HUMAN RESOURCES DEPARTMENT
13801 E Benson Highway • Vail, AZ 85641 • 520-879-2002 • FAX 520-879-2076
Pre-Employment Packet
This packet is given to applicants as part of the pre-employment
process.
This packet does not constitute an offer of employment.
Offers of employment are contingent upon the hiring supervisor
obtaining satisfactory employment verification and background checks,
and the hiring recommendation being approved by the Governing
Board.
If you have any questions regarding a position with the Vail School
District, please follow up with the site’s principal, or the District’s
Human Resources Director.
10/01/2011
Form W-4 (2016)
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 2016 expires
February 15, 2017. 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 cannot claim exemption
from withholding if your 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 do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not 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 2016. 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
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
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
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
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.)
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.
G
• 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 . .
▶
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
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
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
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ 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.
Your first name and middle initial
2
Last name
Home address (number and street or rural route)
3
Single
Married
2016
Your social security number
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
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, 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.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2016)
Page 2
Form W-4 (2016)
Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
1
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your
income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300
and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and
not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . .
$12,600 if married filing jointly or qualifying widow(er)
2
Enter:
$9,300 if head of household
. . . . . . . . . . .
$6,300 if single or married filing separately
3
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
4
Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
5
Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
6
7
8
9
10
}
Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
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
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
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.
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” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . .
1
2
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
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2016. 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 2016. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
6
7
8
$
$
9
$
Table 2
All Others
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $6,000
6,001 - 14,000
14,001 - 25,000
25,001 - 27,000
27,001 - 35,000
35,001 - 44,000
44,001 - 55,000
55,001 - 65,000
65,001 - 75,000
75,001 - 80,000
80,001 - 100,000
100,001 - 115,000
115,001 - 130,000
130,001 - 140,000
140,001 - 150,000
150,001 and over
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$0 - $9,000
9,001 - 17,000
17,001 - 26,000
26,001 - 34,000
34,001 - 44,000
44,001 - 75,000
75,001 - 85,000
85,001 - 110,000
110,001 - 125,000
125,001 - 140,000
140,001 and over
0
1
2
3
4
5
6
7
8
9
10
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.
If wages from HIGHEST
paying job are—
$0 - $75,000
75,001 - 135,000
135,001 - 205,000
205,001 - 360,000
360,001 - 405,000
405,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,420
1,600
All Others
If wages from HIGHEST
paying job are—
$0 - $38,000
38,001 - 85,000
85,001 - 185,000
185,001 - 400,000
400,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,600
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.
Arizona Form
A-4
2016
Employee’s Arizona Withholding Election
Type or print your Full Name
Your Social Security Number
Home Address – number and street or rural route
City or Town
State
ZIP Code
Choose either box 1 or box 2:
 1 Withhold from gross taxable wages at the percentage checked (check only one percentage):
 0.8%
 1.3%
 1.8%
 2.7%
 3.6%
 4.2%
  Check this box and enter an extra amount to be withheld from each paycheck ................
 5.1%
$
 2 I elect an Arizona withholding percentage of zero, and I certify that I expect to have
no Arizona tax liability for the current taxable year.
Print
I certify that I have made the election marked above.
SIGNATURE
DATE
Employee’s Instructions
Arizona law requires your employer to withhold Arizona income
tax from your wages for work done in Arizona. This amount
is applied to your Arizona income tax due when you file your
tax return. The amount withheld is a percentage of your gross
taxable wages of every paycheck. You may also have your
employer withhold an extra amount from each paycheck.
Complete this form to select a percentage and any extra
amount to be withheld from each paycheck.
What are my “Gross Taxable Wages”?
For withholding purposes, your “gross taxable wages” are the
wages that will generally be in box 1 of your federal Form W-2.
It is your gross wages less any pretax deductions, such as your
share of health insurance premiums.
New Employees
Complete this form in the first five days of employment to select
an Arizona withholding percentage. You may also have your
employer withhold an extra amount from each paycheck. If you
do not file this form, the department requires your employer to
withhold 2.7% of your gross taxable wages.
Current Employees
If you want to change the current amount withheld, you must
file this form to change the Arizona withholding percentage or
change the extra amount withheld.
What Should I do With Form A-4?
Give your completed Form A-4 to your employer.
ADOR 10121 (15)
Electing a Withholding Percentage of Zero
You may elect an Arizona withholding percentage of zero
if you expect to have no Arizona income tax liability for the
current year. Arizona tax liability is gross tax liability less any
tax credits, such as the family tax credit, school tax credits, or
credits for taxes paid to other states. If you make this election,
your employer will not withhold Arizona income tax from your
wages for payroll periods beginning after the date you file
the form. Zero withholding does not relieve you from paying
Arizona income taxes that might be due at the time you file
your Arizona income tax return. If you have an Arizona tax
liability when you file your return or if at any time during the
current year conditions change so that you expect to have a tax
liability, you should promptly file a new Form A-4 and choose a
percentage that applies to you.
