SLSS NEW EMPLOYEE FORM HFB OCT 2019

Simplified Labor Staffing Solutions, Inc.
RE: Employee Contact Information and Emergency Contact



EMPLOYEE CONTACT INFORMATION

IN CASE OF EMERGENCY NOTIFY:

THE INFORMATION PROVIDED ABOVE IS CORRECT. I WILL IMMEDIATELY NOTIFY
THE COMPANY OF ANY CHANGES TO THE ABOVE INFORMATION.


Simplified Labor Staffing Solutions, Inc.
Anti-Discrimination and Anti-Harassment Policies


A. EQUAL OPPORTUNITY EMPLOYMENT

The Company is an equal opportunity employer and makes employment decisions on the basis of experience, skill, qualification and merit. We want to have the best available person in every job. Company policy and the law prohibits unlawful discrimination based on sex (including pregnancy, childbirth, breastfeeding or related medical conditions), race, religion (including religious creed or religious dress and grooming practices), color, gender (including gender identity and gender expression), national origin (including language use restrictions and possession of a driver’s license), ancestry, physical or mental disability, medical condition, genetic information, marital status, registered domestic partner status, age, sexual orientation, military and veteran status or any other basis protected by federal, state or local laws, regulations or ordinances. The Company also prohibits discrimination based on the perception that anyone has any of those characteristics, or is associated with a person who has or is perceived as having any of those characteristics. All such discrimination is strictly prohibited.

The Company is committed to complying with all applicable laws providing equal employment opportunities. This commitment applies to all persons involved in the operations of the Company and prohibits unlawful discrimination by any employee of the Company, including supervisors and co-workers.

If you believe you have been subjected to any form of discrimination in violation of this policy, you should provide a written complaint to jackie.flores@yourstaffingfirm.com, Company Human Resources. The Company will immediately undertake an investigation and attempt to resolve the situation. If the Company determines that any discrimination in violation of this policy has occurred, remedial action will be taken commensurate with the severity of the offense, up to and including termination. The Company will not retaliate against you for filing a complaint and will not knowingly permit retaliation by management employees or your co-workers.

B. EMPLOYMENT OF PEOPLE WITH DISABILITIES

It is the policy of the Company to comply with all applicable federal, State and local laws that forbid discrimination in employment against qualified individuals with disabilities. To this end, the Company will:

    1. Ensure that qualified individuals with disabilities are treated in a nondiscriminatory manner in the pre-employment process, and that disabled employees are treated in a nondiscriminatory manner for all terms, conditions, and privileges of employment;
    2. Maintain all medical-related information in a confidential manner in separate confidential files; and
    3. Afford applicants and employees with disabilities reasonable accommodation, except where making an accommodation would create an undue hardship on the Company.

If you have a disability which requires accommodation in order for you to perform the essential functions of your job, please provide your supervisor with a written request for such accommodation. In most cases, you will be required to provide a medical certification. If you believe you have been improperly denied accommodation, you must submit a written appeal to Human Resources at jackie.flores@yourstaffingfirm.com.

C. ANTI-HARASSMENT POLICY

To create an atmosphere conducive to equal opportunity in employment, the Company prohibits employee conduct that results in harassment of other employees on the basis of sex (including pregnancy, childbirth, breastfeeding or related medical conditions), race, religion (including religious creed or religious dress and grooming practices), color, gender (including gender identity and gender expression), national origin (including language use restrictions and possession of a driver’s license), ancestry, physical or mental disability, medical condition, genetic information, marital status, registered domestic partner status, age, sexual orientation, military and veteran status or any other basis protected by federal, state or local laws, regulations or ordinances. All such harassment is strictly prohibited.

This policy prohibits harassment by all persons involved in the operation of the Company and prohibits unlawful harassment by any employee of the Company, including supervisors and coworkers. It also prohibits harassment engaged in by the Company’s apprentices and vendors, including delivery personnel and other non-employees who you come into contact with in performing your job duties.

