numbers will be your account number, WRITE CLEARLY and place these EXACT numbers on the direct deposit form. If the appointee wishes to have his/her check deposited into a savings account, he/she should contact the bank to get the Bank ID number (transit routing number) and account number.

8. Conflict of Interest Law Requirements Annual conflict of interest law education and training is mandated by the University of Massachusetts Boston and the Commonwealth of Massachusetts

Received by appointee

The appointee will check off the appropriate box on the Checklist Page to acknowledge receipt and understanding of the University policies listed below. The ACA notification is a separate link (3 pgs.).The policies can be downloaded as a packet from the Forms page of the HR website.

Federal Affordable Care Act (ACA) notification/information

Guide to the Conflict of Interest Law

Guide to Political Activity (Public Employees and Fundraising)

Drug-Free Workplace Policy Sexual Harassment Policy

University of Massachusetts Policy on Fraudulent Financial Activities

University of Massachusetts Principles of Employee Conduct

UNIVERSITY OF MASSACHUSETTS BOSTON DEPARTMENT OF HUMAN RESOURCES

PERSONAL DATA QUESTIONNAIRE

Social Security Number

First Name Middle Name Last Name

Street Address Telephone

City State/Country Zip Code Marital Statu Single

s Married

Birth Date** Place of Birth Gender Male

Female

**If you are currently age 60 or over and starting a benefited position, you will be affected by Section 5 of Chapter 32 of the M.G.L. Please bring this fact to the attention of the Benefits Office Staff when you attend the New Employee Orientation.

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleIV/Chapter32/Section5

Educational Data

Educational Level Degree Major School Name Year Awarded

High School/Equivalent

Technical Certificate

College/University

Master’s Level Degree

Doctorate

EMERGENCY CONTACTS Name Address Telephone Relationship

PRIMARY

SECONDARY

PRIOR SERVICE IN ANY MASSACHUSETTS GOVERNMENT AGENCY If retired from any government agency: (CHECK)

Name of Agency From To

“I attest that I have read and understood all of the contents of this form and that all of the information provided on this form is correct and complete to the best of my knowledge."

Signature: Date:

Revised: August 2011 Personal Data Questionnaire

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleIV/Chapter32/Section5

N P

E U

FORM M-4

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

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

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

Employee: File this form or Form W-4 with

your employer. Otherwise, Massachusetts Income Taxes will be withheld from your

wages without exemptions.

Employer: Keep this certificate with your

records. If the employee is believed to have claimed excessive exemptions, the

Massachusetts Department of Revenue should be so advised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. 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 income

will 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

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

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

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

If you work for more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer.

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

B. Changes. You may file a new certificate at any time if the number of exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son’s income indicates that you will not provide 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 not claiming the personal exemption or the age 65 or over exemption, generally you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemptions for your spouse or for any dependents that will not be claimed on your annual tax return.

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

D. Dependent(s). You may claim an exemption in line 3 for each individual who 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 and adjustments” under the Massachusetts withholding system.

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

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.

}

Form W-4 (2017)

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:

• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don’t apply to supplemental wages greater than $1,000,000.

Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or

• You’re married, have only one job, and your spouse doesn’t work; or

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

. . . B

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

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you

have two to four eligible children or less “2” if you have five or more eligible children.

• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” 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

{ • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

For accuracy, complete all

worksheets that apply.

and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

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

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4 Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2017

1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶ 5 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 . . . . . . . . . . . . . . 5 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

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

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

http://www.irs.gov/w4

Form W-4 (2017) Page 2

Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $9,350 if head of household } . . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $

4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $

5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $

6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $

7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $

8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

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

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here.

1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more

than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to

figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4

5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5

6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $

8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $

9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter

the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST

paying job are— Enter on

line 2 above If wages from LOWEST

paying job are— Enter on

line 2 above If wages from HIGHEST

paying job are—

Enter on

line 7 above

If wages from HIGHEST

paying job are—

Enter on

line 7 above $0 - $7,000 0 $0 - $8,000 0 $0 - $75,000 $610 $0 - $38,000 $610

7,001 - 14,000 1 8,001 - 16,000 1 75,001 - 135,000 1,010 38,001 - 85,000 1,010 14,001 - 22,000 2 16,001 - 26,000 2 135,001 - 205,000 1,130 85,001 - 185,000 1,130 22,001 - 27,000 3 26,001 - 34,000 3 205,001 - 360,000 1,340 185,001 - 400,000 1,340 27,001 - 35,000 4 34,001 - 44,000 4 360,001 - 405,000 1,420 400,001 and over 1,600 35,001 - 44,000 5 44,001 - 70,000 5 405,001 and over 1,600 44,001 - 55,000 6 70,001 - 85,000 6 55,001 - 65,000 7 85,001 - 110,000 7 65,001 - 75,000 8 110,001 - 125,000 8 75,001 - 80,000 9 125,001 - 140,000 9 80,001 - 95,000 10 140,001 and over 10 95,001 - 115,000 11

115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

of 3 Form I-9 11/14/2016 N

1. A citizen of the United States

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

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

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:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

Country of Issuance:

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

►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):

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

of 3 Form I-9 11/14/2016 N




USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

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.")

Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status

List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization

Document Title Document Title Document Title

Issuing Authority Issuing Authority Issuing Authority

Document Number Document Number Document Number

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

Document Title

Additional Information QR Code - Sections 2 & 3

Do Not Write In This Space 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) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (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. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

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

of 3 Form I-9 11/14/2016 N

LISTS OF ACCEPTABLE DOCUMENTS

All 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

Documents that Establish

Both Identity and

Employment Authorization

OR

LIST B LIST C

Documents that Establish Documents that Establish

Identity Employment Authorization

AND

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

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

1. A Social Security Account Number

card, unless the card includes one of

the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machine-

readable immigrant visa 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. Employment Authorization Document

that contains a photograph (Form

I-766)

2. Certification of Birth Abroad issued

by the Department of State (Form

FS-545) 3. School ID card with a photograph

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

a. Foreign passport; and

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.

3. Certification of Report of Birth

issued by the Department of State

(Form DS-1350) 4. Voter's registration card

5. U.S. Military card or draft record 4. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document 5. Native American tribal document 9. Driver's license issued by a Canadian

government authority

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

7. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

For persons under age 18 who are

unable to present a document

listed above: 8. Employment authorization

document issued by the


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

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 Instructions 11/14/2016 N Page 1 of 15

Instructions for Form I-9,




USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

Anti-Discrimination Notice. It is illegal to discriminate against work-authorized individuals in hiring, firing, recruitment or

referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's

citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) the employee may

present to establish employment authorization and identity. The employer must allow the employee to choose the documents to

be presented from the Lists of Acceptable Documents, found on the last page of Form I-9. The refusal to hire or continue to

employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at

1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TTY), or visit www.justice.gov/crt/about/osc.

What is the Purpose of This Form?

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new

employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the

Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment

authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011.

General Instructions

Both employers and employees are responsible for completing their respective sections of Form I-9. For the purpose of

completing this form, the term “employer” means all employers, including those recruiters and referrers for a fee who are

agricultural associations, agricultural employers, or farm labor contractors, as defined in section 3 of the Migrant and Seasonal

Agricultural Worker Protection Act, Public Law 97-470 (29 U.S.C. 1802). An “employee” is a person who performs labor or

services in the United States for an employer in return for wages or other remuneration. The term “Employee” does not include

those who do not receive any form of remuneration (volunteers), independent contractors or those engaged in certain casual

domestic employment. Form I-9 has three sections. Employees complete Section 1. Employers complete Section 2 and, when

applicable, Section 3. Employers may be fined if the form is not properly completed. See 8 USC § 1324a and 8 CFR § 274a.10.

Individuals may be prosecuted for knowingly and willfully entering false information on the form. Employers are responsible for

retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or

Immigration and Customs Enforcement (ICE).

These instructions will assist you in properly completing Form I-9. The employer must ensure that all pages of the instructions

and Lists of Acceptable Documents are available, either in print or electronically, to all employees completing this form. When

completing the form on a computer, the English version of the form includes specific instructions for each field and drop-down

lists for universally used abbreviations and acceptable documents. To access these instructions, move the cursor over each field

or click on the question mark symbol ( ) within the field. Employers and employees can also access this full set of

instructions at any time by clicking the Instructions button at the top of each page when completing the form on a computer that

is connected to the Internet.

Employers and employees may choose to complete any or all sections of the form on paper or using a computer, or a

combination of both. Forms I-9 obtained from the USCIS website are not considered electronic Forms I-9 under DHS

regulations and, therefore, cannot be electronically signed. Therefore, regardless of the method you used to enter information

into each field, you must print a hard copy of the form, then sign and date the hard copy by hand where required.

Employers can obtain a blank copy of Form I-9 from the USCIS website at https://www.uscis.gov/sites/default/files/files/form/

i-9.pdf. This form is in portable document format (.pdf) that is fillable and savable. That means that you may download it, or

simply print out a blank copy to enter information by hand. You may also request paper Forms I-9 from USCIS.

Certain features of Form I-9 that allow for data entry on personal computers may make the form appear to be more than two

pages. When using a computer, Form I-9 has been designed to print as two pages. Using more than one preparer and/or

translator will add an additional page to the form, regardless of your method of completion. You are not required to print, retain

or store the page containing the Lists of Acceptable Documents.

http://www.justice.gov/crt/about/osc

http://www.uscis.gov/sites/default/files/files/form/


The form will also populate certain fields with N/A when certain user choices ensure that particular fields will not be

completed. The Print button located at the top of each page that will print any number of pages the user selects. Also, the Start

Over button located at the top of each page will clear all the fields on the form.

The Spanish version of Form I-9 does not include the additional instructions and drop-down lists described above. Employers

in Puerto Rico may use either the Spanish or English version of the form. Employers outside of Puerto Rico must retain the

English version of the form for their records, but may use the Spanish form as a translation tool. Additional guidance to

complete the form may be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274) and on USCIS’

Form I-9 website, I-9 Central.

Completing Section I: Employee Information and Attestation

You, the employee, must complete each field in Section 1 as described below. Newly hired employees must complete and sign

Section 1 no later than the first day of employment. Section 1 should never be completed before you have accepted a job offer.

Entering Your Employee Information

Last Name (Family Name): Enter your full legal last name. Your last name is your family name or surname. If you

have two last names or a hyphenated last name, include both names in the Last Name field. Examples of correctly entered

last names include De La Cruz, O’Neill, Garcia Lopez, Smith-Johnson, Nguyen. If you only have one name, enter it in

this field, then enter “Unknown” in the First Name field. You may not enter “Unknown” in both the Last Name field and

the First Name field.

First Name (Given Name): Enter your full legal first name. Your first name is your given name. Some examples of

correctly entered first names include Jessica, John-Paul, Tae Young, D’Shaun, Mai. If you only have one name, enter it

in the Last Name field, then enter “Unknown” in this field. You may not enter “Unknown” in both the First Name field

and the Last Name field.

Middle Initial: Your middle initial is the first letter of your second given name, or the first letter of your middle name, if

any. If you have more than one middle name, enter the first letter of your first middle name. If you do not have a middle

name, enter N/A in this field.

Other Last Names Used: Provide all other last names used, if any (e.g., maiden name). Enter N/A if you have not used

other last names. For example, if you legally changed your last name from Smith to Jones, you should enter the name

Smith in this field.

Address (Street Name and Number): Enter the street name and number of the current address of your residence. If

you are a border commuter from Canada or Mexico, you may enter your Canada or Mexico address in this field. If your

residence does not have a physical address, enter a description of the location of your residence, such as “3 miles

southwest of Anytown post office near water tower.”

Apartment: Enter the number(s) or letter(s) that identify(ies) your apartment. If you do not live in an apartment, enter N/A.

City or Town: Enter your city, town or village in this field. If your residence is not located in a city, town or village, enter

your county, township, reservation, etc., in this field. If you are a border commuter from Canada, enter your city and

province in this field. If you are a border commuter from Mexico, enter your city and state in this field.

State: Enter the abbreviation of your state or territory in this field. If you are a border commuter from Canada or Mexico,

enter your country abbreviation in this field.

ZIP Code: Enter your 5-digit ZIP code. If you are a border commuter from Canada or Mexico, enter your

5- or 6-digit postal code in this field.

Date of Birth: Enter your date of birth as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example,

enter January 8, 1980 as 01/08/1980.

U.S. Social Security Number: Providing your 9-digit Social Security number is voluntary on Form I-9 unless your

employer participates in E-Verify. If your employer participates in E-Verify and:

1. You have been issued a Social Security number, you must provide it in this field; or

2. You have applied for, but have not yet received a Social Security number, leave this field blank until you receive

a Social Security number.


Employee’s E-mail Address (Optional): Providing your e-mail address is optional on Form I-9, but the field cannot be left

blank. To enter your e-mail address, use this format: name@site .domain. One reason Department of Homeland Security (DHS)

may e-mail you is if your employer uses E-Verify and DHS learns of a potential mismatch between the information provided and

the information in government records. This e-mail would contain information on how to begin to resolve the potential mismatch.

You may use either your personal or work e-mail address in this field. Enter N/A if you do not enter your e-mail address.

Employee’s Telephone Number (Optional): Providing your telephone number is optional on Form I-9, but the field

cannot be left blank. If you enter your area code and telephone number, use this format: 000-000-0000. Enter N/A if you do

not enter your telephone number.

Attesting to Your Citizenship or Immigration Status

You must select one box to attest to your citizenship or immigration status.

1. A citizen of the United States.

2. A noncitizen national of the United States: An individual born in American Samoa, certain former citizens of the

former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

3. A lawful permanent resident: An individual who is not a U.S. citizen and who resides in the United States under legally

recognized and lawfully recorded permanent residence as an immigrant. This term includes conditional residents. Asylees and

refugees should not select this status, but should instead select "An Alien authorized to work" below.

If you select “lawful permanent resident,” enter your 7- to 9-digit Alien Registration Number (A-Number), including the

“A,” or USCIS Number in the space provided. When completing this field using a computer, use the dropdown provided

to indicate whether you have entered an Alien Number or a USCIS Number. At this time, the USCIS Number is the same

as the A-Number without the “A” prefix.

4. An alien authorized to work: An individual who is not a citizen or national of the United States, or a lawful permanent

resident, but is authorized to work in the United States.

If you select this box, enter the date that your employment authorization expires, if any, in the space provided. In most cases,

your employment authorization expiration date is found on the document(s) evidencing your employment authorization.

Refugees, asylees and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau,

and other aliens whose employment authorization does not have an expiration date should enter N/A in the Expiration Date

field. In some cases, such as if you have Temporary Protected Status, your employment authorization may have been

automatically extended; in these cases, you should enter the expiration date of the automatic extension in this space.

Aliens authorized to work must enter one of the following to complete Section1:

1. Alien Registration Number (A-Number)/USCIS Number; or

2. Form I-94 Admission Number; or

3. Foreign Passport Number and the Country of Issuance

Your employer may not ask you to present the document from which you supplied this information.