Voluntary Withholding Election by Certain
Nonresident Employees
Compensation earned by nonresidents while physically working
in Arizona for temporary periods is subject to Arizona income
tax. However, under Arizona law, compensation paid to certain
nonresident employees is not subject to Arizona income tax
withholding. These nonresident employees need to review
their situations and determine whether they should elect to
have Arizona income taxes withheld from their Arizona source
compensation. Nonresident employees may request that their
employer withhold Arizona income taxes by completing this
form to elect Arizona income tax withholding.
EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM
I, [employee] ___________________________________________________ , : hereby
PRINT NAME
Authorize Vail Unified School District and its agents, including financial institutions, to initiate electronic
credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my checking
and/or savings accounts listed below. This authorization will remain in effect until I have informed the
district in writing that I wish to cancel it and the district has had reasonable time to effect such
cancellation. I understand I should contact my bank to verify receipt of funds.
Cancel direct deposit of my paycheck completely. This cancellation is to take effect immediately and
remain in full force and effect until the district has received written notification from me of authorization
to deposit my paycheck automatically. I acknowledge that I will now receive paychecks for which I am
responsible for depositing and/or cashing.
Direct
Deposit
Net Pay
Deduction 1
Deduction 2
Deduction 3
Bank Name
Account Type
Routing Number
Account Number
Checking
Savings
Amount
per
pay period
N/A
Checking
Savings
Checking
Savings
Checking
Savings
Please attach a voided check or bank confirmation letter (showing account information) for each bank account to
which funds will be deposited.
There is a lag time of one pay period before your direct deposit is effective.
Employee’s Signature: ________________________________ Date: _____________ Site: ___________________
Revised 02/2016
VAIL UNIFIED SCHOOL DISTRICT NO. 20
EMPLOYEE INFORMATION FORM
(Information required to comply with Vail School District Employee Reporting to the Arizona Department
of Education and required record keeping for personnel)
(PLEASE PRINT CLEARLY)
SOC. SEC. #:
FULL NAME (Last, First, Middle):
SALUTATION (Mr., Mrs., Ms., Dr., Other):
MARITAL STATUS: Single
Married
Other
NICKNAME (S):
MAIDEN OR OTHER NAMES USED:
HOME ADDRESS:
CITY:
STATE:
ZIP:
STATE:
ZIP:
MAILING ADDRESS:
CITY:
PHONE #: (Home)
(Work)
(Cell)
HOME EMAIL ADDRESS (Optional):
BIRTHDATE (month/day/year):
GENDER (M - Male, F - Female):
EMERGENCY CONTACTS: (please supply contact information for at least two (2) contacts.)
#1: NAME:
RELATIONSHIP:
PHONE:
#2: NAME:
RELATIONSHIP:
PHONE:
#3: NAME:
RELATIONSHIP:
PHONE:
#4: NAME:
RELATIONSHIP:
EMPLOYEE SIGNATURE:
PHONE:
DATE:
-
-
Vail Unified School District No. 20
STATEMENT OF UNDERSTANDING
Hours Worked/Time Recording/At-Will Status
Under the law, the U.S. Fair Labor Standards Act, the District is required to keep certain records
on their employee compensation practices. These include the accurate recording of time on a daily and
weekly basis for classified non-exempt employees.
Classified employees are not permitted to start work early, but they are to be at their work
location to begin work at the starting time. Employees will be expected to abide by the designated lunch
periods and clean-up times each day.
In order to make sure that (1) accurate records are kept, (2) classified non-exempt employees are
not working without recording their time, and (3) the District will not be in violation of the law, we need
to make sure that all employees are aware of the time recording requirements. To do this, and to have
proof for the Department of Labor, the Statement of Understanding must be read and signed by the
employees. A copy of this Statement will be retained in the personnel files. Failure to abide by the laws
and Governing Board Policy which governs wage and hour issues will subject any employee to
disciplinary action.
1. The normal workweek begins on Thursday and ends on Wednesday. The standard
workweek for full-time classified employees consists of 40 hours. If employees
work overtime (in excess of 40 hours in the workweek, they are to be paid one and
one-half (1 1/2) times the regular or average hourly rate for hours worked in excess
of 40.
2. Overtime may not be worked without prior approval from the appropriate
Supervisor.