Prohibited unlawful harassment includes, but is not limited to, the following behavior:

    1. Verbal conduct such as epithets, derogatory jokes or comments, slurs or unwanted sexual advances, invitations or comments;
    2. Visual conduct such as derogatory or sexually-oriented posters, photography, cartoons, drawings or gestures;
    3. Physical conduct such as assault, unwanted touching, blocking normal movement or interfering with work because of sex, race or any other protected basis;
    4. Threats or demands to submit to sexual requests as a condition of continued employment, or offers of employment benefits in return for sexual favors; and
    5. Retaliation for having reported or threatened to report harassment.

All employees should be aware that even horseplay or joking conduct can be misinterpreted by other employees as harassment.

If you believe that you have been unlawfully harassed, you must provide a written complaint to your supervisor or to Human Resources at jackie.flores@yourstaffingfirm.com as soon as possible after the incident. Your complaint should include details of the incident or incidents, the names of the individuals involved and the names of any witnesses. The Company will immediately undertake a thorough and objective investigation of the harassment allegations.

If the Company determines that unlawful harassment has occurred, effective remedial action will be taken in accordance with the circumstances involved. Any employee determined by the Company to be responsible for unlawful harassment will be subject to appropriate disciplinary action, up to and including termination. Whatever action is taken against the harasser will be made known to the complaining employee and the Company will take appropriate action to remedy any loss to you resulting from harassment. The Company has an open door policy and will not retaliate against you for filing a complaint and will not tolerate or permit retaliation by management, employees or co-workers.

D. ALL EMPLOYMENT IS AT WILL

Every employee is employed at will. This means that employment is for no definite period of time and may be terminated at any time by the Company or by the employee, with or without cause and with or without notice. Nothing in this Policy or in any document or oral statement shall limit the right to terminate your employment at-will. No representative of the Company has or had any authority to make any representations or promises not contained in this provision, and each employee acknowledges by continuing his/her employment with the Company, that he/she is not relying upon such any representation or promise. There is no exception to this policy unless in writing and signed by the President of the Company.


Simplified Labor Staffing Solutions, Inc.
Policy on Meal Periods, Rest Breaks, and
Timekeeping for Non-Exempt Employees


A. MEAL PERIODS

Under California law, employees are entitled to a 30 minute duty-free meal period when they work 5 or more hours in a workday. Pursuant to our obligations under California law, the Company authorizes and permits employees to take a duty-free 30 minute meal period before beginning the sixth hour of work in a workday. This means that you are required to start your meal period no later than the end of five hours of work (including rest periods).

If you work more than 10 hours in a workday, the Company’s policy authorizes and permits you to take a second duty-free 30 minute unpaid meal period. You are required to take this second meal period unless you have signed and have on file with the Company a meal period waiver form and have taken the first meal period in the workday. However, if you work in excess of 12 hours in a workday, you are required to take a second duty-free 30 minute meal period regardless of whether you have signed a meal period waiver.

You are relieved of all duties during your meal periods and you are free to leave the work location during your meal periods. You are required to record the beginning and the end of your meal period on your time record.

It is your responsibility to take your meal breaks. If for some reason you do not take a meal break you must notify the Company in writing. Failure to take your meal break and to correspondingly record it will result in discipline up to and including termination. If you are required to work through or during your meal period, you must note this on your time record and you will be paid for the time worked and one hour’s pay for missing the meal period. No supervisor is authorized to direct or encourage you to work through or during a meal period without this compensation, and you should report any violation of this policy to Human Resources at jackie.flores@yourstaffingfirm.com.

B. REST BREAKS

Under California law, employees are entitled to take rest breaks at the rate of 10 minutes net rest time for each 4 hours of work or major fraction of four hours. No rest break is required for employees who work fewer than three and one half hours in the workday.

The Company’s policy requires employees to take one rest break of 10 minutes for every four hours of work (or major fraction of four hours). Thus, if you work an 8 hour workday, you are authorized, permitted and required to take two 10 minute rest breaks in addition to your 30 minute meal period. If you work more than 10 hours in a workday, you are authorized, permitted, and required to take a third paid 10 minute rest break.

As far as practicable, you should take your rest breaks in the middle of each four hour work period. Although the Company pays for your time during your rest breaks, you are relieved of all duties during your rest breaks and you are free to leave the work location during your rest breaks.