Alien Registration Number/USCIS Number: Enter your 7- to 9-digit Alien Registration Number (A-Number),

including the “A,” or your USCIS Number in this field. At this time, the USCIS Number is the same as your

A-Number without the “A” prefix. When completing this field using a computer, use the dropdown provided to indicate

whether you have entered an Alien Number or a USCIS Number. If you do not provide an A-Number or USCIS Number,

enter N/A in this field then enter either a Form I-94 Admission Number, or a Foreign Passport and Country of Issuance in

the fields provided.

Form I-94 Admission Number: Enter your 11-digit I-94 Admission Number in this field. If you do not provide an I-94

Admission Number, enter N/A in this field, then enter either an Alien Registration Number/USCIS Number or a Foreign

Passport Number and Country of Issuance in the fields provided.

Foreign Passport Number: Enter your Foreign Passport Number in this field. If you do not provide a Foreign Passport

Number, enter N/A in this field, then enter either an Alien Number/USCIS Number or a I-94 Admission Number in the

fields provided.

Country of Issuance: If you entered your Foreign Passport Number, enter your Foreign Passport’s Country of Issuance. If

you did not enter your Foreign Passport Number, enter N/A.


Signature of Employee: After completing Section 1, sign your name in this field. If you used a form obtained from the

USCIS website, you must print the form to sign your name in this field. By signing this form, you attest under penalty of

perjury (28 U.S.C. § 1746) that the information you provided, along with the citizenship or immigration status you selected,

and all information and documentation you provide to your employer, is complete, true and correct, and you are aware that you

may face severe penalties provided by law and may be subject to criminal prosecution for knowingly and willfully making

false statements or using false documentation when completing this form. Further, falsely attesting to U.S. citizenship may

subject employees to penalties, removal proceedings and may adversely affect an employee's ability to seek future immigration

benefits. If you cannot sign your name, you may place a mark in this field to indicate your signature. Employees who use a

preparer or translator to help them complete the form must still sign or place a mark in the Signature of Employee field on the

printed form.

If you used a preparer, translator, and other individual to assist you in completing Form I-9:

Both you and your preparer(s) and/or translator(s) must complete the appropriate areas of Section 1, and then sign

Section 1. If Section 1 was completed on a form obtained from the USCIS website, the form must be printed to sign

these fields. You and your preparer(s) and/or translator(s) also should review the instructions for Completing the

Preparer and/or Translator Certification below.

If the employee is a minor (individual under 18) who cannot present an identity document, the employee's parent or

legal guardian can complete Section 1 for the employee and enter “minor under age 18” in the signature field. If Section

1 was completed on a form obtained from the USCIS website, the form must be printed to enter this information. The

minor's parent or legal guardian should review the instructions for Completing the Preparer and/or Translator

Certification below. Refer to the Handbook for Employers: Guidance for Completing Form I-9 (M-274) for more

guidance on completion of Form I-9 for minors. If the minor's employer participates in E-Verify, the employee must

present a list B identity document with a photograph to complete Form I-9

If the employee is a person with a disability (who is placed in employment by a nonprofit organization, association or as

part of a rehabilitation program) who cannot present an identity document, the employee's parent, legal guardian or a

representative of the nonprofit organization, association or rehabilitation program can complete Section 1 for the

employee and enter “Special Placement” in this field. If Section 1 was completed on a form obtained from the USCIS

website, the form must be printed to enter this information. The parent, legal guardian or representative of the nonprofit

organization, association or rehabilitation program completing Section 1 for the employee should review the

instructions for Completing the Preparer and/or Translator Certification below. Refer to the Handbook for Employers:

Guidance for Completing Form I-9 (M-274) for more guidance on completion of Form I-9 for certain employees with

disabilities.

Today's Date: Enter the date you signed Section 1 in this field. Do not backdate this field. Enter the date as a 2-digit month,

2-digit day and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014. A preparer or translator who

assists the employee in completing Section 1 may enter the date the employee signed or made a mark to sign Section 1 in this

field. Parents or legal guardians assisting minors (individuals under age 18) and parents, legal guardians or representatives of a

nonprofit organization, association or rehabilitation program assisting certain employees with disabilities must enter the date

they completed Section 1 for the employee.

Completing the Preparer and/or Translator Certification

If you did not use a preparer or translator to assist you in completing Section 1, you, the employee, must check the box marked

I did not use a Preparer or Translator. If you check this box, leave the rest of the fields in this area blank.

If one or more preparers and/or translators assist the employee in completing the form using a computer, the preparer and/or

translator must check the box marked “A preparer(s) and/or translator(s) assisted the employee in completing Section 1” ,

then select the number of Certification areas needed from the dropdown provided. Any additional Certification areas generated

will result in an additional page. Form I-9 Supplement, Section 1 Preparer and/or Translator Certification can be separately

downloaded from the USCIS Form I-9 webpage, which provides additional Certification areas for those completing Form I-9

using a computer who need more Certification areas than the 5 provided or those who are completing Form I-9 on paper. The

first preparer and/or translator must complete all the fields in the Certification area on the same page the employee has signed.

There is no limit to the number of preparers and/or translators an employee can use, but each additional preparer and/or

translator must complete and sign a separate Certification area. Ensure the employee's last name, first name and middle initial

are entered at the top of any additional pages. The employer must ensure that any additional pages are retained with the

employee's completed Form I-9.


Signature of Preparer or Translator: Any person who helped to prepare or translate Section 1of Form I-9 must sign his or

her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this

field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement”

is entered in lieu of the employee’s signature in Section 1.

Today's Date: The person who signs the Preparer and/or Translator Certification must enter the date he or she signs in this

field on the printed form. Do not backdate this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/

yyyy). For example, enter January 8, 2014 as 01/08/2014.

Last Name (Family Name): Enter the full legal last name of the person who helped the employee in preparing or translating

Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a

hyphenated last name, include both names in this field.

First Name (Given Name): Enter the full legal first name of the person who helped the employee in preparing or translating

Section 1 in this field. The first name is also the given name.

Address (Street Name and Number): Enter the street name and number of the current address of the residence of the person

who helped the employee in preparing or translating Section 1 in this field. Addresses for residences in Canada or Mexico may

be entered in this field. If the residence does not have a physical address, enter a description of the location of the residence,

such as “3 miles southwest of Anytown post office near water tower.” If the residence is an apartment, enter the apartment

number in this field.

City or Town: Enter the city, town or village of the residence of the person who helped the employee in preparing or

translating Section 1 in this field. If the residence is not located in a city, town or village, enter the name of the county,

township, reservation, etc., in this field. If the residence is in Canada, enter the city and province in this field. If the residence is

in Mexico, enter the city and state in this field.

State: Enter the abbreviation of the state, territory or country of the preparer or translator’s residence in this field.

ZIP Code: Enter the 5-digit ZIP code of the residence of the person who helped the employee in preparing or translating

Section 1 in this field. If the preparer or translator's residence is in Canada or Mexico, enter the 5- or 6-digit postal code.

Presenting Form I-9 Documents

Within 3 business days of starting work for pay, you must present to your employer documentation that establishes your

identity and employment authorization. For example, if you begin employment on Monday, you must present documentation

on or before Thursday of that week. However, if you were hired to work for less than 3 business days, you must present

documentation no later than the end of the first day of employment.

Choose which unexpired document(s) to present to your employer from the Lists of Acceptable Documents. An employer

cannot specify which document(s) you may present from the Lists of Acceptable Documents. You may present either one

selection from List A or a combination of one selection from List B and one selection from List C. Some List A documents,

which show both identity and employment authorization, are combination documents that must be presented together to be

considered a List A document: for example, the foreign passport together with a Form I-94 containing an endorsement of the

alien’s nonimmigrant status and employment authorization with a specific employer incident to such status. List B documents

show identity only and List C documents show employment authorization only. If your employer participates in E-Verify and

you present a List B document, the document must contain a photograph. If you present acceptable List A documentation, you

should not be asked to present, nor should you provide, List B and List C documentation. If you present acceptable List B and

List C documentation, you should not be asked to present, nor should you provide, List A documentation. If you are unable to

present a document(s) from these lists, you may be able to present an acceptable receipt. Refer to the Receipts section below.

Your employer must review the document(s) you present to complete Form I-9. If your document(s) reasonably appears to be

genuine and to relate to you, your employer must accept the documents. If your document(s) does not reasonably appear to be

genuine or to relate to you, your employer must reject it and provide you with an opportunity to present other documents from

the Lists of Acceptable Documents. Your employer may choose to make copies of your document(s), but must return the

original(s) to you. Your employer must review your documents in your physical presence.


Your employer will complete the other parts of this form, as well as review your entries in Section 1. Your employer may ask

you to correct any errors found. Your employer is responsible for ensuring all parts of Form I-9 are properly completed and is

subject to penalties under federal law if the form is not completed correctly.

Minors (individuals under age 18) and certain employees with disabilities whose parent, legal guardian or representative

completed Section 1 for the employee are only required to present an employment authorization document from List C. Refer to

the Handbook for Employers: Guidance for Completing Form I-9 (M-274) for more guidance on minors and certain individuals

with disabilities.

Receipts

If you do not have unexpired documentation from the Lists of Acceptable Documents, you may be able to present a receipt(s) in

lieu of an acceptable document(s). New employees who choose to present a receipt(s) must do so within three business days of

their first day of employment. If your employer is reverifying your employment authorization, and you choose to present a

receipt for reverification, you must present the receipt by the date your employment authorization expires. Receipts are not

acceptable if employment lasts fewer than three business days.

There are three types of acceptable receipts:

1. A receipt showing that you have applied to replace a document that was lost, stolen or damaged. You must present the

actual document within 90 days from the date of hire or, in the case of reverification, within 90 days from the date your

original employment authorization expires.

2. The arrival portion of Form I-94/I-94A containing a temporary I-551 stamp and a photograph of the individual. You must

present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary I-551 stamp, or, if there is

no expiration date, within 1 year from the date of admission.

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. You must present an unexpired Employment

Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security Card

within 90 days from the date of hire or, in the case of reverification, within 90 days from the date your original employment

authorization expires.

Receipts showing that you have applied for an initial grant of employment authorization, or for renewal of your expiring or

expired employment authorization, are not acceptable.

Completing Section 2: Employer or Authorized Representative Review and Verification

You, the employer, must ensure that all parts of Form I-9 are properly completed and may be subject to penalties under federal

law if the form is not completed correctly. Section 1 must be completed no later than the end of the employee’s first day of

employment. You may not ask an individual to complete Section 1 before he or she has accepted a job offer. Before completing

Section 2, you should review Section 1 to ensure the employee completed it properly. If you find any errors in Section 1, have

the employee make corrections, as necessary and initial and date any corrections made.

You or your authorized representative must complete Section 2 by examining evidence of identity and employment

authorization within 3 business days of the employee’s first day of employment. For example, if an employee begins

employment on Monday, you must review the employee's documentation and complete Section 2 on or before Thursday of that

week. However, if you hire an individual for less than 3 business days, Section 2 must be completed no later than the end of the

first day of employment.

Entering Employee Information from Section 1

This area, titled, “Employee Info from Section 1” contains fields to enter the employee's last name, first name, middle initial

exactly as he or she entered them in Section 1. This area also includes a Citizenship/Immigration Status field to enter the

number of the citizenship or immigration status checkbox the employee selected in Section 1. These fields help to ensure that

the two pages of an employee's Form I-9 remain together. When completing Section 2 using a computer, the number entered in

the Citizenship/Immigration Status field provides drop-downs that directly relate to the employee's selected citizenship or

immigration status.


Entering Documents the Employee Presents

You, the employer or authorized representative, must physically examine, in the employee's physical presence, the unexpired

document(s) the employee presents from the Lists of Acceptable Documents to complete the Document fields in Section 2.

You cannot specify which document(s) an employee may present from these lists. If you discriminate in the Form I-9 process

based on an individual's citizenship status, immigration status, or national origin, you may be in violation of the law and subject

to sanctions such as civil penalties and be required to pay back pay to discrimination victims. A document is acceptable as long

as it reasonably appears to be genuine and to relate to the person presenting it. Employees must present one selection from List

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

List A documents show both identity and employment authorization. Some List A documents are combination documents that

must be presented together to be considered a List A document, such as a foreign passport together with a Form I-94 containing

an endorsement of the alien’s nonimmigrant status.

List B documents show identity only, and List C documents show employment authorization only. If an employee presents a List

A document, do not ask or require the employee to present List B and List C documents, and vice versa. If an employer

participates in E-Verify and the employee presents a List B document, the List B document must include a photograph.

If an employee presents a receipt for the application to replace a lost, stolen or damaged document, the employee must present

the replacement document to you within 90 days of the first day of work for pay, or in the case of reverification, within 90 days

of the date the employee's employment authorization expired. Enter the word “Receipt” followed by the title of the receipt in

Section 2 under the list that relates to the receipt.

When your employee presents the replacement document, draw a line through the receipt, then enter the information from the

new document into Section 2. Other receipts may be valid for longer or shorter periods, such as the arrival portion of Form I-94/

I-94A containing a temporary I-551 stamp and a photograph of the individual, which is valid until the expiration date of the

temporary I-551 stamp or, if there is no expiration date, valid for one year from the date of admission.

Ensure that each document is an unexpired, original (no photocopies, except for certified copies of birth certificates) document.

Certain employees may present an expired employment authorization document, which may be considered unexpired, if the

employee's employment authorization has been extended by regulation or a Federal Register Notice. Refer to the Handbook for

Employers: Guidance for Completing Form I-9 (M-274) or I-9 Central for more guidance on these special situations.

Refer to the M-274 for guidance on how to handle special situations, such as students (who may present additional documents

not specified on the Lists) and H-1B and H-2A nonimmigrants changing employers.

Minors (individuals under age 18) and certain employees with disabilities whose parent, legal guardian or representative

completed Section 1 for the employee are only required to present an employment authorization document from List C. Refer to

the M-274 for more guidance on minors and certain persons with disabilities. If the minor's employer participates in E-Verify,

the minor employee also must present a List B identity document with a photograph to complete Form I-9.

You must return original document(s) to the employee, but may make photocopies of the document(s) reviewed. Photocopying

documents is voluntary unless you participate in E-Verify. E-Verify employers are only required to photocopy certain

documents. If you are an E-Verify employer who chooses to photocopy documents other than those you are required to

photocopy, you should apply this policy consistently with respect to Form I-9 completion for all employees. For more

information on the types of documents that an employer must photocopy if the employer uses E-Verify, visit E-Verify’s website

at www.dhs.gov/e-verify. For non-E-Verify employers, if photocopies are made, they should be made consistently for ALL new

hires and reverified employees.

Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or another federal government

agency. You must always complete Section 2 by reviewing original documentation, even if you photocopy an employee’s

document(s) after reviewing the documentation. Making photocopies of an employee’s document(s) cannot take the place of

completing Form I-9. You are still responsible for completing and retaining Form I-9.

http://www.dhs.gov/e-verify


List A - Identity and Employment Authorization: If the employee presented an acceptable document(s) from List A or an

acceptable receipt for a List A document, enter the document(s) information in this column. If the employee presented a List A

document that consists of a combination of documents, enter information from each document in that combination in a separate

area under List A as described below. All documents must be unexpired. If you enter document information in the List A

column, you should not enter document information in the List B or List C columns. If you complete Section 2 using a

computer, a selection in List A will fill all the fields in the Lists B and C columns with N/A.

Document Title: If the employee presented a document from List A, enter the title of the List A document or receipt in this

field. The abbreviations provided are available in the dropdown when the form is completed on a computer. When completing the

form on paper, you may choose to use these abbreviations or any other common abbreviation to enter the document title or issuing

authority. If the employee presented a combination of documents, use the second and third Document Title fields as necessary.

Full name of List A Document Abbreviations

U.S. Passport U.S. Passport

U.S. Passport Card U.S. Passport Card

Permanent Resident Card (Form I-551) Perm. Resident Card (Form I-551)

Alien Registration Receipt Card (Form I-551) Alien Reg.Receipt Card (Form I-551)

Foreign passport containing a temporary I-551 stamp 1. Foreign Passport

2. Temporary I-551 Stamp Foreign passport containing a temporary I-551 printed

notation on a machine-readable immigrant visa (MRIV) 1. Foreign Passport

2. Machine-readable immigrant visa (MRIV)

Employment Authorization Document (Form I-766) Employment Auth. Document (Form I-766)

For a nonimmigrant alien authorized to work for a specific

employer because of his or her status, a foreign passport

with Form I/94/I-94A that contains an endorsement of the

alien's nonimmigrant status

1. Foreign Passport, work-authorized non-

immigrant

2. Form I-94/I94A

3. "Form I-20" or "Form DS-2019"

Note: In limited circumstances, certain J-1

students may be required to present a letter

from their Responsible Officer in order to work.

Enter the document title, issuing authority,

document number and expiration date from this

document in the Additional Information field.

Passport from the Federated States of Micronesia (FSM)

with Form I-94/I-94A 1. FSM Passport with Form I-94

2. Form I-94/I94A Passport from the Republic of the Marshall Islands (RMI)

with Form I-94/I94A 1. RMI Passport with Form I-94

2. Form I-94/I94A Receipt: The arrival portion of Form I-94/I-94A containing a

temporary I-551 stamp and photograph

Receipt: Form I-94/I-94A w/I-551 stamp, photo

Receipt: The departure portion of Form I-94/I-94A

with an unexpired refugee admission stamp

Receipt: Form I-94/I-94A w/refugee stamp

Receipt for an application to replace a lost, stolen or

damaged Permanent Resident Card (Form I-551) Receipt replacement Perm. Res. Card

(Form I-551) Receipt for an application to replace a lost, stolen or

damaged Employment Authorization Document (Form I-766)

Receipt replacement EAD (Form I-766)

Receipt for an application to replace a lost, stolen or

damaged foreign passport with Form I-94/I-94A that contains

an endorsement of the alien's nonimmigrant status

1. Receipt: Replacement Foreign Passport,

work-authorized nonimmigrant

2. Receipt: Replacement Form I-94/I-94A

3. Form I-20 or Form DS-2019, if presented Receipt for an application to replace a lost, stolen or

damaged passport from the Federated States of Micronesia

with Form I-94/I-94A

1. Receipt: Replacement FSM Passport with

Form I-94

2. Receipt: Replacement Form I-94/I-94A Receipt for an application to replace a lost, stolen or

damaged passport from the Republic of the Marshall Islands

with Form I-94/I-94A

1. Receipt: Replacement RMI Passport

with Form I-94

2. Receipt: Replacement Form I-94/I-94A

Issuing Authority: Enter the issuing authority of the List A document or receipt. The issuing authority is the specific

entity that issued the document. If the employee presented a combination of documents, use the second and third Issuing

Authority fields as necessary.


Document Number: Enter the document number, if any, of the List A document or receipt presented. If the document

does not contain a number, enter N/A in this field. If the employee presented a combination of documents, use the second

and third Document Number fields as necessary. If the document presented was a Form I-20 or DS-2019, enter the

Student and Exchange Visitor Information System (SEVIS) number in the third Document Number field exactly as it

appears on the Form I-20 or the DS-2019.

Expiration Date (if any) (mm/dd/yyyy): Enter the expiration date, if any, of the List A document. The document is not

acceptable if it has already expired. If the document does not contain an expiration date, enter N/A in this field. If the

document uses text rather than a date to indicate when it expires, enter the text as shown on the document, such as “D/

S”(which means, “duration of status”). For a receipt, enter the expiration date of the receipt validity period as described

above. If the employee presented a combination of documents, use the second and third Expiration Date fields as

necessary. If the document presented was a Form I-20 or DS-2019, enter the program end date here.

List B - Identity: If the employee presented an acceptable document from List B or an acceptable receipt for the application to

replace a lost, stolen, or destroyed List B document, enter the document information in this column. If a parent or legal guardian

attested to the identity of an employee who is an individual under age 18 or certain employees with disabilities in Section 1,

enter either "Individual under age 18" or "Special Placement" in this field. Refer to the Handbook for Employers: Guidance for

Completing Form I-9 (M-274) for more guidance on individuals under age 18 and certain person with disabilities.

If you enter document information in the List B column, you must also enter document information in the List C column. If an

employee presents acceptable List B and List C documents, do not ask the employees to present a List A document. No entries

should be made in the List A column. If you complete Section 2 using a computer, a selection in List B will fill all the fields in

the List A column with N/A.

Document Title: If the employee presented a document from List B, enter the title of the List B document or receipt in this

field. The abbreviations provided are available in the dropdown when the form is completed on a computer. When completing the

form on paper, you may choose to use these abbreviations or any other common abbreviations to document the document title or

issuing authority.

Full name of List B Document Abbreviations Driver's license issued by a State or outlying possession of

the United States

Driver's license issued by state/territory

ID card issued by a State or outlying possession of the

United States

ID card issued by state/territory

ID card issued by federal, state, or local government

agencies or entities

Government ID

School ID card with photograph School ID

Voter's registration card Voter registration card

U.S. Military card U.S. Military card

U.S. Military draft record U.S. Military draft record

Military dependent's ID card Military dependent's ID card

U.S. Coast Guard Merchant Mariner Card USCG Merchant Mariner card

Native American tribal document Native American tribal document

Driver's license issued by a Canadian government authority Canadian driver's license School record (for persons under age 18 who are unable to

present a document listed above)

School record (under age 18)

Report card (for persons under age 18 who are unable to


Report Card (under age 18)

Clinic record (for persons under age 18 who are unable to


Clinic record (under age 18)

Doctor record (for persons under age 18 who are unable to


Doctor record (under age 18)

Hospital record (for persons under age 18 who are unable to


Hospital record (under age 18)

Day-care record (for persons under age 18 who are unable to


Day-care record (under age 18)

Nursery school record (for persons under age 18 who are

unable to present a document listed above)

Nursery school record (under age 18)


Full name of List B Document Abbreviations

Individual under age 18 endorsement by parent or guardian Individual under Age 18

Special placement endorsement for persons with disabilities Special Placement

Receipt for the application to replace a lost, stolen or

damaged Driver's License issued by a State or outlying

possession of the United States

Receipt: Replacement driver's license


damaged ID card issued by a State or outlying possession of

the United States

Receipt: Replacement ID card


damaged ID card issued by federal, state, or local

government agencies or entities

Receipt: Replacement Gov't ID


damaged School ID card with photograph

Receipt: Replacement School ID


damaged Voter's registration card

Receipt: Replacement Voter reg. card


damaged U.S. Military card

Receipt: Replacement U.S. Military card


damaged Military dependent's ID card

Receipt: Replacement U.S. Military dep. card


damaged U.S. Military draft record Receipt: Replacement Military draft

record Receipt for the application to replace a lost, stolen or

damaged U.S. Coast Guard Merchant Mariner Card

Receipt: Replacement Merchant Mariner card


damaged Driver's license issued by a Canadian government

authority

Receipt: Replacement Canadian DL


damaged Native American tribal document Receipt: Replacement Native American

tribal doc Receipt for the application to replace a lost, stolen or

damaged School record (for persons under age 18 who are


Receipt: Replacement School record

(under age 18)


damaged Report card (for persons under age 18 who are


Receipt: Replacement Report card

(under age 18)


damaged Clinic record (for persons under age 18 who are


Receipt: Replacement Clinic record

(under age 18)


damaged Doctor record (for persons under age 18 who are


Receipt: Replacement Doctor record

(under age 18)


damaged Hospital record (for persons under age 18 who are


Receipt: Replacement Hospital record

(under age 18)


damaged Day-care record (for persons under age 18 who

are unable to present a document listed above)

Receipt: Replacement Day-care record

(under age 18)


damaged Nursery school record (for persons under age 18

who are unable to present a document listed above)

Receipt: Replacement Nursery school record

(under age 18)

Issuing Authority: Enter the issuing authority of the List B document or receipt. The issuing authority is the entity that

issued the document. If the employee presented a document that is issued by a state agency, include the state as part of

the issuing authority.

Document Number: Enter the document number, if any, of the List B document or receipt exactly as it appears on the

document. If the document does not contain a number, enter N/A in this field.

Expiration Date (if any) (mm/dd/yyyy): Enter the expiration date, if any, of the List B document. The document is not

acceptable if it has already expired. If the document does not contain an expiration date, enter N/A in this field. For a

receipt, enter the expiration date of the receipt validity period as described in the Receipt section above.


List C - Employment Authorization: If the employee presented an acceptable document from List C, or an acceptable

receipt for the application to replace a lost, stolen, or destroyed List C document, enter the document information in this

column. If you enter document information in the List C column, you must also enter document information in the List B

column. If an employee presents acceptable List B and List C documents, do not ask the employee to present a list A document.

No entries should be made in the List A column.

Document Title: If the employee presented a document from List C, enter the title of the List C document or receipt in

this field. The abbreviations provided are available in the dropdown when the form is completed on a computer. When

completing the form on paper, you may choose to use these abbreviations or any other common abbreviations to document

the document title or issuing authority. If you are completing the form on a computer, and you select an Employment

authorization document issued by DHS, the field will populate with List C#8 and provide a space for you to enter a

description of the documentation the employee presented. Refer to the M-274 for guidance on entering List C #8

documentation.

Full name of List C Document Abbreviations

Social Security Account Number card without restrictions (Unrestricted) Social Security Card

Certification of Birth Abroad (Form FS-545) Form FS-545

Certification of Report of Birth (Form DS-1350) Form DS-1350

Original or certified copy of a U.S. birth certificate bearing an

official seal

Birth Certificate

Native American tribal document Native American tribal document

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

Identification Card for use of Resident Citizen in the United

States (Form I-179)

Form I-179

Employment authorization document issued by DHS (List C #8) Employment Auth. document (DHS) List C #8 Receipt for the application to replace a lost, stolen or

damaged Social Security Account Number Card without

restrictions

Receipt: Replacement Unrestricted SS

Card


damaged Original or certified copy of a U.S. birth certificate

bearing an official seal

Receipt: Replacement Birth Certificate


damaged Native American Tribal Document Receipt: Replacement Native American Tribal

Doc.

Receipt for the application to replace a lost, stolen or damaged

Employment Authorization Document issued by DHS Receipt: Replacement Employment Auth. Doc.

(DHS)

Issuing Authority: Enter the issuing authority of the List C document or receipt. The issuing authority is the entity that

issued the document.

Document Number: Enter the document number, if any, of the List C document or receipt exactly as it appears on the

document. If the document does not contain a number, enter N/A in this field.

Expiration Date (if any) (mm/dd/yyyy): Enter the expiration date, if any, of the List C document. The document is not

acceptable if it has already expired, unless USCIS has extended the expiration date on the document. For instance, if a

conditional resident presents a Form I-797 extending his or her conditional resident status with the employee's expired Form

I-551, enter the future expiration date as indicated on the Form I-797. If the document has no expiration date, enter N/A in

this field. For a receipt, enter the expiration date of the receipt validity period as described in the Receipt section above.

Additional Information: Use this space to notate any additional information required for Form I-9 such as:

Employment authorization extensions for Temporary Protected Status beneficiaries, F-1 OPT STEM students, CAP-

GAP, H-1B and H-2A employees continuing employment with the same employer or changing employers, and other

nonimmigrant categories that may receive extensions of stay

Additional document(s) that certain nonimmigrant employees may present

Discrepancies that E-Verify employers must notate when participating in the IMAGE program

Employee termination dates and form retention dates

E-Verify case number, which may also be entered in the margin or attached as a separate sheet per E-Verify

requirements and your chosen business process.

Any other comments or notations necessary for the employer's business process

You may leave this field blank if the employee's circumstances do not require additional notations.


Entering Information in the Employer Certification

Employee's First Day of Employment: Enter the employee's first day of employment as a 2-digit month, 2-digit day and

4-digit year (mm/dd/yyyy).

Signature of Employer or Authorized Representative: Review the form for accuracy and completeness. The person who

physically examines the employee's original document(s) and completes Section 2 must sign his or her name in this field. If you

used a form obtained from the USCIS website, you must print the form to sign your name in this field. By signing Section 2,

you attest under penalty of perjury (28 U.S.C. § 1746) that you have physically examined the documents presented by the

employee, the document(s) reasonably appear to be genuine and to relate to the employee named, that to the best of your

knowledge the employee is authorized to work in the United States, that the information you entered in Section 2 is complete,

true and correct to the best of your knowledge, and that you are aware that you may face severe penalties provided by law and

may be subject to criminal prosecution for knowingly and willfully making false statements or knowingly accepting false

documentation when completing this form.

Today's Date: The person who signs Section 2 must enter the date he or she signed Section 2 in this field. Do not backdate this

field. If you used a form obtained from the USCIS website, you must print the form to write the date in this field. Enter the date

as a 2-digit month, 2-digit day and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

Title of Employer or Authorized Representative: Enter the title, position or role of the person who physically examines the

employee's original document(s), completes and signs Section 2.

Last Name of the Employer or Authorized Representative: Enter the full legal last name of the person who physically

examines the employee’s original documents, completes and signs Section 2. Last name refers to family name or surname. If

the person has two last names or a hyphenated last name, include both names in this field.

First Name of the Employer or Authorized Representative: Enter the full legal first name of the person who physically

examines the employee’s original documents, completes, and signs Section 2. First name refers to the given name.

Employer’s Business or Organization Name: Enter the name of the employer’s business or organization in this field.

Employer’s Business or Organization Address (Street Name and Number): Enter an actual, physical address of the

employer. If your company has multiple locations, use the most appropriate address that identifies the location of the employer.

