valid driver’s license and or - hanover ma
TRANSCRIPT
TOWN OF HANOVER
PAYROLL & BENEFITS OFFICE
188 BROADWAY
HANOVER, MASSACHUSETTS 02339
(781) 878-0786
Website: www.hanover-ma.gov
Welcome to the Town of Hanover! The Payroll and Benefits Office for the Town of Hanover would like to congratulate and welcome you on your new
position. The staff is available and prepared to offer assistance in whatever you need.
Please complete all of the enclosed documents and contact Audrey Barresi at (781)878-0786 X 5009 to set up an
appointment to bring in and review your paperwork. It is VERY IMPORTANT you bring the required
documentation listed below with you to your appointment.
Conflict of Interest Law Summary and Training (must bring completed certificate with you
when you bring in your new hire paperwork.) Use this link to complete the required
training http://www.muniprog.eth.state.ma.us/
Voided check or bank authorization form for direct deposit.
Valid Driver’s License AND social security card OR birth certificate
OR a Valid U.S. Passport
Copy of your birth certificate (for all employees hired for 20+ hours per week)
Social Security numbers and birthdates for any dependents or beneficiaries you may be including
on health, life, or retirement documents.
Birth Certificates for any dependents you are adding to your health insurance.
Primary Care Physician (PCP) #’s for health insurance forms.
** You may NOT begin employment until all documents and proper identification needed
have been received.
All new employees are also required to review the following documents which can be found on our website at
http://www.hanover-ma.gov/payrollbenefits-office/pages/required-notices
Children’s Health Insurance Program (CHIP) Notice
HIPAA Notice of Privacy Practices
HIPAA Notice of Special Enrollment Rights
Creditable Coverage Disclosure Notice
Health Insurance Marketplace Information
Sexual Harassment Policy
For more information please feel free to contact the office with any questions or concerns at
781-878-0786.
Payroll/Benefits Supervisor Lisa Keefe Ext. 5007
Benefits Administrator: Audrey Barresi Ext. 5009
Payroll Assistant: Lisa Feeney Ext. 5008
------------------------------------------------------------------------------------------------------------------------------- Please sign below in acknowledgment that you have been notified of the required employee documents listed.
__________________________ _______________________ __________________
Employee signature Benefits Administrator Date
MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/12
Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City. . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .
FORMM-4
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Employee:File this form or Form W-4 withyour employer. Otherwise,Massachusetts Income Taxeswill be withheld from yourwages without exemptions.
Employer:Keep this certificate with yourrecords. If the employee isbelieved to have claimedexcessive exemptions, theMassachusetts Departmentof Revenue should be soadvised.
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . . . . . . . . . .
2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will
be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Additional withholding per pay period under agreement with employer $ _____________________
A. Check if you will file as head of household on your tax return.
B. Check if you are blind. C. Check if spouse is blind and not subject to withholding.
D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual incomewill not exceed $8,000.
EMPLOYER: DO NOT withhold if Box D is checked.
I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THIS FORM MAY BE REPRODUCED
THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE
IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.
A. Number. If you claim more than the correct number of exemptions, civiland criminal penalties may be imposed. You may claim a smaller number ofexemptions. If you do not file a certificate, your employer must withhold onthe basis of no exemptions.
If you expect to owe more income tax than will be withheld, you may eitherclaim a smaller number of exemptions or enter into an agreement with youremployer to have additional amounts withheld.
You should claim the total number of exemptions to which you are entitled toprevent excessive overwithholding, unless you have a significant amount ofother income.
If you work for more than one employer at the same time, you mustnot claim any exemptions with employers other than your principalemployer.
If you are married and if your spouse is subject to withholding, each mayclaim a personal exemption.
B. Changes. You may file a new certificate at any time if the number ofexemptions increases. You must file a new certificate within 10 days if thenumber of exemptions previously claimed by you decreases. For example,if during the year your dependent son’s income indicates that you will notprovide over half of his support for the year, you must file a new certificate.
C. Spouse. If your spouse is not working or if she or he is working but notclaiming the personal exemption or the age 65 or over exemption, general-ly you may claim those exemptions in line 2. However, if you are planning tofile separate annual tax returns, you should not claim withholding exemp-tions for your spouse or for any dependents that will not be claimed on yourannual tax return.