It is your responsibility to take your rest breaks. If for some reason you do not take a rest break, you must notify your supervisor in writing. Failure to take your rest break will result in discipline up to and including termination. If you are required to work through or during your rest break so that you do not receive the full rest break, you must note this on your time record and you will be paid one hour’s pay for missing one or more rest breaks per day. No supervisor is authorized to direct or encourage you to miss a rest break without this compensation, and you should report any violation of this policy to Human Resources at jackie.flores@yourstaffingfirm.com.

C. ACCURATE TIME RECORDING

The Company is required by law and wants to pay its hourly employees for all time worked. For this reason, all hourly employees are required by Company policy to accurately record their working time. Your timecard must fully and accurately report all of the time that you worked. It is a violation of Company policy for you to perform any “off the clock” work which is not recorded on your timecard. You are prohibited from performing any work which is not reported to the Company as working time.

No supervisor is authorized to direct or encourage you to work any time that is not compensated, “off the clock,” not recorded on your timecard, or not reported to the Company. You should report any violation of this policy to Human Resources at jackie.flores@yourstaffingfirm.com.


Simplified Labor Staffing Solutions, Inc.
RE: Receipt of Company Policies


On

was presented with and

received a copy of the following policies of Simplified Labor Staffing Solutions, Inc.:

1. Equal Opportunity, Anti-Harassment, and At-Will Policies
2. Policy on Meal Periods, Rest Breaks, and Timekeeping for Non-Exempt Employees

(2 witnesses required—Please turn in to Human Resources)

EMPLOYEE ACKNOWLEDGEMENT OF RECEIPT OF EMPLOYEE POLICIES

This is to acknowledge that I have received a copy of the policies listed above and understand that these policies contain important information on the Company’s general personnel policies and on my privileges and obligations as an employee. I acknowledge that I have read, understand and agree to adhere to Company policies and will familiarize myself with those policies. I further acknowledge that I have had an opportunity to ask questions about any policy that is not completely clear to me.

I understand that I am governed by these policies and that the Company may change, rescind or add to any policies, benefits or practices described above from time to time in its sole and absolute discretion, with or without prior notice; provided, however, that there shall be no change to the separate Mutual Arbitration Policy without my express written consent.


I also understand that my employment with the Company is not for a specified term, is at-will, and may be terminated with or without cause or notice at any time. I further understand that no representative of the Company, other than the President, has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

Notice To Employees About Our Mutual Arbitration Policy

Simplified Labor Staffing Solutions, Inc., herinafter referred to as the Company, has adopted and implemented a new arbitration policy, requiring mandatory, binding arbitration of all disputes, for all employees, regardless of length of service. This memorandum explains the procedures, as well as how the arbitration policy works as a whole. Please take the time to read this material. IT APPLIES TO YOU. It will govern any existing and all future disputes between you and the Company that relate in any way to your employment.

Arbitration Policy & Procedures

The Company sincerely hopes that you will never have a dispute relating to your employment here. However, we recognize that disputes sometimes arise between an employer and its employees relating to the employment relationship. We also recognize that not every dispute can be successfully resolved informally. The Company believes that it is in the best interests of the employees and the Company to resolve those disputes in a forum that provides the fastest and fairest method for resolving them based on the individual facts of your situation. Therefore, the Company has adopted and implemented this Mutual Arbitration Policy (“MAP”) as a mandatory condition of employment.

The MAP applies to all Company employees, regardless of length of service or status, and covers all disputes relating to or arising out of or in connection with employment at the Company or the termination of that employment, whether those disputes already exist today or arise in the future. Examples of the type of disputes or claims covered by the MAP include, but are not limited to, claims against employees for fraud, conversion, misappropriation of trade secrets, or claims by employees for wrongful termination of employment, breach of contract, fraud, employment discrimination, harassment or retaliation under the Americans With Disabilities Act, the Age Discrimination in Employment Act, the Fair Labor Standards Act, Title VII of the Civil Rights Act of 1964 and its amendments, the California Fair Employment and Housing Act or any other state or local anti-discrimination laws, tort claims, wage or overtime claims or other claims under the Labor Code, or any other legal or equitable claims and causes or action recognized by local, state or federal law or regulations. The MAP does not cover workers’ compensation claims, unemployment insurance claims or any claims that could be made to the National Labor Relations Board. Because it changes the forum in which you may pursue claims against the Company and affects your legal rights, you may wish to review the MAP with an attorney or other advisor of your choice. The Company encourages you to do so.