Do not provide a P.O. Box address.

City or Town: Enter the city or town for the employer’s business or organization address. If the location is not a city or town,

you may enter the name of the village, county, township, reservation, etc. that applies.

State: Enter the two-character abbreviation of the state for the employer’s business or organization address.

ZIP Code: Enter the 5-digit ZIP code for the employer’s business or organization address.

Completing Section 3: Reverification and Rehires

Section 3 applies to both reverification and rehires. When completing this section, you must also complete the Last Name, First

Name and Middle Initial fields in the Employee Info from Section 1 area at the top of Section 2, leaving the Citizenship/

Immigration Status field blank. When completing Section 3 in either a reverification or rehire situation, if the employee’s name

has changed, record the new name in Block A.

Reverification

Reverification in Section 3 must be completed prior to the earlier of:

The expiration date, if any, of the employment authorization stated in Section 1, or

The expiration date, if any, of the List A or List C employment authorization document recorded in Section 2

(with some exceptions listed below).

Some employees may have entered “N/A” in the expiration date field in Section 1 if they are aliens whose employment

authorization does not expire, e.g. asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the

Marshall Islands, or Palau. Reverification does not apply for such employees unless they choose to present evidence of

employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766,

Employment Authorization Document.

You should not reverify U.S. citizens and noncitizen nationals, or lawful permanent residents (including conditional residents)

who presented a Permanent Resident Card (Form I-551). Reverification does not apply to List B documents.


For reverification, an employee must present an unexpired document(s) (or a receipt) from either List A or List C showing he or

she is still authorized to work. You CANNOT require the employee to present a particular document from List A or List C. The

employee is also not required to show the same type of document that he or she presented previously. See specific instructions

on how to complete Section 3 below.

Rehires

If you rehire an employee within three years from the date that the Form I-9 was previously executed, you may either rely on

the employee’s previously executed Form I-9 or complete a new Form I-9.

If you choose to rely on a previously completed Form I-9, follow these guidelines.

If the employee remains employment authorized as indicated on the previously executed Form I-9, the employee does

not need to provide any additional documentation. Provide in Section 3 the employee’s rehire date, any name changes if

applicable, and sign and date the form.

If the previously executed Form I-9 indicates that the employee’s employment authorization from Section 1 or

employment authorization documentation from Section 2 that is subject to reverification has expired, then

reverification of employment authorization is required in Section 3 in addition to providing the rehire date. If the

previously executed Form I-9 is not the current version of the form, you must complete Section 3 on the current

version of the form.

If you already used Section 3 of the employee’s previously executed Form I-9, but are rehiring the employee within

three years of the original execution of Form I-9, you may complete Section 3 on a new Form I-9 and attach it to the

previously executed form.

Employees rehired after three years of original execution of the Form I-9 must complete a new Form I-9.

Complete each block in Section 3 as follows:

Block A - New Name: If an employee who is being reverified or rehired has also changed his or her name since originally

completing Section 1 of this form, complete this block with the employee’s new name. Enter only the part of the name that has

changed, for example: if the employee changed only his or her last name, enter the last name in the Last Name field in this

Block, then enter N/A in the First Name and Middle Initial fields. If the employee has not changed his or her name, enter N/A in

each field of Block A.

Block B - Date of Rehire: Complete this block if you are rehiring an employee within three years of the date Form I-9 was

originally executed. Enter the date of rehire in this field. Enter N/A in this field if the employee is not being rehired.

Block C - Complete this block if you are reverifying expiring or expired employment authorization or employment

authorization documentation of a current or rehired employee. Enter the information from the List A or List C document(s) (or

receipt) that the employee presented to reverify his or her employment authorization. All documents must be unexpired.

Document Title: Enter the title of the List A or C document (or receipt) the employee has presented to show continuing

employment authorization in this field.

Document Number: Enter the document number, if any, of the document you entered in the Document Title field

exactly as it appears on the document. Enter N/A if the document does not have a number.

Expiration Date (if any) (mm/dd/yyyy): Enter the expiration date, if any, of the document you entered in the

Document Title field as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). If the document does not contain an

expiration date, enter N/A in this field.

Signature of Employer or Authorized Representative: The person who completes Section 3 must sign in this field. If you

used a form obtained from the USCIS website, you must print Section 3 of the form to sign your name in this field. By signing

Section 3, you attest under penalty of perjury (28 U.S.C. §1746) that you have examined the documents presented by the

employee, that the document(s) reasonably appear to be genuine and to relate to the employee named, that to the best of your

knowledge the employee is authorized to work in the United States, that the information you entered in Section 3 is complete,

true and correct to the best of your knowledge, and that you are aware that you may face severe penalties provided by law and

may be subject to criminal prosecution for knowingly and willfully making false statements or knowingly accepting false

documentation when completing this form.


Today's Date: The person who completes Section 3 must enter the date Section 3 was completed and signed in this field. Do

not backdate this field. If you used a form obtained from the USCIS website, you must print Section 3 of the form to enter the

date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8,

2014 as 01/08/2014.

Name of Employer or Authorized Representative: The person who completed, signed and dated Section 3 must enter his

or her name in this field.

What is the Filing Fee?

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be

retained by the employer and made available for inspection by U.S. Government officials as specified in the “USCIS Privacy

Act Statement” below.

USCIS Forms and Information

For additional guidance about Form I-9, employers and employees should refer to the Handbook for Employers: Guidance for

Completing Form I-9 (M-274) or USCIS’ Form I-9 website at www.uscis.gov/I-9Central.

You can also obtain information about Form I-9 by e-mailing USCIS at [email protected], or by calling 1-888-464-4218 or 1-

877-875-6028 (TTY).

You may download and obtain the English and Spanish versions of Form I-9, the Handbook for Employers, or the instructions

to Form I-9 from the USCIS website at https://www.uscis.gov/i-9. To complete Form I-9 on a computer, you will need the latest

version of Adobe Reader, which can be downloaded for free at http://get.adobe.com/reader/. You may order USCIS forms by

calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National

Customer Service Center at 1-800-375-5283 or 1-800-767-1833 (TTY).

Information about E-Verify, a fast, free, internet-based system that allows businesses to determine the eligibility of their employees

to work in the United States, can be obtained from the USCIS website at http://www.uscis.gov/e-verify, by e-mailing USCIS at

[email protected] or by calling 1-888-464-4218 or 1-877-875-6028 (TTY).

Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781 or

1-877-875-6028 (TTY).

Photocopying Blank and Completed Forms I-9 and Retaining Completed Forms I-9

Employers may photocopy or print blank Forms I-9 for future use. All pages of the instructions and Lists of Acceptable

Documents must be available, either in print or electronically, to all employees completing this form. Employers must retain

each employee's completed Form I-9 for as long as the individual works for the employer and for a specified period after

employment has ended. Employers are required to retain the pages of the form on which the employee and employer entered

data. If copies of documentation presented by the employee are made, those copies must also be retained. Once the individual's

employment ends, the employer must retain this form and attachments for either 3 years after the date of hire (i.e., first day of

work for pay) or 1 year after the date employment ended, whichever is later. In the case of recruiters or referrers for a fee (only

applicable to those that are agricultural associations, agricultural employers, or farm labor contractors), the retention period is 3

years after the date of hire (i.e., first day of work for pay).

Forms I-9 obtained from the USCIS website that are not printed and signed manually (by hand) are not considered complete. In

the event of an inspection, retaining incomplete forms may make you subject to fines and penalties associated with incomplete

forms.

Employers should ensure that information employees provide on Form I-9 is used only for Form I-9 purposes. Completed

Forms I-9 and all accompanying documents should be stored in a safe, secure location.

Form I-9 may be generated, signed, and retained electronically, in compliance with Department of Homeland Security

regulations at 8 CFR 274a.2.

http://www.uscis.gov/I-9Central

mailto:[email protected]

http://www.uscis.gov/i-9

http://get.adobe.com/reader/

http://www.uscis.gov/e-verify



USCIS Privacy Act Statement

AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public

Law 99-603 (8 USC § 1324a).

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and

Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire

for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in

the United States.

DISCLOSURE: Providing the information collected by this form is voluntary. However an employer should not continue to

employ an individual without a completed form. Failure of the employer to prepare and/or ensure proper completion of this

form for each employee hired in the United States after November 6, 1986 or in the Commonwealth of the Mariana Islands after

November 27, 2011, may subject the employer to civil and/or criminal penalties. In addition, employing individuals knowing

that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties.

ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an

employee to work in the United States. The employer must retain this form for the required period and make it available for

inspection by authorized officials of the Department of Homeland Security, Department of Labor and Office of Special Counsel

for Immigration-Related Unfair Employment Practices.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of

information unless it displays a currently valid OMB control number. The public reporting burden for this collection of

information is estimated at 35 minutes per response, when completing the form manually, and 26 minutes per response when

using a computer to aid in completion of the form, including the time for reviewing instructions and completing and retaining

the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office

of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your

completed Form I-9 to this address.

Updated 7/24/2015

Self-Identification Form The University of Massachusetts Boston is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws and regulations, it is important that our recordkeeping and reporting information is accurate. The information collected via this form will be entered in UMass Boston’s Human Resources’ information system (but will be kept separately from your personnel file) and may be used in accordance with the applicable laws and regulations concerning equal employment opportunity. The university’s policy on the collection, maintenance, and reporting of such information is available at: ww w.u mb .ed u /od i .

Instructions: New hires and re-hires, please complete Sections I and II of this form in their entirety. Section III is voluntary. Current

employees requesting changes, please complete all of Sections I and II and only the information you wish to update on Section III.

Upon completion please return this form to the Office of Diversity and Inclusion (ODI.) Additionally, any data collected as part of

this process will not be used to make employment-related decisions. PLEASE PRINT.

Section I: Name and Status

Select One: New Hire/Rehire Start Date or Effective Date of Change:

Current Employee (ID#: )

Name: Last First Middle

Section II: Department and Position Information

Department:

Position Title:

Position Classification: Faculty Professional Classified

Section III: Personal Information and Self-Identification (Please refer to definitions on reverse side of this form. Completion of the following information is v o lu n ta ry , and choosing to not self-identify will not subject you to any adverse treatment.)

Gender: Female Race/Ethnicity (Provide both): Male 1. Hispanic Ethnicity: Hispanic or Latino Not Hispanic or Latino

2. Racial Identity: American Indian or Alaska Native

Asian

Black or African American White

Native Hawaiian or Other Pacific Islander Two or more

Military Status (Select one): No Military Service Veteran of the Vietnam Era

Recently Separated Veteran Pre-JVA Veteran

Armed Forces Service Medal Veteran Other Protected Veteran

Active Duty or Wartime Campaign Badge Veteran

Disability Status: I Do Not Have a Disability Individual With a Disability

Disabled Veteran Special Disabled Veteran NOTE: For accommodations please contact the Director for Diversity and ADA Compliance, (617) 287-6587.

Section IV: Signature and Date

SIGNATURE: DATE: I do not wish to self-identify.*

http://www.umb.edu/odi

Updated 7/24/2015

SELF-IDENTIFICATION DEFINITIONS: Completion of this information is voluntary. All information is confidential and will be reported in aggregate form only. Declining to provide this information will not subject you to any adverse treatment.

RACE AND ETHNICITY This two-part question is requested for statistical reporting purposes to government agencies, including the U.S. Department of Education.

Hispanic Ethnicity– Hispanic or Latino is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other

Pacific Islands

Two or more - A person who primarily identifies with two or more of the above race/ethnicity categories.

MILITARY STATUS AND DISABILITY STATUS SELF-IDENTIFICATION Veteran of the Vietnam Era Defined as a person who served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred:

In the Republic of Vietnam between February 28, 1961, and May 7, 1975; or

Between August 5, 1964, and May 7, 1975, in all other cases; or

Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975, in all other cases.

Recently Separated Veteran Any veteran who served on active duty in the U.S. military, ground, naval or air service during the one year period beginning on the date of such veteran’s discharge or release from active duty.

Pre-JVA Veteran Defined as an individual who is an employee of or applicant to a contractor with a contract of $25,000 or more entered into prior to December 1, 2003 and unmodified since to $100,000 or more, and who is a special disabled veteran, veteran of the Vietnam era, pre-JVA recently separated veteran, or other protected veteran.

Armed Forces Service Medal Veteran Defined as any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Active Duty or Wartime Campaign Badge Veteran Defined as a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Individual with Disabilities Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

Disabled Veteran Defined as (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability.

Special Disabled Veteran Defined as a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability: 1. Rated at 30 percent or more; or 2. Rated at 10 or 20 percent in the case of a veteran who has been determined under 38 U.S.C. 3106 to have a serious employment handicap; or 3. A person who was discharged or released from active duty because of a service-connected disability.

*If you choose to not self-identify your race/ethnicity and/or gender, the federal government requires the University of Massachusetts Boston to determine this information by visual survey and/or other available information.

Massachusetts Deferred Compensation SMART Plan – Mandatory OBRA Office of the State Treasurer and Receiver General

P A R T I C I P A T E

OBRA Information Guide

S A V E M O N E Y A N D R E T I R E T O M O R R O W

Basic Facts About OBRA and the Massachusetts Deferred Compensation SMART Plan As a part-time, seasonal or temporary

employee of the Commonwealth of Massachusetts or a part-time, seasonal or temporary employee of a participating Massachusetts local government employer and not eligible to participate in the employer’s retirement program or not covered under a section 218 agreement, you are required to participate in the Massachusetts Deferred Compensation SMART Plan (SMART Plan).1 The SMART Plan is an alternative to Social Security as permitted by the federal Omnibus Budget Reconciliation Act of 1990 (OBRA). OBRA, passed by the U.S. Congress, requires that beginning July 1, 1991, employees not eligible to participate in their employer’s retirement program be placed in Social Security or another program meeting federal requirements. The SMART Plan meets those federal requirements.

Mandatory Contributions As an OBRA employee, you must contribute at least 7.5% of your gross compensation per pay period to the SMART Plan. This contribution is deducted on a pre-tax basis, reducing your current taxable income. This means that you will not pay any tax on this money until it is distributed from your account.

Your human resources or payroll center representative will provide you with an OBRA Mandatory Participation Agreement. Please complete and return the form to either your human resources or payroll center representative.

Investment Option All mandatory contributions to the SMART Plan will be invested in the Income Fund. The Income Fund is designed to protect your principal and maximize earnings. Your account will earn interest based upon the prevailing rates for this type of investment. Mandatory contributions may not be transferred out of the Income Fund.

Additional information regarding

the Income Fund may be obtained online at www.mass-smart.com > Invest > Investment Options or via the SMART Plan Service Center at (877) 457-1900.2

Administrative Fee There is a fee of $14.10 per OBRA account, per annum, charged monthly. Fees are used to pay for administrative, recordkeeping, communication and investment education expenses.