If claiming a wife or husband, write “4” in line 2. Using “4” is the withholdingsystem adjustment for the $4,400 exemption for a spouse.
D. Dependent(s). You may claim an exemption in line 3 for each individualwho qualifies as a dependent under the Federal Income Tax Law. In addition,if one or more of your dependents will be under age 12 at year end, add “1”to your dependents total for line 3.
You are not allowed to claim “federal withholding deductions andadjustments” under the Massachusetts withholding system.
If you have income not subject to withholding, you are urged to haveadditional amounts withheld to cover your tax liability on such income.See line 5.
TOWN OF HANOVER PAYROLL & BENEFITS OFFICE
188 BROADWAY
HANOVER, MASSACHUSETTS 02339 (781) 878-0786
Website: www.hanover-ma.gov
DIRECT DEPOSIT
The Town of Hanover offers the use of direct deposit for all employees. This benefit allows you to have your paycheck deposited
electronically to any bank account(s) YOU specify. There are no restrictions on your choice of financial institutions.
Direct deposit will benefit you in many ways. There is no need to stand in line at the bank and there will be no hold on your money
until your payroll check clears. Your money is available for immediate use each Thursday at 12:01 a.m. To sign up for direct deposit,
please complete the information requested below. If your funds will be deposited into a checking account please attach a voided check
and return it to the Payroll/Benefits Department.
** A voided check or a bank authorization form is required for all direct deposits.
Employee Name: _____________________________ Department: School Town
Primary Direct Deposit-
(Full Net Amount of Check to be deposited)
Financial Institution: ______________________________________ NEW CHANGE
Routing Number ____________________________ Account Number ____________________
Checking Account Savings account
PLEASE STOP THIS DIRECT DEPOSIT:_______________
DATE
If you wish to deposit funds into additional accounts such as Savings Account, Christmas Club or an
additional Checking Account please complete below and specify amount
Financial Institution 2: ______________________________________
Checking Account Savings account
Routing Number ____________________________ Account Number ______________________
Amount $ __________ PLEASE STOP THIS DEDUCTION:_______________
DATE
Financial Institution 3: ______________________________________
Checking Account Savings account
Routing Number ____________________________ Account Number ______________________
Amount $ _________ PLEASE STOP THIS DEDUCTION:_______________
DATE
I hereby authorize the Town of Hanover to electronically deposit my paycheck to the financial institutions noted above.
Signature__________________________________________ Date____________________________
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 07/17/17 N Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1
Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
7. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
EMERGENCY CONTACT FORM
TOWN OF HANOVER
PAYROLL & BENEFITS OFFICE
188 BROADWAY
HANOVER, MA 02339
(781)878-0876 X23
EMPLOYEE EMERGENCY CONTACT INFORMATION FORM
EMPLOYEE PERSONAL INFORMATION
LAST NAME: FIRST NAME: MIDDLE INITIAL:
ADDRESS:
CITY: STATE: ZIP CODE:
CELL PHONE: HOME PHONE:
PERSONAL E-MAIL ADDRESS:
TOWN INFORMATION
WORK PHONE: E-MAIL ADDRESS:
PRIMARY EMERGENCY CONTACT INFORMATION (emergency contacts should be local)
LAST NAME: FIRST NAME:
CELL PHONE # HOME PHONE #:
SECONDARY EMERGENCY CONTACT INFORMATION
LAST NAME: FIRST NAME:
CELL PHONE # HOME PHONE #:
I CHOOSE NOT TO PROVIDE PERSONAL CONTACT INFORMATION.
ACKNOWLEDGE THAT BY NOT DOING SO THERE MAY BE CRITICAL INFORMATION NOT ABLE TO BE SENT TO ME IN A TIMELY FASHION.
THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS
Criminal Offender Record Information (CORI) Acknowledgement Form
To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes.