Your decision to accept employment or to continue employment with the Company constitutes your agreement to be bound by the MAP. Likewise, the Company agrees to be bound by the MAP. This mutual obligation to arbitrate claims means that both you and the Company are bound to use the MAP as the only means of resolving any employment-related disputes covered by the policy. By agreeing to arbitrate, both you and the Company are agreeing to use procedures in arbitration that may be materially different from the procedures that would apply in court. This mutual agreement to arbitrate claims also means that both you and the Company forego any right either may have to a jury trial on claims relating in any way to your employment. Because the arbitration proceeding will be a traditional, bilateral arbitration, it also means that both you and the Company forego and waive any right to join or consolidate claims in arbitration with others or to make collective or class claims in arbitration, either as a representative or a member of a class, unless such procedures are agreed to by both you and the Company. No substantive remedies that otherwise would be available to you individually or to the Company in a court of law, however, will be forfeited by virtue of this agreement to use and be bound by the MAP.

The MAP shall be governed solely by the Federal Arbitration Act ("FAA"), 9 U.S.C. § 1, et seq. If for any reason the FAA is deemed inapplicable, only then will the MAP be governed by the applicable state arbitration statutes. The Employment Arbitration Rules of the American Arbitration Association (“AAA”) in place at the time of the dispute will govern the procedures to be used in arbitration, unless you and the Company agree otherwise in writing. The current version of those Rules is available for you to review at www.adr.org and you may also request a copy from the Company.

What Is Arbitration?

Arbitration is a process in which a dispute is presented to a neutral third party, the arbitrator, for a final and binding decision. The arbitrator makes this decision after both sides present their evidence and arguments at the arbitration hearing. There is no jury. If you win, you can be awarded anything you might individually have received in a court.

The arbitration process is limited to disputes, claims or controversies that a court of law would be authorized to entertain or would have jurisdiction over to grant relief and that in any way arise out of, relate to or are associated with your employment with the Company or the termination of your employment. The parties in any such arbitration will be limited to you and the Company, unless you and the Company agree otherwise in writing. An impartial and independent arbitrator, chosen by agreement of both you and the Company, will be retained to make a final decision on your dispute or claim, based on application of the facts, the Company’s policies and procedures and the applicable law. The arbitrator's decision is final and binding on you and the Company.

A neutral party, the American Arbitration Association (“AAA”), runs the proceedings, which are held privately. Since 1926, AAA has handled many thousands of cases. Though arbitration is much less formal than a court trial, it is an orderly proceeding, governed by rules of procedure and legal standards of conduct. The arbitrator's responsibility is to determine whether the Company’s policies and procedures and applicable law have been complied with in the matter submitted for arbitration. The arbitrator shall render a written decision on the matter within 30 days after the arbitration hearing is concluded and post-hearing briefs, if any, are submitted.

The Company and you will share the cost of the AAA's filing fee and the arbitrator's fees and costs, but your share of such fees and costs shall not exceed an amount equal to your local court civil filing fee. Except as otherwise provided by law, you and the Company will be responsible for the fees and costs of your own respective legal counsel, if any, and any other expenses and costs, such as costs associated with witnesses or obtaining copies of hearing transcripts.

The Company has access to legal advice through its outside lawyers. You may consult with a lawyer or any other adviser of your choice. You are not required, however, to hire a lawyer to participate in arbitration.

The Company will not modify or change the agreement between you and the Company to use final and binding arbitration to resolve employment-related disputes without notifying you and obtaining your consent to such changes, although specific MAP procedures or AAA Rules may be modified from time to time as required by applicable law. Also, the Arbitrator or a court may sever any part of the MAP that does not comport with the Federal Arbitration Act.