3. Employees cannot volunteer to work overtime. Employees should not be
intimidated into working overtime without recording it. If the employees attempts
to volunteer (come in early, stay late, work during the duty free lunch period, or
bringing work home), disciplinary action may have to be taken. Likewise, if
supervisory personnel try to force employees to work overtime without recording it,
notice must be given to the personnel director so that disciplinary action maybe
taken.
4. Employees must record their time worked in the time keeping system. This time
will be confirmed by the supervisor and submitted to Payroll. Adjustments will be
processed the following pay period.
You are expected to comply with the requirements of the job description and Board policies while
employed by the District.
A Vail School District employee can resign his/her position at will, at any time, with or without cause
unless both the employee and the District have signed a written contract to the contrary. Similarly, the
District may terminate the at will employment relationship at any time, with or without notice or cause, so
long as there is no violation of applicable federal or state law.
Employee Name – Please Print
Signature of Employee
Date
Revised 07/2013
PROOF OF IMMUNIZATION
Check one:
_____I am providing a record of immunization against Rubella and
Rubeola with a live virus vaccine given on or after the
first birthday.
_____I am providing a statement, signed by a licensed physician or a state
or local health officer, that affirms serologic evidence of having had
Measles. (Titer)
_____I was born prior to January 1, 1957 therefore according to district
policy I shall be considered to be immune to Rubeola and Rubella.
_____I claim exemption due to a medical contraindication for receiving
vaccines or due to religious beliefs.
I understand that in the event of an outbreak of Rubeola/Rubella non-immune
staff members including those who utilize the exemption must be
excluded from school.
PRINT NAME:________________________________DATE:_________
SIGNATURE:________________________________________________
Vail Unified School District
Certified Substitute Preferences
Name:
___
Assignment Preferences
Days Available:
(check)
All
Mon
Full Day: (check)
YES
NO
Half Day: (check)
YES
NO
Specified Grade Level: (check)
Grade Level Comments:
ALL
Tue
Elementary
Wed
Thur
Middle
Fri
High School
__________________________________________________
____________________________________________________________________________
Specified Subjects: (check)
ALL
Preschool Special Needs
K-3 Classroom
4-6 Classroom
Middle School Math
High School Math
Science/Biology/Chemistry
Language Arts/English
Social Studies/History
Foreign Language
PE
Art
Music/Band
Drama
Special Education
Subject Comments: ___________________________________________________________
____________________________________________________________________________
Specified Campus (if any): ______________________________________________________
____________________________________________________________________________
Are you interested in substituting in classified positions?
YES
NO
Confidentiality Requirements
The Family Education Rights and Privacy Act (FERPA), and Vail School District
Governing Board Policy require that all student records shall be developed, maintained,
utilized, and disseminated in such a manner as to protect the privacy rights of students.
All school district personnel must maintain the confidentiality of personally identifiable
information pertaining to any Vail student. This includes any student name; educational
records and test results; any verbal/written anecdotal information; any placement data;
any information relating to counseling services rendered to any student or parent; or any
information relating to a student’s handicapping condition, or placement in special
education.
Discussion between any school personnel concerning any student should occur only
between school personnel who have a direct interest in the education of the student. Such
discussions are frequently necessary and advisable but must occur in a private place with
no other personnel in attendance. Personnel shall refrain from such confidential
discussions in the teachers’ lounge, office, hallways, cafeteria, bus areas, school
playgrounds, etc.
I have received and read these guidelines and understand my duty of confidentiality.
_______________________________________________________________________
Signature
Date
_______________________________________________________________________
Printed Name
Vail Unified School District
Letter of Reasonable Assurance
Dear Substitute:
This letter provides notice of reasonable assurance of continued employment with the
district when each school term resumes after a school break. By virtue of this notice,
please understand that you may not be eligible for unemployment compensation benefits
drawn on school district wages during any scheduled school breaks including, but not
limited to, the summer, fall, winter, and spring breaks. This assurance is contingent on
continued school operations and will not apply in the event of any disruption that is
beyond the control of the district (e.g., lack of school funding, natural disasters, court
orders, public insurrections, war, etc.).
Nothing contained herein constitutes an employment contract. Your continued
employment is on an at-will basis. At-will employers may terminate employees at any
time for any reason or for no reason, except for legally impermissible reasons. At-will
employees are free to resign at any time for any reason or for no reason.
Your services on behalf of the children of the district are appreciated, and we hope that
you will be able to continue your association with the district.