Voluntary Contributions You may make additional contributions (voluntary contributions) above the mandatory contribution of 7.5% of compensation per pay period. Any voluntary contributions that you elect to make may be invested among the SMART Plan’s wide array of investment options and are freely transferable among options in accordance with the terms of the SMART Plan. OBRA voluntary contributions will not be charged an additional administrative fee.

To set up voluntary contributions or to learn more, please contact your local SMART Plan representative at (877) 457-1900 and say “representative.”3

Account Management Once you are enrolled in the SMART Plan, you will have access to your account 24 hours a day, seven days a week through the website at www.mass-smart.com or via the SMART Plan Service Center at (877) 457-1900.2 All you need is your Social Security number (SSN) and Personal Identification Number (PIN). Your PIN will be mailed to your home as soon as you are enrolled in the SMART Plan.4

To register your account for the first time, click on the “First Time Visiting? Let’s Get Started!” link. For security purposes, you will then be asked to create a personalized Username.

Through either the website or SMART Plan Service Center, you can:

• Obtain your account balance(s), allocations and transaction history

• Obtain investment option information and returns

• Order a new PIN or personalize your PIN

• Update your beneficiary information as needed

Statements You will receive an annual statement in January of each year showing contributions, earnings, fees, distributions and the total value of your account. Please review your statement carefully to ensure your information is correct. It is extremely important that you keep the Plan administrator advised of your current address.

To update your address, call the SMART Plan Service Center at (877) 457-1900. You can also go to www.mass-smart.com. Once you log in to your account, click on “My Profile” to update your personal account information.

Distributions Distribution of your SMART Plan benefits can only be made upon:

• Severance from employment

• Your death

Severance from employment occurs because of your voluntary or involuntary termination of employment. There is no early withdrawal penalty for taking a distribution of your account upon separation of service, regardless of your age.5

If you no longer work for the Commonwealth of Massachusetts or a Massachusetts local government employer, you may take a lump-sum distribution (payable to you or to your beneficiary upon your death) or roll over your assets into another eligible employer-sponsored plan or traditional Individual Retirement Account (IRA).6

http://www.mass-smart.com/



A leave of absence is not a severance from employment. Also, a change from part-time to full-time employment, or any similar change, is not considered an event that could result in a distribution from the SMART Plan. Benefits attributable to your voluntary contribution account may be distributed under other options available under the SMART Plan.

You may elect to receive your distribution immediately upon severance from employment. For more information or to access a Distribution Request Form, please contact the SMART Plan Service Center at (877) 457-1900 or visit www.mass-smart.com > Participate > Forms.

Beneficiaries and Death If you die before receiving all of your SMART Plan assets, the funds will go to your designated beneficiary. If you do not designate a beneficiary, your funds will be paid to your estate and will be distributed in accordance with Massachusetts probate law. It is essential that you designate a beneficiary on the enrollment form to ensure your assets will pass on as you intended.

Updating your beneficiary is quick and easy. You have two choices:

Online Log in to the SMART Plan website at www.mass-smart.com. Then go to My Profile > Beneficiary.

Paper Go to www.mass-smart.com > Participate > OBRA. Click on the link OBRA Mandatory Beneficiary Designation form. Mail or fax the completed form to the address or fax number provided on the form.

You will receive a written confirmation after your beneficiary information has been updated. It is extremely important that you keep the Plan administrator advised of your beneficiary changes.

Converting to Full-Time Status If you become a permanent, full-time employee and at one time made contributions to an OBRA mandatory account, you may elect to transfer your OBRA mandatory account to your voluntary account in the SMART Plan. In order to take advantage of this option, you cannot be actively contributing to the OBRA mandatory plan. To implement this change or to learn more, please contact your local SMART Plan representative at (877) 457-1900 and say “representative.”3

Service Buyback If you reach a point where you are no longer making OBRA mandatory contributions but you’re still working for a Commonwealth of Massachusetts state agency or municipality, you may be eligible for a “Service Buyback” of your credible years of service to your qualified governmental defined benefit retirement plan. Service buybacks may be funded from transferred assets from the OBRA mandatory and/or

voluntary contribution accounts.

More Information To obtain additional information, please call the SMART Plan Service Center at (877) 457-1900, Monday through Friday, from 9:00 a.m. to 8:00 p.m. Eastern Time.

1 The Social Security Administration website at http://www.socialsecurity.gov/form1945 reminds state and local governmental employers of the requirement under the Social Security Protection Act of 2004 to disclose the effect of the Windfall Elimination Provision (WEP) and the Government Pension Offset (GPO) to employees hired on or after January 1, 2005, in jobs not covered by Social Security. Some jobs may not be covered under Social Security because they are not subject to mandatory coverage and there is no Section 218 agreement that covers them. The GPO provision impacts the amount of Social Security benefits received as a spouse or as an ex-spouse. The WEP affects the retirement or disability benefits received under Social Security if an individual has worked for an employer who does not withhold Social Security taxes. The law requires newly hired public employees to sign a statement, Form SSA-1945, that they are aware of a possible reduction in their future Social Security benefit entitlement. A copy of Form SSA-1945 is available at http://www.socialsecurity.gov/form1945/SSA-1945.pdf.

2 Access to the SMART Plan Service Center and website may be limited or unavailable during periods of peak demand, market volatility, systems upgrades/maintenance or other reasons.

3 Representatives of GWFS Equities, Inc. are not registered investment advisors and cannot offer financial, legal or tax advice. Please consult with your financial planner, attorney and/ or tax advisor as needed.

4 The account owner is responsible for keeping the assigned PIN confidential. Please contact Great-West Financial® immediately if you suspect any unauthorized use.

5 Withdrawals may be subject to ordinary income tax.

6 You are encouraged to discuss rolling money from one account to another with your financial advisor/planner, considering any potential fees and/or limitation of investment options.

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.

Core investment options offered through a group fixed and variable deferred annuity issued by GWL&A, and mutual funds, separately managed accounts, and/or collective trust funds. Great-West Financial® refers to products and services provided by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO, its subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A. ©2013 Great-West Life & Annuity Insurance Company. Form# CB1096OBRAPH (12/2013) PT187859




http://www.socialsecurity.gov/form1945

http://www.socialsecurity.gov/form1945/SSA-1945.pdf

][Form 1 ][GWRS FENRAP 3121 ][11/17/12 ][Page 1 of 2 ][RIVK][/304247983

][ADMIN FORMAT

A01:100212

Participant Enrollment Governmental 457(b) Plan

Massachusetts Deferred Compensation SMART Plan - Mandatory OBRA 98966-02

Participant Information

Last Name First Name MI Social Security Number

Address - Number & Street E-Mail Address

❑ Married ❑ Unmarried ❑ Female ❑ Male

City State Zip Code

( ) ( )

Mo Day Year Mo Day Year

Home Phone Work Phone Date of Birth Date of Hire

Do you have a retirement savings account with a previous employer or an IRA? ❑ Yes or ❑ No

Important Notice: Employees participating in the Massachusetts Deferred Compensation SMART Plan - OBRA Mandatory Plan (the Plan) must complete Social Security Form SSA-1945. The Plan has been designated as an alternative retirement system for part time employees not covered by their employers retirement system. The SSA-1945 explains the potential effects of the Windfall Elimination Provision and Government Pension Offset Provision under the Social Security law which may reduce the amount of your Social Security retirement or disability benefits, and/or benefits received by you as a spouse or an ex-spouse. If you have any questions regarding SSA-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 environmentally friendly alternative, please visit www.mass-smart.com for fast and easy enrollment in our Online File Cabinet service.

Payroll Information

UMass Boston

To be completed by Representative: 6521

Division Name Division Number

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

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

INVESTMENT OPTION NAME

INVESTMENT

OPTION CODE

(Internal Use Only)

The Income Fund ..........................................................................................MELINC ...............................................100%


][Form 1 ][GWRS FENRAP 3121 ][11/17/12 ][Page 2 of 2 ][RIVK][/304247983

][ADMIN FORMAT

A01:100212

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

Contingent Beneficiary

100.00%

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

Last Name First Name MI Social Security Number

Plan Beneficiary Designation

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

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

Primary Beneficiary

100.00%

Participation Agreement

Withdrawal Restrictions - I understand that the Internal Revenue Code (the "Code") and/or my employer’s Plan Document may impose restrictions on transfers and/or distributions. I understand that I must contact the Plan Administrator/Trustee to determine when and/or under 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 your wages and invested on your behalf based on your employer’s Plan Document. I agree that my employer or Plan Administrator/Trustee may take any action that may be necessary to ensure that my participation in the Plan is in compliance with any applicable requirement of the Plan Document and/or the Code. I understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Code. I understand that it is my responsibility to monitor my total annual contributions to ensure that I do not exceed the amount 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 Provider at the address below prior to the receipt of any deposits, I specifically consent to Service Provider retaining all monies received and allocating them to the default investment option.

Account Corrections - I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies or errors. Corrections will be made only for errors which I communicate within 90 calendar days of the last calendar quarter. After this 90 days, account information shall be deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days, the correction 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 required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated 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. I verify that this enrollment was unsolicited. I did not meet with a representative on a one-on-one basis regarding investment options.

Participant Signature Date

Participant forward to Service Provider at: Great-West Retirement ServicesP.O. Box 173764 Denver, CO 80217-3764 Phone #: 1-877-457-1900 Fax #: 1-866-745-5766 Web site: www.mass-smart.com

http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx

http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx


University of Massachusetts AMHERST • BOSTON • DARTMOUTH • LOWELL • WORCESTER

AUTHORIZATION AGREEMENT FOR EMPLOYEE DIRECT PAYROLL DEPOSITS

Employee Name:

Employee ID:

Effective Date:

Phone:

BANK INFORMATION

(Select Balance on Only One Box)

Deposit Priority (1) – Deducts this amount 1st Allow Partial Deduction FullDepositorBalance

New Delete Change NewAmount $

Bank Transit/Routing# (9 digits): Account Number:

Bank Name: Checking Savings

Deposit Priority (2) – Deducts this amount 2nd Allow Partial Deduction FullDepositorBalance


Bank Transit/Routing # (9 digits): Account Number:


Deposit Priority (3) – Deducts this amount 3rd Allow Partial Deduction FullDepositorBalance




Deposit Priority (4) – Deducts this amount 4th Allow Partial Deduction FullDepositorBalance




I herby authorize the University of Massachusetts to deposit my net pay as indicated above at the financial institution(s) named above. I understand the University of Massachusetts may cause my account to be adjusted to the extent necessary to correct any over deposit and I agree to hold the above named financial institution(s) harmless for any erroneous deposits or adjustments not caused by the financial institution.

It is understood that I may terminate this agreement at any time by written notification to the University of Massachusetts. Any such notification to the University of Massachusetts shall be effective only with respect to entries initiated by the University after receipt of such notification and reasonable opportunity to act upon it. Any such notification to the bank by the employee is unacceptable. The bank may terminate this agreement by written notice to the employee for just cause.

EMPLOYEE SIGNATURE: DATE:

MEMORANDUM

To: UMass Boston Staff and Faculty

From: Marie H. Bowen, Assistant Vice Chancellor for Human Resources

Date: April 27, 2017

Subject: Annual Notice - Conflict of Interest Law Education Requirements _____________________________________________________________________

The conflict of interest law seeks to prevent conflicts between private interests and public

duties, foster integrity in public service, and promote the public's trust and confidence in

that service by placing restrictions on what employees of the university may do on the

job, after hours, and after leaving public service.

The current compliance period for the university runs through June 30, 2017.

Annual conflict of interest law education and training is mandated by the University of

Massachusetts Boston and the Commonwealth of Massachusetts, which requires that all

employees complete the training every two (2) years. New employees should complete

the training within thirty (30) days of the date of hire.

To ensure compliance with the Conflict of Interest requirements, please complete the

following steps no later than June 30, 2017.

1. Acknowledge Receipt of the Summary of the Conflict of Interest Law for State

Employees:

The summary of the conflict of interest law, General Laws chapter 268A, is

intended to help employees understand how that law applies to them. The

summary is not a substitute for legal advice, nor does it mention every aspect of

the law that may apply in a particular situation.

The law requires that this form, which may be accessed at

http://www.mass.gov/ethics/education-and-training-resources/required-education-

and-training/state-employees-summary.html be submitted annually.

Please print and sign the form and return it to Sandra Knight, Human Resources

by June 30, 2017.

2. Complete the Conflict of Interest Law Online Training Program:

The training program covers various issues you may encounter as a public

employee and provides examples and reference information to help you recognize

conflicts of interest. Recognizing and properly responding to a conflict of interest

is a key element to maintaining the public’s confidence in government and in the

integrity of the work we do as public employees.

The training program can be found at: www.stateprog.eth.state.ma.us. It should

take approximately one (1) hour to complete.

http://www.mass.gov/ethics/education-and-training-resources/required-education-and-training/state-employees-summary.html

http://www.mass.gov/ethics/education-and-training-resources/required-education-and-training/state-employees-summary.html

http://www.stateprog.eth.state.ma.us/

Upon completion of the training you will have the ability to print a Certificate of

Completion. Please do so, make a copy for your records and send the certificate to Sandra

Knight, Human Resources by June 30, 2017. You must complete the entire training in

order to receive a certificate.

NOTE: The online training program is not compatible with the Google Chrome web

browser and make sure to disable pop-up blockers.

If you have questions, please review the Education and Training Guidelines available on

the State Ethics Commission’s website, www.mass.gov/ethics. The guidelines provide

helpful information about who is required to comply with these statutory requirements,

record-keeping requirements, and the process.

Thank you for your time and attention to this important matter. If you have any

questions, please contact Sandra Knight in Human Resources at

[email protected].

http://www.mass.gov/ethics/education-and-training-resources/education-training-guidelines.html

http://www.mass.gov/ethics


To: All University Employees

From: Marie H. Bowen, Assistant Vice Chancellor for Human Resources

RE: Federal Affordable Care Act

Under the federal Affordable Care Act, by October 1, 2013, all employees must be

notified of their health coverage options, including the availability of coverage through

the Health Insurance Marketplace (in Massachusetts, the Massachusetts Health

Connector). This notice provides some basic information concerning your current

coverage and the availability of other coverage. Note that most GIC-eligible employees

are not eligible for tax credits toward Marketplace or Connector coverage. Those who

are low income and face high premium costs (e.g., because they are low income and live

out of state) might be eligible for tax credits toward Marketplace or Connector coverage;

the Notice has this contact information. All employees received this notice through their

agency or municipality by October 1, 2013. New hires also receive a copy of this notice.