Conclusion

If after reading the above summary of the Company’s arbitration policy, you have questions, you should direct them to the Company’s President. If you would like to receive or review a copy of the Company’s arbitration policy in Spanish, please request a Spanish version. If you would like to receive or review a copy of the AAA Rules in either English or Spanish, please request a copy or visit the website www.adr.org.

The Company is proud of its strong relationship with its employees, and is confident that most problems, disputes and complaints can be handled either by your immediate supervisor or by a higher level of management. The MAP will complement these policies, by allowing you and the Company to resolve any remaining disputes in a quick, private and final manner that benefits all of us.


EMPLOYEE AGREEMENT TO ARBITRATE


I acknowledge that I have received and reviewed a copy of the Company's Mutual Arbitration Policy (“MAP”) and have been provided an opportunity to request and review a Spanish translation as well, and I understand that the MAP is a condition of my employment. I agree that it is my obligation to make use of the MAP and to submit to final and binding arbitration any and all claims and disputes, whether they exist now or arise in the future, that are related in any way to my employment or the termination of my employment with the Company except as otherwise permitted by the MAP. I understand that final and binding arbitration will be the sole and exclusive remedy for any such claim or dispute against the Company or any affiliated companies or entities, and all of their owners, employees, officers, directors or agents, and that, by agreeing to use arbitration to resolve my disputes, both the Company and I agree to forego any right we each may have had to a jury trial on issues covered by the MAP, and forego any right to bring claims on a class or collective basis. I also agree that such arbitration will be conducted before an arbitrator chosen by me and the Company, and will be conducted under the Federal Arbitration Act and the applicable procedural rules of the American Arbitration Association (“AAA”), which I have been provided an opportunity to request and review.

I acknowledge that in exchange for my agreement to arbitrate, the Company also agrees to submit all claims and disputes it may have with me to final and binding arbitration, and the Company further agrees that if I submit a request for binding arbitration, my maximum out-of-pocket expenses for the arbitrator and AAA administrative costs will be an amount equal to the local civil court filing fee and the Company will pay all of the remaining fees and administrative costs of the arbitrator and the AAA. If any provision of the MAP is found unenforceable, that provision may be severed without affecting this agreement to arbitrate. I further acknowledge that this mutual obligation to arbitrate may not be modified or rescinded except by the mutual consent of both me and the Company.

SIMPLIFIED LABOR STAFFING SOLUTIONS, INC. EMPLOYEE AGREEMENT TO ARBITRATE


Simplified Labor Staffing Solutions, Inc.
RE: Receipt of Mutual Arbitration Policy


On

was presented

with and received a copy of the Simplified Labor Staffing Solutions, Inc. Mutual Arbitration Policy, and was given the opportunity to read the entire Mutual Arbitration Policy. After receiving and reading the Mutual Arbitration Policy, the above identified employee was informed by the undersigned that the Mutual Arbitration Policy is a mandatory condition of employment and that his or her continued employment would constitute acceptance of the policy.

(2 witnesses required—Please turn in to Human Resources)


SIMPLIFIED LABOR STAFFING SOLUTIONS, INC.
THE NAME SAYS IT ALL!



2019 HEALTHCARE BENEFITS OFFERINGS
EMPLOYEE ACKNOWLEDGMENT FORM

  • I acknowledge that as an active employee of Simplified Staffing I am eligible to enroll in the Simplified Group Health Plan offered through Kaiser.
  • I understand if I am interested in enrolling in one of the Kaiser plans it is my responsibility to provide my contact Information below. Upon receipt of my signed form a representative from TAC Benefits Group will contact me with more information on the plans and enrollment.
  • I understand if I enroll in either of these plans my coverage will become effective on the 1st of the month 60 days after my date of hire.
  • I understand if I do enroll in one of the medical plans offered within 60 days of my hire date, I will have premiums deducted from my pay beginning with the first payroll after my benefits effective date.
  • I understand I may only cancel or modify my elected benefits during Open Enrollment, or as the result of a qualifying event.

There is no obligation to enroll. Your information will not be used for any other purposes. All Information shared is confidental and protected by HIPPA.