_______________________________________________________________________________ is registered under the (Organization)
provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to __________________________________________________________
(Organization) to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing
with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
The _______________________________________________________________________________ may conduct (Organization)
subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that _______________________________________________________________________________, must first provide me
(Organization) with written notice of this check.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
___________________________________________________________ _________________________________ Signature of CORI Subject Date
IMPORTANT - Please complete below
SCHOOL or BUILDING__________________________________
POSITION (Please circle one):
Employee Contractor Volunteer Student Teacher/Observer Other(Please Specify)______________
THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS
2
SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are requesting. The fields marked with an asterisk (*) are required fields.
* First Name: ________________________________________________________ Middle Initial: _________________
* Last Name:_________________________________________________________ Suffix (Jr., Sr., etc.): _____________
Former Last Name 1: _______________________________________________________________________________
Former Last Name 2: _______________________________________________________________________________
Former Last Name 3: _______________________________________________________________________________
Former Last Name 4: _______________________________________________________________________________
* Date of Birth (MM/DD/YYYY): ___________________ Place of Birth: ________________________________________
* Last SIX digits of Social Security Number: ___ ___ ‐‐ ___ ___ ___ ___ ☐ No Social Security Number
Sex: _________________ Height: _____ ft. _____ in. Eye Color: _______________ Race: ______________________
Driver’s License or ID Number: ______________________________________ State of Issue: ____________________
Father’s Full Name: ________________________________________________________________________________
Mother’s Full Name: _______________________________________________________________________________
Current Address
* Street Address: ____________________________________________________________________________________
Apt. # or Suite: _____________ *City: __________________________ *State: ________ *Zip: _______________
DO NOT WRITE BELOW THIS LINE - For Internal Purposes Only
The above information was verified by reviewing the following form(s) of government‐issued identification: _______________________________________________________________________________________________
_______________________________________________________________________________________________ _________________________________________________________________________________________________
Verified by:
_________________________________________________________
Print Name of Person Verifying information
__________________________________________________________Signature
_________________________________ Date
**
Hanover Public Schools
Matthew A. Ferron
Superintendent of Schools
Deborah St. Ives
Assistant Superintendent
Thomas R. Raab, Ed.D.
Business Manager
Keith Guyette
Director of Student Services
188 Broadway, Hanover, MA 02339 ● www.hanoverschools.org ● Telephone 781-878-0786 ● Facsimile 781-871-3374
The mission of the Hanover Public Schools is to guide every student to thrive in a global society.
To: Newly Hired Hanover Public School Employees
From: Lisa Keefe, Payroll & Benefits Office
Subject: Fingerprinting Requirements for Public School Employees
Date: October 15, 2018
Overview:
Effective July 1, 2013, all school employees are required to submit fingerprints for a state and national
criminal records check. Under this law, all newly hired school employees are required to submit their
fingerprints for state and national criminal history background checks prior to beginning their active
employment. Fingerprinting is a one-time process, unlike CORI’s, which we will continue to process
every three years.
The Vendor:
The vendor selected to process school employee fingerprints in the state of Massachusetts is Morpho
Trust USA. They operate IdentoGo Centers throughout the state of Massachusetts. Please refer to their
website https://www.identogo.com/locations/massachusetts for center locations, directions, and additional
information.
Registration Process:
There are two ways to register. You can register on-line at the IdentoGo website
https://www.identogo.com/locations/massachusetts or you can call 866-349-8130 to set up an
appointment. You must make an actual appointment to be fingerprinted. IdentoGo does not allow walk-
in appointments.
Prior to registering, please review the materials provided under the Massachusetts: Forms and Links
section on the IdentoGo website. This is where you can find a list of acceptable forms of identification
(everyone must bring one valid current form of ID to their fingerprinting session), the Registration Guide
for the ESE fingerprinting process and other important information.
The registration process takes about 5 minutes and most of the information requested is of a personal
nature, however, there is specific school district information that is required and that information is
provided below:
Agency/Sector: Pre-K-12th
Grade Education (ESE)
Fingerprinting Information
Continued
Page 2
Provider ID: Location Code
Cedar Elementary 01220004
Center Elementary 01220005
Sylvester 01220015
Hanover Middle 01220305
Hanover High 01220505
Hanover 01220000 (Districtwide/ Salmond employees)
Applicant Employer Information: Hanover Public Schools
188 Broadway
Hanover, MA 02339
(781)878-0786
Employer Contact Name: Lisa Feeney, Payroll & Benefits Office
When you complete your registration, you will receive a confirmation number. You must bring your
confirmation number and a verifiable and unexpired form of ID (as listed on the website) to your
appointment.