Sincerely,
Lisa Cervantez
Chief Administrative Officer
_______________________________________________________________________
Signature
Date
_______________________________________________________________________
Printed Name
G-0981
© 2006 by Arizona School Boards Association
GBEC-E A
DRUG-FREE WORKPLACE
NOTICE TO EMPLOYEES
YOU ARE HEREBY NOTIFIED that it is a violation of Policy GBEC for any employee to violate the
law or District policy in the manufacture, distribution, dispensing, possession, or use, on or in the
workplace, of alcohol or any narcotic drug, hallucinogenic drug, amphetamine, barbiturate, marijuana, or
any other controlled substance, as defined in schedules I through V of section 202 of the Controlled
Substances Act (21 U.S.C. 812) and as further defined by regulation at 21 C.F.R. 1308.11 through
1308.15.
Workplace includes any place where work is performed, including a school building or other school
premises; any school-owned vehicle or any other school-approved vehicle used to transport students to
and from school or school activities; and off school property during any school-sponsored or schoolapproved activity, event, or function, such as a field trip or athletic event, where students are under the
jurisdiction of the District. In addition, the workplace shall include all property owned, leased, or used by
the District for any educational purpose.
YOU ARE FURTHER NOTIFIED that it is a condition of your employment that you will comply with
Policy GBEC, and will notify your supervisor of your conviction under any criminal drug statute for a
violation occurring in the workplace, not later than five (5) days after such conviction.
Any employee who violates the terms of the District's drug-free workplace policy in any manner is
subject to discipline, which may include, but is not limited to, dismissal and/or referral for prosecution.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- I have been provided with two (2) copies of this Notice to Employees for my review and signature. I
understand that a signed copy will be placed in my personnel file.
NAME (Please print)
Signature
VAIL UNIFIED SCHOOL DISTRICT NO. 20
03/28/06
Date
Page 1 of 1
Vail School District Employee Acceptable Use
The Vail School District offers employees (hereinafter referred to as user)
school-wide Internet access and email services. Users may access the vast
resources of the Internet and communicate via email from any workstation on
campus including staff offices, the computer labs, the classroom computers,
and the library.
The purpose of this document is to articulate Vail School District’s Internet
access expectations and to state and obtain a user’s agreement to comply
with the Vail School District Appropriate Use (AUP).
The User Agrees to the Following Terms and Conditions
1. The user agrees to act responsibly and with good behavior on any
computer or communications system using Vail School District’s wired or
wireless network services. The user agrees to follow all School and district
rules for behavior and communications. Access is a privilege - not a right.
2. The primary purpose of the district network (including but not limited to
the Internet, printers, workstations, etc.) is to allow users to conduct School
business. Use of district printers will be limited to school related business.
3. The user agrees to abide by the generally accepted rules of "netiquette"
and conduct himself/herself in a responsible, ethical, and polite manner while
using any Vail School District computing and communication resource.
Specific netiquette guidelines are available on the Vail School District web
site.
4. The user agrees not to use the computing resources for commercial
purposes, product advertising, political lobbying, or political campaigning.
5. The user agrees not to knowingly transmit or receive, submit, or publish
(share) any defamatory, inaccurate, abusive, obscene, profane, sexually
oriented, threatening, offensive, or illegal material.
6. The user agrees NOT to install or use ANY software on Vail School
District computers without the expressed permission of the Site Technology
Coordinator. This includes, but is not limited to, games, chat clients, email
clients, peer to peer (file sharing applications), instant messaging, and other
non-authorized applications or utilities. Downloading of software from the
Internet is permitted only for software that falls within the scope of
educational objectives and only with explicit permission by the Site
Technology Coordinator.
7. The user agrees not to tamper with or attempt to illegally access or "hack"
any Vail School District computer resources. Intentional damage or misuse
of computers or computer networks will not be tolerated. Intentional creation
or spreading of a computer virus will not be tolerated.
8. The user agrees to abide by all patent, trademark, trade name, and
copyright laws. Plagiarism in any form will not be tolerated. All sources must
be cited.
9. Security on any computer system is a high priority. If a user feels he/she
can identify a security problem in the Vail School District computer
systems, he/she agrees to notify a Site Technology Coordinator
immediately. The user agrees not to demonstrate the problem to others. The
user understands and agrees that using someone else’s password or
trespassing in another’s files without written permission is prohibited, and that
attempts to logon to the networks as anyone other than himself/herself is
unacceptable. If users have reason to believe that their password has been
compromised they agree to contact their Site Technology Coordinator
immediately.
10. The Vail School District makes no warranties of any kind, whether
expressed or implied, for the supervision and service it is providing. The user
who signs below agrees that the Vail School District assumes no
responsibility or liability for any loss of data resulting from delays,
non-deliveries, mis-deliveries, or service interruptions caused by its own
negligence or user errors or omissions. Use of any information obtained via
the Internet is at the user’s own risk. The Vail School District specifically
denies any responsibility for the accuracy or quality of information
obtained through its services. Although the district backs up critical data,
users are ultimately responsible for backing up their files.