If you are interested in enrolling in one of the Kaiser plans offered please provide your contact information below. A representative from TAC Benefits Group will reach out to you and review your options, associated costs and enrollment instructions. The signed form must be returned to Human Resources.

By signing this form, I acknowledge that I was informed and I understand the enrollment process.

This is not an enrollment form. Forms submitted without contact information will not be contacted regarding enrollment.


NOTICE TO EMPLOYEE
Labor Code section 2810.5


EMPLOYEE

EMPLOYER

If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity for whom this employee will perform work

WAGE INFORMATION

(If the employee has signed the acknowledgment of receipt below, it does not constitute a “voluntary written agreement” as required under the law between the employer and employee in order to credit any meals or lodging against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.)

WORKERS’ COMPENSATION

PAID SICK LEAVE

Unless exempt, the employee identified on this notice is entitled to minimum requirements for paid sick leave under state law which provides that an employee:

a. May accrue paid sick leave and may request and use up to 3 days or 24 hours of accrued paid sick leave per year;
b. May not be terminated or retaliated against for using or requesting the use of accrued paid sick leave; and
c. Has the right to file a complaint against an employer who retaliates or discriminates against an employee for

1. requesting or using accrued sick days;
2. attempting to exercise the right to use accrued paid sick days;
3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code;
4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any policy or practice or act that is prohibited by Article 1.5 section 245 et seq. of the California Labor Code.

ACKNOWLEDGEMENT OF RECEIPT
(Optional)

Labor Code section 2810.5(b) requires that the employer notify you in writing of any changes to the information set forth in this Notice within seven calendar days after the time of the changes, unless one of the following applies: (a) All changes are reflected on a timely wage statement furnished in accordance with Labor Code section 226; (b) Notice of all changes is provided in another writing required by law within seven days of the changes.


EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

OR

OR


Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.

Give the top portion of this page to your employer and keep the remainder for your records.


YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.

IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.


PURPOSE: This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation.

You should complete this form if either:

(1) You claim a different marital status, number of regular allowances, or different additional dollar amount to be withheld for California PIT withholding than you claim for federal income tax withholding or,

(2) You claim additional allowances for estimated deductions.

THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES.

The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, and/or the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance

certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source.

CHECK YOUR WITHHOLDING: After your Form W-4 and/or DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form.

EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption is good for one year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted by February 15 each year to continue your exemption. If you are not having federal income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new Form W-4 by December 1.

EXEMPTION FROM WITHHOLDING (continued): Under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act, you may be exempt from California income tax on your wages if (i) your spouse is a member of the armed forces present in California in compliance with military orders; (ii) you are present in California solely to be with your spouse; and (iii) you maintain your domicile in another state. If you claim exemption under this act, check the box on Line 3. You may be required to provide proof of exemption upon request.


IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB).

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES

1-800-852-5711 (voice)
1-800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free)

1-916-845-6500

The California Employer’s Guide, DE 44, provides the income tax withholding tables. This publication may be found on the Employment Development Department (EDD) website at www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To assist you in calculating your tax liability, please visit the FTB website at www.ftb.ca.gov/individuals/index.shtml.


NOTIFICATION: If the IRS instructs your employer to withhold federal income tax based on a certain withholding status, your employer is required to use the same withholding status for state income tax withholding.

The burden of proof rests with the employee to show the correct California Income Tax Withholding. Pursuant to section 4340-1(e) of Title 22, California Code of Regulations (CCR), the FTB or the EDD may, by special direction in writing, require an employer to submit a Form W-4 or DE 4 when such forms are necessary for the administration of the withholding tax programs.

PENALTY: You may be fined $500 if you file, with no reasonable basis, a DE 4 that results in less tax being withheld than is properly allowable. In addition, criminal penalties apply for willfully supplying false or fraudulent information or failing to supply information requiring an increase in withholding. This is provided by section 13101 of the California Unemployment Insurance Code and section 19176 of the Revenue and Taxation Code.


INSTRUCTIONS — 1 — ALLOWANCES*

When determining your withholding allowances, you must consider your personal situation:
— Do you claim allowances for dependents or blindness?
— Will you itemize your deductions?
— Do you have more than one income coming into the household?