Fees:
Each individual is responsible for the cost of their fingerprinting. There is a fee of $35.00 for the non-
licensed employees and a $55.00 fee for DESE licensed professionals (including those with pending
applications/ licenses). Payment can be made on-line with a credit card at the time of your registration or
you can pay with a personal check at your IdentoGo center.
Substitutes:
Under the new law, substitutes are school employees so they must adhere to the new fingerprinting
guidelines. Substitutes may, however provide up to 10 district Provided ID codes on their registration.
In order to do this, you will need to contact each district and ask for their code so you can process all of
them at the same time. This will help control the cost and time associated with the process for those
substitutes working in more than one district. Like all other employees, if a substitute teacher is licensed,
the fee is $55.00 and if they are not licensed, the fee is $35.00.
Fingerprinting session:
It only takes about 5 minutes to be fingerprinted. Please make sure you bring your confirmation number
and a valid ID with you to your appointment. When your fingerprints have been processed, you will
receive a SAFIS Fingerprinting Receipt which looks like a credit card slip. You MUST provide a copy
of this to Lisa Feeney, Payroll & Benefits Office, Salmond School, before you can begin your
employment. This is our confirmation that your fingerprints have been processed.
We MUST receive your fingerprinting results before you can begin work.
If you have any questions, please contact Lisa Feeney at [email protected] or call (781)878-
0786 X5008
TO: ALL TOWN ELIGIBLE EMPLOYEES
FROM: PAYROLL & BENEFITS OFFICE
FY 19 INSURANCE RATES
PLAN NAME GROUP WEEKLY BI WEEKLY 21 PAY* 42 PAY* 39 PAY*39 PAY* - LTS-
10 MONTH
EMPLOYEE MONTHLY
COST
BCBS- Blue
Care Elect Rate SaverIndividual $151.00 $302.00 $345.14 $172.57 $185.85 $154.87 $604.00
Family $357.75 $715.50 $817.71 $408.86 $440.31 $366.92 $1,431.00
BCBS- Blue
Care Elect BenchmarkIndividual $135.63 $271.25 $310.00 $155.00 $166.92 $139.10 $542.50
Family $321.50 $643.00 $734.86 $367.43 $395.69 $329.74 $1,286.00
BCBS-
Network Blue Rate SaverIndividual $103.75 $207.50 $237.14 $118.57 $127.69 $106.41 $415.00
Family $276.50 $553.00 $632.00 $316.00 $340.31 $283.59 $1,106.00
BCBS- Network
Blue BenchmarkIndividual $95.75 $191.50 $218.86 $109.43 $117.85 $98.21 $383.00
Family $254.88 $509.75 $582.57 $291.29 $313.69 $261.41 $1,019.50
HARVARD PILGRIM - HMO
Rate SaverIndividual $112.38 $224.75 $256.86 $128.43 $138.31 $115.26 $449.50
Family $299.13 $598.25 $683.71 $341.86 $368.15 $306.79 $1,196.50
HARVARD PILGRIM - Benchmark Individual $105.88 $211.75 $242.00 $121.00 $130.31 $108.59 $423.50
Family $281.88 $563.75 $644.29 $322.14 $346.92 $289.10 $1,127.50
RETIREES
BCBS-MedexIndividual
Only$187.00
Dental Insurance (Active Employees Only)
Dental is offered as an optional insurance with no Town contribution. There is NO increase for the FY19 year.