11. All communication, information and hardware used on district property
shall not be regarded as private. The user agrees and consents to allow
authorized Vail School District personnel to review any and all files, data,
messages and email at any time with or without notice. The user understands
and agrees that use of their own personal hardware on district property falls
under this AUP.
12. The employee assumes all risks and responsibilities when using their own
personal computer equipment. The user will not connect any network-capable
devices without the prior written permission of the Site Technology
Coordinator. This connection privilege can be revoked without reason or
notice.
13. Any violation of the Acceptable Use will result in disciplinary action. Such
action might include suspension or revocation of Internet privileges,
suspension or termination of employment, and/or legal action. Users are
subject to all local, state, and federal laws and understand that illegal activities
may be reported to the appropriate law enforcement authorities. The user
agrees to report any violation of the Acceptable Use observed by the user to
their Site Technology Coordinator immediately.
ACCEPTANCE of the Vail School District Acceptable Use .
I have read the Vail School District Acceptable Use and agree to follow the
rules contained in this . I understand that violation of the rules may result in
disciplinary action up to and including termination of employment.
User Name (please print)_________________________________________
User Signature _________________________________________________
Date ___________________
STAFF CONDUCT
NOTIFICATION CONCERNING
NONAPPEALABLE OFFENSES
Notice is herein provided, in accordance with A.R.S. 15-550, that any employee of a public
school district or charter school in this state who is arrested for or charged with one (1) or more
of the offenses listed below as nonappealable offenses precluding that person from receiving a
fingerprint clearance card shall immediately report the arrest or charge to the person's supervisor
or the person shall be immediately dismissed from employment with the public school district or
charter school. A person dismissed from employment for failure to report being arrested for or
charged with a nonappealable offense has no right to appeal under the provisions of A.R.S. 15539, subsection G.
1. Sexual abuse of a vulnerable adult.
2. Incest.
3. First or second degree murder.
4. Sexual assault.
5. Sexual exploitation of a minor.
6. Sexual exploitation of a vulnerable adult.
7. Commercial sexual exploitation of a minor.
8. Commercial sexual exploitation of a vulnerable adult.
9. Child prostitution as prescribed in section 13-3212.
10. Child abuse.
11. Abuse of a vulnerable adult.
12. Sexual conduct with a minor.
13. Molestation of a child.
14. Molestation of a vulnerable adult.
15. A dangerous crime against children as defined in section 13-705.
16. Exploitation of minors involving drug offenses.
17. Taking a child for the purposes of prostitution as prescribed in section 13-3206.
18. Neglect or abuse of a vulnerable adult.
19. Sex trafficking.
20. Sexual abuse.
21. Production, publication, sale, possession and presentation of obscene items as prescribed in
section 13-3502.
22. Furnishing harmful items to minors as prescribed in section 13-3506.
23. Furnishing harmful items to minors by internet activity as prescribed in section 13-3506.01.
(Continued on back of page)
24. Obscene or indecent telephone communications to minors for commercial purposes as
prescribed in section 13-3512.
25. Luring a minor for sexual exploitation.
26. Enticement of persons for purposes of prostitution.
27. Procurement by false pretenses of person for purposes of prostitution.
28. Procuring or placing persons in a house of prostitution.
29. Receiving earnings of a prostitute.
30. Causing one's spouse to become a prostitute.
31. Detention of persons in a house of prostitution for debt.
32. Keeping or residing in a house of prostitution or employment in prostitution.
33. Pandering.
34. Transporting persons for the purpose of prostitution, polygamy and concubinage.
35. Portraying adult as a minor as prescribed in section 13-3555.
36. Admitting minors to public displays of sexual conduct as prescribed in section 13-3558.
37. Unlawful sale or purchase of children.
38. Child bigamy.
Further, an employee who is convicted of one (1) or more of the above listed offenses shall
immediately:
• Surrender any certificates issued by the department of education.
• Notify the person's employer or potential employer of the conviction.
• Notify the department of public safety of the conviction.
• Surrender the person's fingerprint clearance card.
By my signature I acknowledge receipt of a copy of this notification concerning nonappealable
offenses.
___________________________________________
Employee signature
________________________
Date
STATEMENT OF COMPLIANCE WITH THE
MILITARY SELECTIVE SERVICE ACT
(Please check all boxes that pertain to your status, then sign and date this form.)
I CERTIFY THAT I AM REGISTERED WITH THE SELECTIVE SERVICE.