For more information about the Health Connector, please visit MAhealthconnector.org or call 1-877 MA-ENROLL (1-877-623-6765) or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Overview of Health Insurance Marketplaces

YOU ARE RECEIVING THIS NOTICE AS REQUIRED BY THE NEW NATIONAL HEALTH REFORM LAW (ALSO KNOWN AS THE AFFORDABLE CARE ACT OR ACA)

On January 1, 2014, the Affordable Care Act (ACA) will be implemented in Massachusetts and across the nation. The ACA will bring many benefits to Massachusetts and its residents, helping us expand coverage to more Massachusetts residents, making it more affordable for small businesses to offer their employees healthcare, and providing additional tools to help families, individuals and businesses find affordable coverage. This notice is meant to help you understand health insurance Marketplaces, which are required by the ACA to make it easier for consumers to compare health insurance plans and enroll in coverage. In Massachusetts, the state Marketplace is known as the Massachusetts Health Connector. While you may or may not qualify for health insurance through the Health Connector, it may still be helpful for you to read and understand the information included here.

Overview: When key parts of the national health reform law take effect in January 2014, there will be an easy way for many individuals and small businesses in Massachusetts to buy health insurance: the Massachusetts Health Connector. This notice provides some basic information about the Health Connector, and how coverage available through the Health Connector relates to any coverage that may be offered by your employer. You can find out more by visiting: MAhealthconnector.org, or for non-Massachusetts residents, Healthcare.gov or (1-800-318-2596; TTY: 1-855-889-4325).

What is the Massachusetts Health Connector? The Health Connector is our state’s health insurance Marketplace. It is designed to help individuals, families, and small businesses find health insurance that meets their needs and fits their budget. The Health Connector offers "one-stop shopping" to easily find and compare private health insurance options from the state’s leading health and dental insurance companies. Some individuals and families may also qualify for a new kind of tax credit that lowers their monthly premium right away, as well as cost sharing reductions that can lower out-of- pocket expenses. This new tax credit is enabled by §26B of the Internal Revenue Service (IRS) Code.

Open enrollment for individuals and families to buy health insurance coverage through the Health Connector begins Oct. 1, 2013, for coverage starting as early as Jan. 1, 2014. (And in future years, open enrollment will begin every Oct. 15.) You can find out more by visiting MAhealthconnector.org or calling 1-877-MA ENROLL (1-877-623-6765).

Can I qualify for federal and state assistance that reduces my health insurance premiums and out -of-pocket expenses through the Health Connector?

Depending on your income, you may qualify for federal and/or state tax credits and other subsidies that reduce your premiums and lower your out-of-pocket expenses if you shop through the Health Connector. You can find out more about the income criteria for qualifying for these subsidies by visiting MAhealthconnector.org or calling 1-877-MA ENROLL (1-877-623-6765).

For more information about the Health Connector, please visit MAhealthconnector.org or call 1-877 MA-ENROLL (1-877-623-6765) or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Does access to employer-based health coverage affect my eligibility for subsidized health insurance through the Health Connector?

An offer of health coverage from the Commonwealth of Massachusetts, as the employer, could affect your eligibility for these credits and subsidies through the Health Connector. If your income meets the eligibility criteria, you will qualify for credits and subsidies through the Health Connector if:

The Commonwealth of Massachusetts does not offer coverage to you, or

The Commonwealth of Massachusetts offers you coverage, but: o The coverage the Commonwealth of Massachusetts provides you (not including other family members)

would require you to spend more than 9.5 percent of your household income for the year; or o The coverage the Commonwealth of Massachusetts provides does not meet the "minimum value"

standard set by the new national health reform law (which says that the plan offered has to cover at least 60 percent of total allowed costs)

If you purchase a health plan through the Health Connector instead of accepting health coverage offered by the Commonwealth of Massachusetts please note that you will lose the employer contribution (if any) for your health insurance. Also, please note that the amount that you and your employer contribute to your employer-sponsored health insurance is often excluded from federal and state income taxes. Health Connector premiums have different tax treatment.

As part of considering whether the ACA and Marketplaces will affect you as an employee it is important to understand what the Commonwealth of Massachusetts offers you.

The Commonwealth offers benefited employees health coverage through the Group Insurance Commission. To be eligible for GIC health insurance, a state employee must work a minimum of 18 ¾ hours in a 37.5 hour workweek or 20 hours in a 40 hour workweek. The employee must contribute to a participating GIC retirement system, such as the State Board of Retirement, a municipal retirement board, the Teachers Retirement Board, the Optional Retirement Pension System for Higher Education, a Housing, Redevelopment Retirement Plan, or another Massachusetts public sector retirement system (OBRA is not such a public retirement system for this purpose. Visit www.mass.gov/gic or see your GIC Coordinator for more information.

Temporary employees, contractors, less-than-half time part time workers, and most seasonal employees are not eligible for GIC health insurance benefits. These employees may shop for health insurance through the Health Connector and may be eligible for advanced premium federal tax credits and/or state subsidies if their gross family income is at or below 400% Federal Poverty Level (which is approximately $46,000 for an individual and $94,000 for a family of four). Visit www.MAhealthconnector.org or call 1-877-MA-ENROLL for more information.

If there is any confusion around your employment status and what you are eligible for, please email [email protected] or contact your HR department or GIC Coordinator.

http://www.mass.gov/gic

http://may/

http://www.mahealthconnector.org/



P O L I C Y & G U I D A N C E M E M O R A N D U M

#2008-07: State Ethics Law

This memorandum contains the annual notice of significant features of the State Ethics Law

c.268A).

The conflict of interest law, M.G.L. c. 268A imposes "standards of conduct" on all state,

county and municipal employees.

Incompatible Employment

First, § 23 (b)(1) prohibits public employees from accepting other employment involving

compensation of substantial value, the responsibilities of which are inherently incompatible

with the responsibilities of his public office.

Example: a police officer would be prohibited from serving as a private security guard in his

town because his duties as a law enforcement official are incompatible with the demands of his

private employer.

Unwarranted Privileges

Section 23(b)(2) prohibits a public employee from using or attempting to use his or her official

position to secure for himself or others unwarranted privileges or exemptions which are of

substantial value and which are not properly available to similarly situated individuals;

Example: A governmental official may not use his governmental time or resources, such as

office space, word processors, telephones, photo copiers or fax machines, to conduct a private

business. Section 23(b)(2) dictates that the use of public time and resources must be limited to

serving public rather than private purposes.

The Commission has also emphasized that the use of one's public position to solicit or coerce

special benefits, of substantial value, for oneself or others will constitute a use of one's official

position to secure unwarranted privileges or exemptions not properly available to similarly

situated individuals. In addition, the Commission has advised municipal officials that they

must apply objective criteria to their official duties and that if, for example, a board member

cannot be objective about a matter, he should abstain.

Appearance of Conflict

Section 23(b)(3) prohibits a public employee from acting in a manner which would cause a

reasonable person, having knowledge of the relevant circumstances, to conclude that any

person can improperly influence or unduly enjoy the public employee's favor in the

performance of his or her official duties, or that he or she is likely to act or fail to act as a result

of kinship, rank, position or undue influence of any party or person. It shall be unreasonable to

so conclude if such officer or employee has disclosed in writing to his or her appointing

authority or, if no appointing authority exists, discloses in a manner which is public in nature,

the facts which would otherwise lead to such a conclusion.

Section 23(b)(3) has often been described as the section that covers "appearances" of conflicts

of interest. The statute as it currently reads, however, does not use the term "appearance." It is

worth emphasizing that §23(b)(3) prohibits acting "in a manner which would cause a

reasonable person, having knowledge of the relevant circumstances, to conclude" that the

official would be unduly influenced or unduly favor any party or person.

Example: A reasonable person could conclude that a board of health member might favor or

disfavor his cousin's application. Although the cousin is not a member of his immediate family

under §19, the family link would implicate §23(b)(3). To dispel such a reasonable conclusion,

the board of health member should make a written disclosure to his appointing authority,

describing the relevant facts of the family relationship and the official action, prior to his acting

as a board member. If the board member were popularly elected, she must make a disclosure

that is "public in nature." The Commission has advised that elected municipal officials should

make such disclosures in writing and file them as public records with their municipal clerk. In

some circumstances, it may also be prudent to reiterate the disclosure as part of the meeting

minutes.

Confidential Information

Section 23(c)(1) prohibits a current or former municipal employee from accepting

"employment or engag[ing] in any business or professional activity which will require him to

disclose confidential information which he has gained by reason of his official position."

Section 23(c)(2) prohibits him from "improperly disclos[ing] material or data within the

exemptions to the definition of public records as defined by section seven of chapter four, and

were acquired by him in the course of his official duties nor use such information to further his

personal interest."

Adequate disclosure

Section 23(d) provides that "any activity specifically exempted from any of the prohibitions in

any other section of this chapter shall also be exempt from the provision of this section. The

state ethics commission . . . shall not enforce the provisions of this section with respect to any

such exempted activity."

Example: Because adequate disclosure may be part of complying with §§19 or 20 (which were

discussed in previous Ethics Primers), a municipal employee may comply with the disclosure

requirements of §23(b)(3) by complying with the former. For further guidance regarding

whether more than one disclosure is required, you should review the matter with municipal

counsel or contact the Ethics Commission.

For additional information, call the State Ethics Commission at (617) 727-0060 or visit their

website at: http://www.state.ma.us/ethics.

April 16, 2008 University of Massachusetts Boston Department of Human Resources

100 Morrissey Blvd. Boston, Massachusetts 02125

(617) 287-5150 www.umb.edu/hr

http://www.state.ma.us/ethics

http://www.umb.edu/hr



#2009-07: Political Activity

With the election approaching, it is important to understand what we, as public employees, may or may not do in support of political candidates or ballot questions. Massachusetts General Law Chapter 55 generally covers campaign finance, but also includes sections covering the rights and limitations of public employees and the use of public buildings.

Public employees (other than elected officials) may not:

Sell or distribute tickets for a fundraising event to benefit any political candidate or political committee or solicit attendance at such an event;

Otherwise ask for contributions to support any candidate or political committee (federal, state, county or local) or a ballot question;

Host a political fundraising event;

Accept donations or payment for admission at a political fundraising event or accepting money at the door of a political fundraising event;

Sign a fundraising letter or advertisement on behalf of a candidate or political committee;

Permit his/her name to be listed on campaign stationery as an officer, member or supporter, if the stationery is used to solicit funds for a political purpose;

Provide persons raising money for a candidate or committee with the names of individuals who would then be solicited;

Providing general or specific advice to a political campaign with regard to fundraising strategies

However, a public employee may:

Make a contribution to a candidate or political committee or attend a political fundraiser;

Serve as a member of a political committee or hold a committee position (other than treasurer or any other position that involves fundraising);

Perform any service for a campaign that does not involve fundraising, such as holding signs, stuffing envelopes, signing endorsement letters (as long as those letters do not also ask for money) or working at political fundraisers in a non- fundraising capacity, such as setting up tables or preparing food (not collecting money at the door).

Meet with anyone, including other public employees, for political purposes, as long as no fundraising activity takes place;

Raising money for humanitarian, charitable or educational causes or other issues not related to elections.

The use of public buildings is more restrictive: No one may use a public building:

to ask for or receive contributions to any political committee or candidate;

as a return address for contributions or use a phone number in the building as a contact for buying tickets to a fundraiser;

to post an advertisement or a circular selling tickets to a fundraiser or otherwise seeking contributions

Finally, no public resources (including paid time, telephones, computers, copiers, and/or office supplies) may be use for political campaign purposes.

A complete guide to campaign finance is available on the Office of Campaign & Political Finance’s website at www.mass.gov/ocpf/guides/guide_pub_emp.pdf. Specific questions can be directed to the Office at (617) 979-8300.

September 29, 2008 University of Massachusetts Boston Department of Human Resources


(617) 287-5150 www.umb.edu/hr

http://www.mass.gov/ocpf/guides/guide_pub_emp.pdf


UNIVERSITY OF MASSACHUSETTS BOSTON SEXUAL HARASSMENT POLICY AND PROCEDURES

(Doc. T92-037)

I. POLICY Sexual harassment is sex discrimination and, therefore, a violation of federal and state law. It is the policy of the University of Massachusetts that no member of the University community may sexually harass another. For purposes of this policy and consistent with federal regulations, sexual harassment is defined as follows:

Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of sexual nature constitute sexual harassment when: 1) submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment or academic work, 2) submission to or rejection of such conduct by an individual is used as the basis for employment or academic decisions affecting such individual, or 3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive working or academic environment.

It is the policy of the University to protect the rights of all persons within the University community by providing fair and impartial investigations of all complaints brought to the attention of appropriate officials. Any member of the University community found to have violated this Sexual Harassment Policy will be subject to disciplinary action.

II. PROCEDURES

The University of Massachusetts at Boston will administer the Sexual Harassment Policy and Procedures under the Sexual Harassment Office.

These procedures are available to any person who, at the time of the acts complained of, was employed at or was enrolled as a student at the University of Massachusetts Boston. However, any person who files a compliant with any outside agency or court shall be deemed to have waived his/her rights to an internal University proceeding.

No individual shall be penalized by the University for participating in the procedures stipulated here, nor shall any retaliation be permitted. Complaints of retaliation should be addressed to the Sexual Harassment Office or, where formal proceedings have been initiated, to the respondent’s Vice Chancellor, who, in consultation with the Sitting Panel, shall immediately attempt to address and resolve the issues (see section B.7).

Informal Resolution

Because of the emotional and moral complexities surrounding most sexual harassment incidents, every effort should be made to resolve the complaint on an informal basis.

A. Complaints of sexual harassment should, whenever possible, be discussed informally in the

first instance by the complainant with the respondent’s department head or staff supervisor, in hopes that the department head/supervisor may effect an informal resolution.

B. If this approach is either unacceptable to the complainant or unavailing, the complaint

should be reported to the Sexual Harassment Officer. The Sexual Harassment Officer will inform the complainant concerning the Sexual Harassment Policy and Procedures and will counsel him or her concerning options for proceeding.

-2

The Sexual Harassment Officer may rule that a complaint is (a) frivolous, or (b) outside the purview of the Sexual Harassment Policy and Procedures and decline to pursue it further; such ruling is subject to appeal by the complainant to the Sexual Harassment Hearing Board, which is empowered to instruct the Sexual Harassment Officer to entertain the case.

Upon certification that a complaint is non-frivolous and within the purview of this Policy and Procedures, the complainant may elect to file a written Informal Complaint Form. Upon the filing of this form, the Sexual Harassment Officer shall attempt an informal resolution of any complaint of sexual harassment, provided it is brought within 180 calendar days of the alleged act . In his/her neutral capacity, the Sexual Harassment Officer shall inform the parties of all possible courses of action, such as informal resolution and formal hearing, and of campus support and counseling services.

Steps of the Informal Resolution Process:

1. The Sexual Harassment Officer will counsel the complainant concerning options for responding to the problem on his/her own initiative (e.g. through oral or written communication to the respondent). If the complainant expresses willingness to proceed in this fashion, the Sexual Harassment Officer shall provide guidance and support to the complainant, throughout the process.