Plan Name Group Weekly Bi Weekly 21 Pay* 42 Pay* 39 Pay*39 LTS Pay* -
10 month
Employee’s Monthly
Cost
Delta Dental Premier Individual $9.75 $19.50 $22.29 $11.14 $12.00 $10.00 $39.00
Delta Dental Premier Family $24.25 $48.50 $55.43 $27.71 $29.85 $24.87 $97.00
*21 -Pay applies to Teachers only
*42- Pay applies to paraprofessionals and tutors
*39- Pay applies to cafeteria employees
*39 LTS Pay- applies to 10 Month coverage
Page 10 of 10
Employee Acknowledgement:
(Employees with MMHG health insurance must sign and return to employer)
� I understand that I am required to notify my employer within thirty (30) days of the following
events:
a. marriage
b. birth of a child
c. adoption of a child or placement for adoption
d. legal guardianship
e. divorce
f. death of a dependent
g. dependent’s loss of status as a dependent (except for turning age 26)
h. myself, my spouse or dependent becoming eligible for Medicare and/or enrolling in
Medicare
i. divorced spouse’s re-marriage
j. change of address
Caution: Failure to notify your employer that your dependent(s) is/are no longer eligible may
result in being financially responsible for any claims that were paid for an ineligible dependent.
Your contract may be cancelled retroactively if you have committed fraud or misrepresented
yourself and/or dependent(s).
� I understand that I may cancel health insurance for myself and/or dependent(s) voluntarily at
any time with 30 days advance notice.
� If I refuse health insurance or cancel coverage I understand that I may only enroll during the
next open enrollment period (effective July 1st) unless a valid qualifying event occurs.
� I have received the comparison of benefits, Summary of Benefits and Coverage (SBC) and/or
other benefit plan summary information that explain my health insurance benefits, HIPAA
notice of privacy practices or have gone online to receive this information at
www.MMHG.org
Mayflower Municipal Health Group reserves the right to request additional information to
support eligibility in accordance with G.L. c.32B section 6.
In order to process your Health Insurance enrollment please read this form, sign, and date. Attach
this document to your completed enrollment application. Please keep a copy of this form for your
records.
VISIT US ON THE WEB AT: WWW.MMHG.ORG
___________________________________ ______________
Signature (subscriber) Date
Print Name:_______________________ / Employer/Governmental Unit:______________________
Email address __________________________ (you will receive wellness email updates with
important incentive programs and your email address will not be shared with anyone)
Insurance plan selected (circle one): BCBS HP / Type of plan (circle one): IND FAM
TOWN OF HANOVER
PAYROLL & BENEFITS OFFICE
188 BROADWAY
HANOVER, MASSACHUSETTS 02339
(781) 878-0786 Website: www.hanover-ma.gov
The Town of Hanover offers health insurance, dental insurance, and life insurance to all of its
eligible employees. To be eligible for benefits, an employee is required by state law to work a
minimum of twenty (20) hours per week. Upon date of hire, employees have only thirty (30) days
to enroll in these plans. Employees must enroll the first day of the month following date of hire,
during open enrollment (generally held in April and effective July 1), or following a qualifying
event.
Benefits are administered one month in advance; and employees who choose to elect benefits
may be responsible for the first month’s or a portion of the first month’s premium directly.
Employees who elect dental insurance must stay on the plan for a minimum of one year from the
start or coverage date.
Your signature below indicates that you have been offered benefits as explained with the Town of
Hanover and if you do not accept them at this time, you must wait for open enrollment or may
become eligible after a qualifying event such as marriage, birth/ adoption of a child, divorce, or loss
of coverage.
I have been offered Health Insurance Benefits with the Town of Hanover, I understand that I have
thirty (30) days from my hire date to accept this benefit. If I do not accept at this time, I understand
that if I am eligible, I may have an option of joining the Town’s Health Plan(s) only during the open
enrollment period.
Signed _______________________________ Date ________________________
I have been offered Life Insurance Benefits with the Town of Hanover, I understand that I have
thirty (30) days from my hire date to accept this benefit. If I do not accept at this time, I understand
that if I am eligible, I may have an option of joining the Town’s Life Insurance Plan(s) only during
the open enrollment period unless I take and pass a physical as per the requirement of the Town’s
insurance carrier.
Signed _______________________________ Date ________________________
I have been offered Dental Insurance Benefits with the Town of Hanover, I understand that I have
thirty (30) days from my hire date to accept this benefit. If I do not accept at this time, I understand
that if I am eligible, I may have an option of joining the Town’s Dental Plan(s) only during the open
enrollment period.