I CERTIFY THAT I AM NOT REQUIRED TO BE REGISTERED WITH
SELECTIVE SERVICE BECAUSE:
I AM FEMALE
I AM IN THE ARMED SERVICES ON ACTIVE DUTY.
(Note: Members of the Reserves and National Guard are not considered on active
duty.)
I HAVE NOT REACHED MY 18TH BIRTHDAY
I HAVE PASSED MY 26TH BIRTHDAY
I AM A PERMANENT RESIDENT OF THE TRUST TERRITORY OF THE PACIFIC
ISLANDS FOR THE NORTHERN MARIANA ISLANDS.
SIGNATURE
DATE.
Equal Employment Opportunity Data
Pursuant to Federal regulations, we collect responses to the questions below for record keeping
purposes. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age,
national origin, religion, or disability.
Gender and Race Information
Check the appropriate box below.
Male
Female
Check the box for the racial or ethnic group with
which you identify:
Hispanic or Latino (includes person of Mexican,
Puerto Rican, Central American, South American or
other Spanish origin or culture)
White (not Hispanic or Latino)
Black or African American (A person having
origins in any of the black racial groups of Africa)
Please indicate your date of birth:
/
/
mm
dd
yyyy
Asian (Not Hispanic or Latino, includes peoples
of the Far East, Southeast Asia, or the Indian
Subcontinent)
Native Hawaiian or Other Pacific Islander
(Not Hispanic or Latino, includes peoples of Hawaii,
Guam, Samoa, or other Pacific Islands)
American Indian or Alaska Native (includes
Central America, and those who maintain tribal
affiliation or community attachment.)
Two or More Races (Not Hispanic or Latino)
Veteran Status Information
Please check the appropriate boxes below.
Status:
Veteran
Special Disabled Veteran
Not applicable
Veteran of:
Iraq War
Gulf War
Korean Era
Vietnam Era
World War II
Disability Information
Please check the appropriate boxes below:
Visually Impaired
Hearing Impaired
Wheel Chair Confined
Revised: 10/16/2008
Branch:
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Separation Date:
/
mm
/
dd
yyyy
Arizona State Retirement System
3300 North Central Avenue, Phoenix, AZ 85012
WWW.AZASRS.GOV
Fact Sheet
Contact information:
Member Services Advisory Center
Phoenix (602) 240-2000
Tucson (520) 239-3100
Toll-free (800) 621-3778
RETURNING TO WORK AFTER RETIREMENT
Arizona statute and federal age discrimination laws require the ASRS to treat rehired annuitants under the
same membership rules as any new employee. The member status of a retired member returning to work with
an ASRS employer shall be determined according to the same criteria applied to any employee of the
employer. This means that the same 20 weeks of 20 hours membership criteria applies to both new members
and rehired members.
Returning to Work After Normal Retirement (ARS §38-766)
Arizona Revised Statute §38-766 allows members who retire on or after reaching normal retirement to
continue working and all members who have truly terminated employment (i.e. there is no agreement to be
rehired when they terminate) to resume working while still receiving retirement benefits as along as their
employers agree that they will work either 1) less than 20 hours a week for any length of time, or 2) 20 hours
or more a week for no more than 19 weeks in any fiscal year and less than 20 hours per week for the
remainder of that fiscal year.
If the employer re-employs the member with the employer’s intent that the member will meet the 20/20 criteria
for membership, the pension is suspended immediately and retirement contributions will be withheld from the
member’s wages. Or, if the member continues working 20 hours or more per week for 20 weeks or more, the
member will resume active membership the first day of the 20th week, the ASRS will suspend the member’s
pension benefit and the member’s employer will withhold retirement contributions from the member’s wages.
The member may owe a refund to the ASRS for any retirement benefits received after the member’s benefits
should have been suspended.
EXAMPLES:
A.
The member retires June 30 of a given fiscal year. The member returns to work July 1. With
the prior agreement of the employer, the member may work for 19 weeks full time and then
reduce the hours to less than 20 hours a week for the remainder of the fiscal year. If,
however, the employer is hiring the member with the intent that the member will meet
the 20/20 membership criteria, the member’s right to retirement benefits will be
suspended immediately and ASRS contributions are withheld from wages.
B.
The member terminates work October 15 and retires October 16.The member has already
worked 15 weeks full time. This leaves 4 weeks after retiring that the member could work full
time. After working the 4 weeks the member must reduce their hours to less than 20 hours a
week for the remainder of the year. Again, if the employer is hiring the member with the
intent that the member will meet the 20/20 membership criteria, the member’s right to
retirement benefits will be suspended immediately and ASRS contributions are
withheld from wages.