2. If this approach is either unacceptable to the complainant or unavailing, the Sexual

Harassment Officer will undertake an Informal Hearing Process, in an attempt to reach a disposition agreeable to both complainant and respondent, to include the following.

a. a private informal hearing with the complainant;

b. a private informal hearing with the respondent;

c. if deemed necessary, an informal hearing among the Sexual Harassment Officer, the

complainant and the respondent.

d. The Sexual Harassment Officer shall normally complete his/her investigation and all efforts to arrive at an informal resolution within thirty (30) calendar days of receipt of the complaint, unless extraordinary circumstances dictate otherwise. When it is determined, as a result of the Sexual Harassment Officer’s review, that an incident of sexual harassment has in fact occurred, the Sexual Harassment Officer’s attempts to arrive at informal resolution shall be guided by concern to provide appropriate relief to the aggrieved party while sensitizing the person at fault to the effects of such behavior.

e. Upon completion of the review, the Sexual Harassment Officer shall send a

confidential report to both parties and to the Chancellor, outlining his/her findings. If a resolution is reached that has been agreed to by both parties, the Sexual Harassment Officer shall include the terms of that resolution in the report. The Chancellor shall move to implement any sanctions called for by the terms of the resolution.

The Sexual Harassment Officer shall ensure that all communications shall be kept confidential. He/she may not be called to testify at any University hearing regarding these privileged communications unless otherwise agreed by both parties.

-3

If no Informal Complaint Form is filed by the complainant, no written records shall be kept. Where an informal resolution process is initiated, written records indicating the nature of the complaint, the names of the parties, and a dated copy of the terms and the resolution (if any) shall be kept by the Sexual Harassment Officer for a period of eight years. Such records shall normally be available only to the complainant, the respondent, the Sexual Harassment Officer and the Chancellor; they shall be made available to the respondent’s Vice Chancellor in the event that, in accordance with these procedure, this or any subsequent charge of sexual harassment against the respondent or any charge of retaliation by the respondent is brought before the Vice Chancellor for review. These records are also available pursuant to a judicial subpoena, subject to the provisions of the University’s Fair Information Practices Regulations (Doc. T77-059).

In extraordinary circumstances and for good cause, the Sexual Harassment Officer may, at his or her discretion, rule that the Informal Resolution Process may be omitted, and a complainant may move directly to Formal Proceedings.

Formal Proceedings

1. Hearing Process

a. Filing a Complaint

If informal proceedings do not result in resolution, or if the resolution agreed upon is not carried out, or if the Sexual Harassment Officer rules that the Informal Resolution Process may be omitted, the Sexual Harassment Officer shall advise the complainant of his/her right to a formal hearing. The Sexual Harassment Officer shall review the formal procedures for both parties.

If the complainant decides to proceed with a formal hearing, a formal written complaint shall be filed with the respondent’s Vice Chancellor. The complaint shall state, clearly and concisely, the facts which are the grounds for the proceeding and the relief sought. Within two (2) working days the complaint shall be forwarded by the Vice Chancellor to the Sexual Harassment Officer in his/her capacity as coordinator of the Sexual Harassment Hearing Board and to the respondent, with notice that an answer must be filed with the Vice Chancellor within ten (10) calendar days.

The respondent’s answer shall contain full, direct and specific responses to each claim in the complaint, admitting to, denying or explaining the material facts. The Vice Chancellor shall forward the answer to the complainant within two (2) working days of its filing.

It shall be the Sexual Harassment Officer’s responsibility to appoint a Sitting Panel, schedule a hearing date, and notify the respective parties at least twenty-one (21) calendar days before the hearing. The hearing will be schedule and held no later than forty-five (45) calendar days after the formal written complaint has been filed, unless continued by the Board pursuant to Section d, ii, 6 or 7 below.

-4

b. Composition of the Hearing Board

The Chancellor, in consultation with the appropriate governing and administrative bodies, shall appoint a 12-member Sexual Harassment Hearing Board. The Sexual Harassment Officer shall act as the coordinator of the Board.

The Hearing Board shall be composed of 3 faculty members, 3 members of the professional staff, 3 classified employees and 3 students.

Appointments will be guided by consideration of continuity, experience, and sensitivity to the concerns of those most profoundly affected by sexual harassment. Insofar as possible the Board shall reflect the diversity of the campus community. The membership of each constituency shall include at least one woman and one man. Members are to serve for staggered terms of three years.

The members of the Board shall act at all times to preserve the confidentiality of complainants and respondents. Board members shall participate in sexual harassment training workshops designed to sensitize them to the issues encompassing sexual harassment, including confidentiality, and the hearing procedures herein.

c. The Sitting Panel

Upon notice of a formal complaint, the Sexual Harassment Officer shall designate 5 members of the Board to serve as Sitting Panel. The Sitting Panel shall normally include two Board members from the respondent’s constituency (faculty, professional or classified staff, students), two from the complainant’s, and a fifth drawn from a neutral constituency. In such case as the complainant and respondent come from the same constituency, or Board members disqualify themselves in sufficient numbers to make the normal configuration of the Panel impossible, the Sitting Panel shall normally include three Board members from that constituency, the remaining membership to be chosen by the Sexual Harassment Officer from neutral constituencies; but in no case shall a student sit on a case which does not involve students. The Sitting Panel shall elect a Presiding Officer at its first meeting.

The function of a Sitting Panel is to hear and consider testimony and other relevant, reliable evidence, to make findings of fact, to determine whether the University Policy on Sexual Harassment has been violated, and, if so, to recommend appropriate penalties and relief.

d. Duties and Powers of the Presiding Officer and the Sitting Panel

i. The Presiding Officer shall have the following specific duties:

1. To ensure an orderly presentation of evidence and issues;

2. To ensure that a record is made of the proceedings; and

3. To ensure that a fair, independent, impartial decision based on the issues and evidence

presented at the hearing is issued by the Sitting Panel no later than fourteen (14) calendar days, or thirty (30) calendar days when briefs are submitted, after the conclusion of the hearing.

-5

ii. The Sitting Panel shall have the following specific duties or prerogatives:

1. To conduct a fair hearing to ensure that all the rights of the parties are protected;

2. To define issues;

3. To receive and consider all relevant and reliable evidence of the kind which reasonable people are accustomed to rely upon in the conduct of serious business;

4. To assist all those present in making a full and free statement of the facts in order to

bring out all the information necessary to decide the issues involved;

5. To ensure that all parties have full opportunity to represent their claims orally, or in writing, and to secure witnesses and evidence to establish their claims;

6. To continue the hearing to a subsequent date to permit either party to produce

additional evidence, witnesses, and other material;

7. To change the date, time or place of the hearing on its own motion or upon request of any party, for good cause shown and upon due notice to the parties;

8. To permit the parties or their representatives to submit briefs within fourteen (14)

calendar days of the conclusion of the hearing, on the condition that notification of intent to files is made to the Presiding Officer of the Panel within three (3) calendar days of the conclusion of the hearing;

9. By majority vote to rule on all questions of fact; interpretations of rules, regulations

and policies; penalties and relief; and such requests as are made during the hearing.

e. Hearing Procedure

1. Unless otherwise agreed by a majority of the Sitting Panel (pursuant to Numbers 6, 7 or 9 of the preceding section), a closed hearing shall be held within forty-five (45) calendar days of the receipt of the formal complaint by the Sexual Harassment Officer.

2. Each party shall be afforded the opportunity to hear all the testimony; to examine all

the evidence; to respond to any adverse testimony; to present evidence and witnesses; to advance any pertinent arguments on his/her own behalf; and to file a brief within fourteen (14) calendar days of the conclusion of the hearing, on the condition that notification of intent to file is made to the Presiding Officer of the Panel within three (3) calendar days of the conclusion of the hearing.

3. Each party shall have the right to be accompanied, advised and/or represented by up

to two members of the campus community (not legal counsel) at any stage of the proceedings.

1

1 N.B.: Each party is free to retain legal counsel for advise, but may not bring legal counsel to University proceedings.

-6

4. The hearing shall be tape-recorded by the Sitting Panel, the tape to remain the property of the University. Subsequently, either party shall have supervised access to the tape through the Sexual Harassment Officer.

5. The proceedings before the Sitting Panel shall be as follows (unless waived or

modified by the parties at such point as the respondent admits his/her guilt):

a. The Presiding Officer shall read the charge(s) and allow the respondent to either admit to or challenge the allegations;

b. First the complainant, then the respondent may present a brief opening

statement;

c. First the complainant, then the respondent will present any and all evidence and testimony germane to the allegations, with the following provisions:

i. each party may question evidence and testimony introduced by the other; ii. each party may rebut any inferences drawn by the other

d) First the complainant, then the respondent may briefly summarize his/her case to the Board.

f. Decision of the Sitting Panel

After the hearing and the filing of briefs (if any), the Sitting Panel shall convene for private deliberations to determine whether the University’s Policy on Sexual Harassment has been violated. If so, the Panel will make findings of fact and propose penalties for the respondent and relief for the complainant.

The Panel’s findings of fact and its proposal of penalty and relief shall be based solely on the testimony and evidence presented at the hearing and in the briefs (if any). In making its determination, the Panel will examine the totality of the circumstances, such as the nature of the sexual harassment and the context in which the alleged incident(s) occurred. Penalties should reflect the severity of the incident(s).

Possible penalties for employees shall include, but not limited to, oral admonition, written reprimand, to be included in the individual’s personnel file, probation, suspension with or without pay, ineligibility to receive merit pay for a state period of time, involuntary demotion, removal from administrative duties within a department, required professional counseling, and dismissal.

Possible penalties for students shall include, but not be limited to, oral admonition, disciplinary reprimand, disciplinary probation, suspension from the University for a stated period of time, and expulsion from the University.

The Sexual Harassment Officer shall review the Panel’s proposed penalty in conjunction with any records of previous sexual harassment violations by the respondent and, if evidence of recidivism is found, may adjust the severity of the Panel’s proposal accordingly.

In cases (a) where the respondent has been found guilty of sexual harassment and (b) where the Panel finds substantial reason to believe that the complainant may have been unfairly treated with respect to a grade, the Panel shall have the power to mandate to the respondent’s department or program that the department or program appoint a committee

-7

of three faculty members to determine the student’s grade. Unless extraordinary circumstances dictate otherwise, final determination of the student’s grade by this committee shall be made within thirty (30) calendar days of the Panel’s referral of the case to the department of program.

Within fourteen (14) calendar days, or, if briefs are to be submitted, within thirty (30) calendar days of the hearing, the Panel’s written decision (including findings of fact and recommendations for penalty and relief, if any) shall be forwarded to the complainant, the respondent, and the appropriate Vice Chancellor.

The Sitting Panel’s decision shall be implemented within ten (10) calendar days, unless a review at the Vice Chancellor’s level is requested within that period.

2. Standard of Proof

In cases where the allegations of sexual harassment are contested by the respondent, a violation of the Policy on Sexual Harassment shall be found only when there is a preponderance of evidence that a violation occurred. The Sitting Panel, the Vice Chancellors, and Chancellor shall be bound to make their determinations based on this standard of proof.

3. Vice Chancellor’s Review

Either party may request review within ten (10) calendar days of the date of the Panel’s decision by filing a written petition with the respondent’s Vice Chancellor. The petition shall set forth in detail the specific grounds upon which review is sought. The Vice Chancellor shall immediately forward a copy of the petition to the Sitting Panel and the other party. Upon review, the Vice Chancellor may affirm the decision of the Panel; request specific findings from the Panel; remand the matter for further hearing (either for reconsideration or because additional evidence has been presented which, for good reason, could not be presented at the hearing); or, following due consultation with the Sitting Panel, se aside or modify the decision, if he/she determines that the substantial rights of any party may have been prejudiced because the Panel’s decision is:

a. unsupported by substantial evidence; or b. in violation of constitutional provisions, academic freedom, or these procedures; or c. arbitrary, in abuse of discretion or in excess of the Panel’s powers; or d. reflective of arbitrary or unreasonable adjustment in severity by the Sexual Harassment

Officer on the basis of respondent recidivism.

The Vice Chancellor shall make his/her determination upon consideration of the entire record, indicating specific reasons for any change of the Panel’s decision. Within twenty-one (21) calendar days of the request for review, his/her final written decision shall be sent to the complainant, the respondent and the Sitting Panel. This 21-day period shall include any time allotted to the Panel upon request of the Vice Chancellor for specific findings or further hearings. The final decision of the Vice Chancellor shall be implemented without delay.

4. Reconsideration by the Chancellor

Either party may request reconsideration within ten (10) calendar days of the date of the Vice Chancellor’s decision by filing a written petition with the Chancellor. The provisions and procedures of the Vice Chancellor’s review (see previous section) shall apply to the Chancellor’s reconsideration. The decision of the Chancellor shall constitute final University disposition of the matter, and the parties shall, upon the rendering of the Chancellor’s final decision, have exhausted their administrative remedies within the University.

-8

5. Retaliation

No reprisal or retaliation of any kind shall be taken against any person participating in these procedures. Where there is an allegation that retaliatory action has been taken, immediate review of such allegation shall be granted by the respondent’s Vice Chancellor. The person alleging retaliatory action shall set forth in detail, in a written petition, the facts which are the grounds for the allegation and the relief sought. The Vice Chancellor shall immediately notify the respondent of the charge and request a written response. If a case of retaliatory action is established to the satisfaction of the Vice Chancellor, in consultation with the Sitting Panel, the Vice Chancellor shall take immediate action to redress any and all negative consequences resulting from such retaliatory action.

6. Retention of Records

Records of the hearing process and any review or reconsideration shall be kept by the Affirmative Action Office for eight years. During that period, the records shall be available only to the Sexual Harassment Officer, the respondent’s Vice Chancellor or the Chancellor. The records are also available pursuant to a judicial subpoena, subject to the provisions of the University’s Fair Information Practices Regulations (Doc. T77-059).



#2008-06: Drug-Free Workplace

University policy requires that the following notice be distributed each year throughout the

UMass Boston community.

The University of Massachusetts Boston, in accordance with both federal legislation and

existing University policy, is committed to providing a drug-free, healthful, and safe

environment for all employees.

In the event that an employee is observed to be under the influence of drugs or alcohol during

work hours, appropriate disciplinary action is to be taken. The progression of actions, from the

least to the most severe, is the following:

1. The immediate supervisor will discuss his/her concerns and observations with the employee.

He/she will recommend that the employee seek professional assistance and will suggest a

referral to a substance abuse counseling/rehabilitation program. This will occur on an informal

(verbal) basis and will not be included in the employee’s personnel record. Appropriate

arrangements will be made to ensure that the employee reaches his/her home safely that day.

2. Should there be a repeat occurrence, a formal written warning will be given, and again, the

employee will be encouraged to utilize the services of a counseling/rehabilitation program.

3. Any continued use by the employee of drugs and/or alcohol at work will result in a

suspension from work ranging from one to five days. At this time, the employee will be

required to utilize the services of a counseling/rehabilitation program as a condition of

employment.

4. Further use in the workplace of drugs and/or alcohol or failure to utilize the services of a

counseling/rehabilitation program will result in a longer suspension and/or termination.