Signed _______________________________ Date ________________________
The mission of Hanover Public Schools is to guide every student to thrive in a global society.”
Hanover Public Schools 188 Broadway
Hanover, MA 02339
Telephone (781) 878-0786
Facsimile (781) 871-3374
Matthew A. Ferron
Superintendent of Schools
Hanover Public School Employees 403(b) Salary Reduction Contribution Eligibility Notification
I have been notified that I am eligible to participate in the Hanover Public School 403(b) Salary
Reduction Program. Should I elect to participate, I will complete a Salary Amendment
Agreement form and return it to the Payroll & Benefits Office. New staff may begin participating
upon their date of hire. Existing staff are encouraged to make changes to previous elections or
elect to participate during the first 90 days of each school year.
Name: _______________________________________ Date of Hire: _____________
Signature: ____________________________________ Date: ____________________
The following Companies are currently available with the Town of Hanover:
• Life Insurance Co. of the Southwest
• VALIC
• Ameriprise Financial
• Fidelity Investments
• Metlife Resources
• Great American Financial Resources
• Horace Mann
• AXA Equitable
• Lincoln Investment
• Oppenheimer Funds
• Secure Benefits
Please note, under the new regulations, there may be no life insurance, incidental or otherwise,
component of your chosen investment.
Additional information about the 403(b) Salary Reduction Plan can be found on the Plan
Administrators website, TSA Consulting Group, www.tsacg.com or by contacting the Payroll &
Benefits Office at 781-878-0786.
Hanover Public Schools
Matthew A. Ferron
Superintendent of Schools
Deborah St. Ives
Assistant Superintendent
Thomas R. Raab, Ed.D.
Business Manager
Joan Woodward
Director of Student Services
188 Broadway, Hanover, MA 02339 ● www.hanoverschools.org ● Telephone 781-878-0786 ● Facsimile 781-871-3374
The mission of the Hanover Public Schools is to guide every student to thrive in a global society.
HANOVER PUBLIC SCHOOLS
SECTION 409A INFORMATION SHEET
This is to notify you that under IRS Regulation 409A, employers providing 10 month employees with an option of
21 or 26 payments must provide an election notice prior to the start of the following school year. Employees must
provide the employer with a written notice of their election to avoid paying additional income tax on the amounts
deferred. Amounts are considered deferred under a 26 week election. This election is irrevocable for the school year
in question. However employees may change their election for future years provided they do so before the start of
the school year. Should an employee not notify the school prior to the start of the school year or start working
after the school year has started, the employee will be put on the default option of 21 payments as prescribed
by the IRS. In the event of separation from service as defined in Section 409A of the Treasury Regulations,
employees will be paid based on their per diem for the number of contract days worked.
PAY PREFERENCE In accordance with Section 409A (Tax Rules Defining Deferred Compensation for School Employees), I
acknowledge that I have received written notice that, as an employee with a choice between a 21 or a 26 payment
system, prior to the 2018-2019 school year, I must notify the employer, in writing, of the manner in which I wish to
receive my pay.
Accordingly, I wish to receive my salary payment in the following manner:
21 Payments
26 Payments with payments 22 through 26 paid as a lump sum payment (with separate checks for
each week) along with payment 21 in June
This election is irrevocable for the 2018-2019 school year. If I fail to submit written notice on a timely basis, I
will be paid based on a 21 payment schedule. Failure to submit written notice on a timely basis may also
subject me to a 20% tax penalty on any salary amounts deemed to be deferred by the IRS.
In the event of my separation from service as defined in Section 409A of the Treasury Regulations, if such
separation from service occurs before the end of the payment period, I will be entitled to be paid at my per diem rate
for the number of days worked but not yet paid from the beginning of the school year pay period until the date of my
separation from service. Any adjustment will be included in my final paycheck.
This notice of payment election will continue for future years unless and until I provide a written notice of
revocation prior to the start of such school year.
Name: School:
Signature: ________________________________________________ Date:_______________
This form must be completed and returned to the Payroll & Benefits Office