(over)
July 2006
Returning to Work After Early Retirement (ARS §38-766)
If the member retired before reaching normal retirement - age 65, age 62 with 10 years of service, or at 80
points (age plus years of service) - the member can not return to work for the same ASRS employer without a
break in service. That is, there must be a true termination of employment in order to comply with Internal
Revenue Service Code. The employer may be required to show proof that no re-employment guarantee was
made verbally or in writing with the member before the member retired.
Those members retiring before reaching normal retirement who return to work for an ASRS member must not
meet the 20/20 criteria for membership, or their retirement benefits will be suspended.
EXAMPLES:
A.
The member retires June 30 of a given fiscal year. The member returns to work August 1.
With the agreement of the employer, the member may work for 19 weeks full time and then
reduce their hours to less than 20 hours a week for the remainder of the fiscal year. If the
employer is hiring the member with the intent that the member will meet the 20/20
membership criteria, the member’s right to retirement benefits will be suspended
immediately and ASRS contributions are withheld from wages from the first day of
employment.
B.
The member terminates work October 15 and retires October 16. The member has already
worked 15 weeks full time. This leaves four weeks after retiring that the member could work
full time. After working the four weeks the member must reduce their hours to less than 20
hours a week for the remainder of the year. If the employer is hiring the member with the
intent that the member will meet the 20/20 membership criteria, the member’s right to
retirement benefits will be suspended immediately and ASRS contributions are
withheld from wages from the first day of employment.
Returning to Work After Normal Retirement and Being Retired 12 Months From Retirement Date
(ARS §38-766.01)
A member who is at normal retirement (age 65, or at age 62 with at least 10 years of service, or at 80 points)
and retired for 12 months (not meeting conditions for ASRS membership) may return to work, or continue to
work, any amount of time and continue to receive pension benefits. Such a member must acknowledge the
conditions of their work and notify the ASRS and their employer in writing of their intent to work and not have
retirement contributions withheld from their pay and not accrue additional credited service or LTD benefits.
EXAMPLES:
A. The member retires on June 30, 2005. The member is age 62 with 10 years of service. The
member may return to working 20 or more hours a week at 20 or more weeks a year for an ASRS
employer on or after July 1, 2006.
B. The member retires on December 30, 2005. The member is age 52 with 26 years of service. (Age
52 plus 26 years of service equals 78 points.) The member is an early retiree and may continue to
work less than 20 hours per week without any effect on pension. Once the member has reached
normal retirement age (two years after retirement in this example), the member may resume full
time employment without a suspension of retirement benefits. However, if the member while on
early retirement meets the 20/20 membership criteria during the months prior to reaching normal
retirement, the pension is suspended. The member must re-retire and must once again be at
normal retirement and retired one full year before participating in the Return to Work Program.
This fact sheet does not replace statutory and rule requirements. Arizona Revised Statutes, the Arizona Administrative Code along
with the federal code for both the IRS and Social Security Title 218, shall be final authority.
Human Resources
P. O. Box 800
V ail, AZ 85641
T eleph on e : (520) 879-2070
Fax: (520) 879-2076
w w w . v ail.k12. az.us
Arizona State Retirement System Information
Printed Name
1. Are you an ASRS Retiree
who is receiving a monthly
pension from ASRS?
Social Security Number
Yes*If Yes, carefully read the
No*If No, please review
attached ASRS “Return To Work
the attached ASRS
Fact Sheet”.
“Membership Fact Sheet”.
If you answered No above, please sign below at item 2 to acknowledge that you have received the ASRS
Membership Fact Sheet. You do not need to complete any more information. Please return this form to
Human Resources.
If you answered Yes above, the attached ASRS Return to Work Fact Sheet explains the conditions of your
employment. Please carefully read it, complete items 3, 4 and 5 and return this form to Human
Resources.
2.
Signature
3. Did you take “Normal
Retirement” from ASRS?
4. If you took “Early Retirement”
from ASRS, when will you reach
“Normal Retirement”?
Date
Yes
Date:
No
Date:
If you rescind your retirement with ASRS, you must notify Vail School District Human Resources within 14 days.
I have read and understand the ASRS Return to Work Fact Sheet and understand how the 20/20 rule applies to me. If I retired
under “Normal Retirement” with the ASRS, I understand that I must abide by the 20/20 rule until one year past my “Normal
Retirement” date. If I am an “Early Retiree” with the ASRS, I understand that I must abide by the 20/20 rule until I have been
retired 12 months and reached normal retirement. I understand that if my working hours exceed the 20/20 rule before I am eligible
to work beyond the 20/20 rule, Vail School District will take ASRS contributions from my paycheck and I may lose my pension
benefit. If I choose to continue working after one year past my normal retirement date, I understand that I will not have to abide
by the 20/20 rule and acknowledge that no ASRS retirement contributions will be withheld from my paycheck nor will I accrue
credited service or LTD benefits.