All employees will have available the appropriate hearing and grievance procedures during

these disciplinary actions.

In addition, under the terms of the Drug Free Workplace Act, any employee engaged in the

performance of a federal grant must, as a condition of employment, notify the employer of any

criminal drug statute conviction for a violation occurring in the workplace no later than five

days after such a conviction.

Upon notification by an employee the University must, within 30 days of receiving such

notification with respect to any employee who is so convicted:(1) Take appropriate personnel

action against such an employee, up to and including termination, or (2) Requiring such

employee to participate satisfactorily in a drug abuse assistance or rehabilitation program. The

University recognizes alcohol and drug dependency as an illness and a major health problem.

Alcohol is the number one drug problem in the country. Drinking alcohol has acute effects

on the body. It impairs judgment, vision, coordination and speech and often leads to

dangerous risk-taking behavior. These may include drunken driving, injuries and serious

accidents. Nearly half of all accidental deaths, suicides and homicides are alcohol related. The

misuse of alcohol is often involved in violent behavior, acquaintance rape, unintended

pregnancies, and the exposure to sexually transmitted diseases. Long-term excessive drinking

and drug use can lead to a wide variety of health problems in many different organ systems.

The use of drugs and alcohol can cause physical and psychological dependence. They can

interfere with memory, sensation and perception. Drugs impair the brain’s ability to synthesize

information. Regular users of drugs develop tolerance and physical dependence often

experienced by withdrawal symptoms. The psychological dependence occurs when the drug

taking becomes central to the user’s life.

Finding Help for Alcohol and Other Drug Problems

Many people with alcohol or other drug problems can be treated successfully entirely on an

outpatient basis and do not have to interrupt their work and home lives. Outpatient programs

exist in a variety of settings, including community mental health centers, family service

agencies, private physicians’ and therapists’ offices, and specialized treatment facilities.

Inpatient services, designed for those with more serious alcohol problems, can be found in

hospitals, residential care facilities and community half-way houses.

Paying for Treatment

If you are covered by an insurance plan through the Group Insurance Commission or another

healthcare provider, your insurance will pay for a portion of treatment for alcohol or other drug

problems. Each plan has different provisions, but all provide some level of coverage. Contact

your plan for information as to how you access treatment.

Employee Assistance Program

UMass Boston is pleased to offer LifeWorks to all its employees. LifeWorks is a

comprehensive employee assistance program that provides confidential consultants you can

call on the phone 24/7, as well as an award-winning website where you can read helpful

articles, order free materials and resources, and much more.

To contact LifeWorks, call 888-267-8126 or visit LifeWorks online at www.lifeworks.com

(user id:umass, password: lifeworks). To speak with a Spanish speaking consultant, call 888-

732-9020. For TTY/TDD service, call 800-346-9188. For additional information about how

April 3, 2008 University of Massachusetts Boston Department of Human Resources


(617) 287-5150 www.umb.edu/hr

http://www.lifeworks.com/


to use the program or about LifeWorks’ management line for supervisors and managers,

contact the Department of Human Resources at 617/287-5150.

The Health Education and Wellness Center of University Health Services

The Health Education & Wellness Center is staffed by persons who can provide information

about local referral resources available to you even if you do not have medical insurance. The

Health Education & Wellness Center also has a variety of brochures and pamphlets, as well as

general information related to alcohol and other substance abuse issues.

The Health Education & Wellness Center also provides training to the campus community on a

number of topics related to substance abuse. For more information about the services of the

Health Education & Wellness Center stop by the Campus Center room 2017, call 287-5680, or

visit their website at www.umbwellness.org.

Summary of Massachusetts Substance Abuse Laws

• Massachusetts law prohibits the sale or delivery of alcoholic beverages to persons under 21

years of age, with a fine of up to $2,000 and 1 year imprisonment, or both, for violations.

Misrepresenting one’s age or falsifying an identification to obtain alcoholic beverages is

punishable by a fine of $200 and up to 3 months imprisonment.

• A first conviction for driving under the influence of alcohol has a penalty of a $500 up to

$5,000 fine, a revocation of one’s driver’s license, up to two½ years in prison, and mandatory

participation in an alcohol rehabilitation program.

• Cities and towns in Massachusetts prohibit public consumption of alcohol and impose fines

for violations. The Metropolitan District Commission also prohibits public consumption of

alcohol in its parks.

• Criminal penalties for the illicit use of controlled substances (“drugs”) vary with the type of

drug. In general, narcotics, addictive drugs, and drugs with a high potential for abuse, have

heavier penalties.

• Possession of controlled substances is illegal without valid authorization. While penalties for

possession are generally not as great as for manufacture and distribution of drugs, possession

of a relatively large quantity may be considered distribution. Under both State and Federal

laws, penalties for possession, manufacture and distribution are much greater for second and

subsequent convictions. Many of these laws dictate mandatory prison terms and require that

the full minimum term be served.

• Massachusetts law makes it illegal to be in a place where heroin is kept and to be “in the

company” of a person known to possess heroin. Anyone in the presence of heroin at a private

party risks a serious drug conviction. Sale and possession of “drug paraphernalia” is also illegal

in Massachusetts.

http://www.umbwellness.org/

• It is illegal in Massachusetts to aid or abet a person under the age of 18 in dispensing,

distributing or possessing with the intent to distribute or sell a controlled substance. Conviction

leads to a minimum term of five years in prison. Federal Penalties and Sanctions for Illegal Possession of a Controlled Substance

• 21 U.S.C. 844(a)

1st conviction: Up to 1 year imprisonment and fined at least $1,000 but no more than

$100,000, or both.

After 1 prior drug conviction: At least 15 days in prison, not to exceed 2 years and fined at

least $2,500

After 2 or more prior drug convictions: At least 90 days in prison, not to exceed 3 years and

fined at least $5,000 but no more than $250,000, or both.

special sentencing provision for possession of crack cocaine: Mandatory at least 5 years in

prison, not to exceed 20 years and fined up to $250,000, or both, if:

(a) 1st conviction and the amount of crack possessed exceeds 5 grams.

(b) 2nd crack conviction and the amount of crack possessed exceeds 3 grams.

(c) 3rd or subsequent crack conviction and the amount of crack possessed exceeds 1 gram.

• 21 U.S.C. 853(a)(2) and 881 (a)(7)

Forfeiture of personal and real property used to possess or to facilitate possession of

a controlled substance if that offense is punishable by more than 1 year

imprisonment. (See special sentencing provisions re: crack)

• 21 U.S.C. 881(a)(4)

Forfeiture of vehicles, boats, aircraft or any other conveyance used to transport or

conceal a controlled substance.

• 21 U.S.C. 844a

civil fine of up to $10,000 (pending adoption of final regulations.)

• 21 U.S.C. 853a

Denial of Federal benefits, such as student loans, grants, contracts, and professional

commercial licenses, up to 1 year for the first offense, up to 5 years for second and

subsequent offenses.

• 18 U.S.C. 922(g)

Ineligible to receive or purchase a firearm.

• Miscellaneous

Revocation of certain Federal licenses and benefits, e.g., pilot licenses, public

housing tenancy, etc., are vested within the authorities of individual Federal

agencies

UNIVERSITY OF MASSACHUSETTS

FRAUDULENT FINANCIAL ACTIVITIES GUIDELINES

(Doc. T00-051)

GUIDELINES

These Guidelines are issued pursuant to the Board of Trustees’ Policy Statement on Fraudulent

Financial Activities (Doc. T00-051, adopted August 2, 2000). Described herein are the steps to be

taken when fraud, misappropriation, or similar dishonest activities are suspected.

Each campus will be responsible for developing procedures designed to comply with this University

Guideline and informing all employees of the Policy on Fraudulent Financial Activities.

GENERAL PROTOCOL – REPORTING PROCEDURE

Anyone who believes fraud has occurred should report such incident. Employees are protected under

Massachusetts General Law, Chapter 149, section 185, from retaliatory actions by the employer.

Use the channel of communication with which you are most comfortable. Accordingly, you may report

your concerns to your immediate supervisor, department head, campus audit liaison, vice chancellor,

chancellor, and/or directly to the University Auditor’s Office or their campus police department.

Immediate supervisors, department heads, campus audit liaisons, vice chancellors, and chancellors must

report all apparent cases of fraud brought to their attention to the University Auditor’s Office, and if

appropriate, to their campus police department. Please see the last section of this guideline for situations

deemed Non-Fraud Irregularities, and reference the definition of fraud in Doc. T00-051.

RESPONSIBILITIES

University administrators and all levels of management are responsible for establishing and maintaining

proper internal controls that provide security and accountability for the resources entrusted to them.

Administrators should be familiar with the risks and exposures inherent in their areas of responsibility and

be alert for any indications of improper activities, misappropriation, or dishonest activity.

If the situation warrants immediate action – for example, obvious theft has taken place, security is at risk,

or immediate recovery is possible – management and non-managerial staff receiving reports should

immediately contact the responsible campus police department. In addition, follow the “General Protocol

- Reporting Procedure.”

Responsibilities of management and non-managerial staff for handling fraudulent activities include the

following:

Insure that notification promptly reaches the University Auditor’s Office and the campus police

department. Refer to the “General Protocol - Reporting Procedure.”

Do not contact the suspected individual to determine facts or demand restitution. Under no

circumstances should there be any reference to “what you did”, “the crime”, “the fraud”, “the

forgery”, “the misappropriation”, etc.

Managers should consult with campus or University human resources departments and University

Counsel to determine if any immediate personnel actions are necessary.

-2-

Do not discuss the case, facts, suspicions, or allegations with anyone, unless specifically directed

to do so by the University Counsel, campus police, human resources, or the University Auditor’s

Office.

Direct all inquires from any suspected individual, his or her representative, or his or her attorney

to the University General Counsel. Direct all inquiries from the media to the campus news office.

The University Auditor’s Office may investigate any suspected dishonest or fraudulent activity, which, in

its opinion, may represent risk of significant loss of assets or reputation to the University. The University

Auditor’s Office may work with internal or external departments, such as the University General

Counsel’s Office, University and campus human resources departments, campus police departments, and

Commonwealth law enforcement agencies, as circumstances may require.

Campus management will support the University’s responsibilities and will cooperate with the University

Auditor’s Office and law enforcement agencies in the detection, reporting, and investigation of fraudulent

acts, including prosecution of offenders. The University Auditor’s Office has full, free and unrestricted

access to all records and personnel of the University. Every effort should be made to effect recovery of

University losses from responsible parties or through University insurance coverage.

Great care must be taken in dealing with suspected fraudulent activities to avoid any incorrect

accusations, alerting suspected individuals that an investigation is under way, violating any person’s

right to due process, or making statements that could lead to claims of false accusation or other civil

rights violation.

INVESTIGATION RESPONSIBILITIES

The University Auditor’s Office will evaluate reported situations involving possible impropriety in

financial matters pertaining to the University and make inquiries to the extent necessary to determine

whether the allegation has substance. The campus audit liaison will be kept apprised of these activities.

The University Auditor’s Office is available and receptive to receiving relevant information on a

confidential basis and may be contacted directly whenever a fraudulent activity is suspected.

When warranted, an internal investigation will be conducted. The Auditor’s Office will proceed as

follows if evidence is uncovered showing possible dishonest or fraudulent activities.

Notify the campus audit liaison, respective area management and University General Counsel.

Advise management to meet with the campus human resources director to determine if any

immediate disciplinary personnel actions should be taken.

Coordinate the notification of insurers and filing of claims with the Treasurer’s Office Risk

Manager. The Treasurer is responsible for notifying the bonding companies and filing bonding

claims.

Advise the campus on requirements to notify the Office of the State Auditor as required by

Chapter 647 of the Acts of 1989.

If federal funds are involved, determine the required federal reporting in cooperation with

University General Counsel.

-3-

If illegal activity is indicated, the responsible campus police department will be notified to

coordinate the investigation. If illegal activity appears to have occurred, the findings will be

reported to the appropriate agency for review, such as the District Attorney and/or Attorney

General. This will be coordinated with University General Counsel.

The University Auditor’s Office will review the results of any investigations with responsible

management and cognizant administrators as necessary, making recommendations for

improvement to the systems of internal control.

NON-FRAUD IRREGULARITIES

Identification or allegations of acts outside the scope of this policy, such as personal improprieties or

irregularities, whether moral, ethical, or behavioral, safety or work environment related, or complaints of

discrimination or sexual harassment, should be resolved by the respective area management in

conjunction with human resources and/or reference to any other existing University guidance or resource.

Examples include the scholarly and research misconduct policy, the principles of employee conduct, the

policy against intolerance, the sexual harassment policy, and the MGL Chapter 268A conflict of interest

law (this list is not all-inclusive). The campus Ombuds Office or Equal Opportunity Office may also be

of assistance.

The University Auditor’s Office or University General Counsel may be contacted if guidance is needed to

determine if an action might constitute fraud as defined in this policy.

DOC. T96-136, as amended

Passed by the BoT

12/4/96

PRINCIPLES OF EMPLOYEE CONDUCT

UNIVERSITY OF MASSACHUSETTS

Institutions of higher education are entrusted with great resources and commensurably

great responsibilities. They must meet their mission of research, teaching, and service in

ways that truly enrich the society that supports them and truly serve the students, parents,

and alumni who in joining the university community become life-long members of the

extended university learning family. College and university leaders play a key role in

assuring that high standards of ethical practice attend to the delivery of services to their

various constituents and to the custody and use by all their faculty, staff and students of

the resources entrusted to them. The University of Massachusetts embraces the values

expressed in these Principles of Employee Conduct and expects their observance by all

its employees.

University employees are entrusted with public resources and are expected to

understand their responsibilities with respect to conflicts of interest and to behave

in ways consistent both with law and with University policy.

University employees are expected to be competent and to strive to advance

competence both in themselves and in others.

The conduct of University employees is expected to be characterized by integrity

and dignity, and they should expect and encourage such conduct by others.

University employees are expected to be honest and conduct themselves in ways

that accord respect to themselves and others.

University employees are expected to accept full responsibility for their actions

and to strive to serve others and accord fair and just treatment to all.

University employees are expected to conduct themselves in ways that foster

forthright expression of opinion and tolerance for the view of others.

University employees are expected to be aware of and understand those

institutional objectives and policies relevant to their job responsibilities, be

capable of appropriately interpreting them within and beyond the institution, and

contribute constructively to their ongoing evaluation and reformulation.

The University is responsible for communicating to University employees the content of

these Principles of Employee Conduct and for ensuring that the standards of conduct

contained herein are met.

The University expects to provide its employees:

a work environment that is professional and supportive;

a clear sense of the duties of their job, the procedures for performance review, and

access to relevant University policies and procedures;

within the scope of each employee's assigned areas of authority and

responsibility, the duty to exercise appropriate judgment and initiative in

performing duties;

the right to seek appropriate review of matters that violate the ethical principles

contained in these Principles.