5.
Signature
Date
Notice of Nondiscrimination
The Vail School District does not discriminate on the basis of race, gender, sexual orientation, age, national origin, handicap, religion,
or creed in its education programs or activities which it operates or in its employment practices.
PROFESSIONAL STAFF HIRING
AFFIRMATION OF A RETIRED EMPLOYEE
UPON RETURN TO EMPLOYMENT
To satisfy the requirements of A.R.S. 38-766.01, and to retain my eligibility to receive
retirement benefits from the Arizona State Retirement System (ASRS) following my
return to employment following a qualified retirement, by my signature below I affirm
my awareness and acceptance of the following provisions:
•
I have attained a normal retirement age as defined by the ASRS.
•
I am returning to greater than half (1/2) time employment not sooner than twelve
(12) months following my termination of full time employment for the purpose of
retirement.
•
If I return to work as a certificated teacher, my employment is not subject to the
requirements prescribed in A.R.S. 15-538, 15-538.01, and 15-539 through 15-543.
•
I understand that:
o pursuant to A.R.S. 38-766.01 my election to return to work is irrevocable
for the remainder of the employment for which I have made this election,
and
o I must make this acknowledgement in writing and file it with my employer
within thirty (30) days of returning to work.
__________________________________________
Signature
________________
Date
**NEW CHANGES**
CREDIT FOR CARING-TAX CREDIT PAYROLL DEDUCTION FORM
It’s Important.
This is your chance to have a say where your tax dollars go. Arizona will allow you to send the Vail School District a tax credit and you
may be able to subtract the total deduction from your State income tax.
It’s Easy.
Just fill out this form, directing your tax credit of up to $400 (married, filing jointly) or $200 (single) to the extra-curricular activity of your
choice. Send the completed form back to payroll. The amount you designate can be deducted from your paychecks. Then when you fill out your Arizona State
Tax Form 140, you may be able to deduct the total tax credit from what you owe in taxes.
Just fill out the attached form and send it to Payroll . Questions? Call Payroll at 879-2067 or 879-2026
******************************************************************************************************************************************************************
Please Circle the Year you are applying your contribution to
2015 - The last deduction for a 2015 tax credit is April 15th,2016 (PR 21)
2016 - The last deduction for a 2016 tax credit is April 15th,2017 ( PR 21)
Name ____________________________________________
Phone: (h)_____________________ (w)___________________
Address: __________________________________________________________________ City: ______________ Zip: __________
_____________________________
Total Amount
Start Date of Deduction ____/______/________
__________________________________________________________________
School to Receive Tax Credit (Required)
Please use my tax credit for:
__________________________________________________________________
please list specific extracurricular activity ( activites listed on vailtaxcredit.org)
****Payroll deduction cannot be used for educational trips. ****
Please include childs name if needed
______________________________
Signature
_____________
Date
Approximate End Date of Deduction____/______/__________
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No. 1210-0149
(expires 1-31-2017)
!
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employmentbased health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible
for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an aftertax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact
.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
!
!
!
!
!
!
!
!
!
!
!
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered
by the plan is no less than 60 percent of such costs.
!
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
!
3. Employer name
4. Employer Identification Number (EIN)
Vail School District
76-0617696
!
5. Employer address
6. Employer phone number
PO Box 800
520-879-2000
7. City
8. State
Vail
AZ
9. ZIP code
85641
10. Who can we contact about employee health coverage at this job?
Monica Brick
11. Phone number (if different from above)
12. Email address
520-879-2018
[email protected]
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
 All employees. Eligible employees are:
✔

Some employees. Eligible employees are:
Professional employees working in a regular position one hundred fifteen (115) days or more or the equivalent of a point six zero (.60) full time
equivalent (FTE) and support staff working in a position at the equivalent of point six zero (.60) FTE if regularly scheduled to work fewer than two
hundred forty (240) days per year or at point five zero (.50) FTE if regularly scheduled to work two hundred forty (240) or more days per year.
• With respect to dependents:
✔ We do offer coverage. Eligible dependents are:

Legal spouse, children to age 26, legal dependents to age 26, permanently disabled dependents with documentation of permanent disability

✔

We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended
to be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other factors,
to determine whether you may be eligible for a premium discount. If, for example, your wages vary from
week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly
employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your
monthly premiums.
!
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