TWO-EARNERS/MULTIPLE INCOMES: When earnings are derived from more than one source, underwithholding may occur. If you have a working spouse or more than one job, it is best to check the box “SINGLE or MARRIED (with two or more incomes).” Figure the total number of allowances you are entitled to claim on all jobs using only one DE 4 form. Claim allowances with one employer. Do not claim the same allowances with more than one employer. Your withholding will usually be most accurate when all allowances are claimed on the DE 4 or Form W-4 filed for the highest paying job and zero allowances are claimed for the others.

MARRIED BUT NOT LIVING WITH YOUR SPOUSE: You may check the “Head of Household” marital status box if you meet all of the following tests:
(1) Your spouse will not live with you at any time during the year;
(2) You will furnish over half of the cost of maintaining a home for the entire year for yourself and your child or stepchild who qualifies as your dependent; and
(3) You will file a separate return for the year.

HEAD OF HOUSEHOLD: To qualify, you must be unmarried or legally separated from your spouse and pay more than 50% of the costs of maintaining a home for the entire year for yourself and your dependent(s) or other qualifying individuals. Cost of maintaining the home includes such items as rent, property insurance, property taxes, mortgage interest, repairs, utilities, and cost of food. It does not include the individual’s personal expenses or any amount which represents value of services performed by a member of the household of the taxpayer.


WORKSHEET A

REGULAR WITHHOLDING ALLOWANCES



INSTRUCTIONS — 2 — ADDITIONAL WITHHOLDING ALLOWANCES

If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year’s FTB Form 540 as a model to calculate this year’s withholding amounts.

Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not taxed on this worksheet.

You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $1,000, or fraction of $1,000, by which you expect your estimated deductions for the year to exceed your allowable standard deduction.


WORKSHEET B

ESTIMATED DEDUCTIONS


*Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California PIT withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner in a domestic partner relationship within the meaning of section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center at 1-888-745-3886.


WORKSHEET C

TAX WITHHOLDING AND ESTIMATED TAX


NOTE: Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not agree to withhold the additional amount, you may increase your withholdings as much as possible by using the “single” status with “zero” allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on Form 540-ES with the FTB to avoid a penalty.

THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 2019 ONLY

SINGLE PERSONS, DUAL INCOME MARRIED WITH MULTIPLE EMPLOYERS
IF THE TAXABLE INCOME IS COMPUTED TAX IS
OVER BUT NOT OVER OF AMOUNT OVER PLUS
$0 $8,544 ... 1.10% $0 $0.00
$8,544 $20,255 ... 2.20% $8,544 $93.98
$20,255 $31,969 ... 4.40% $20,255 $351.62
$31,969 $44,377 ... 6.60% $31,969 $867.04
$44,377 $56,085 ... 8.80% $44,377 $1,685.97
$56,085 $286,492 ... 10.23% $56,085 $2,716.27
$286,492 $343,788 ... 11.33% $286,492 $26,286.91
$343,788 $572,980 ... 12.43% $343,788 $32,778.55
$572,980 $1,000,000 ... 13.53% $572,980 $61,267.12
$1,000,000 and over... 14.63% $1,000,000 $119,042.93

MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS
IF THE TAXABLE INCOME IS COMPUTED TAX IS
OVER BUT NOT OVER OF AMOUNT OVER PLUS
$0 $17,088 ... 1.10% $0 $0.00
$17,088 $40,510 ... 2.20% $17,088 $187.97
$40,510 $63,938 ... 4.40% $40,510 $703.25
$63,938 $88,754 ... 6.60% $63,938 $1,734.08
$88,754 $112,170 ... 8.80% $88,754 $3,371.94
$112,170 $572,984 ... 10.23% $112,170 $5,432.55
$572,984 $687,576 ... 11.33% $572,984 $52,573.82
$687,576 $1,000,000 ... 12.43% $687,576 $65,557.09
$1,000,000 $1,145,961 ... 13.53% $1,000,000 $104,391.39
$1,145,961 and over 14.63% $1,145,961 $124,139.90

UNMARRIED HEAD OF HOUSEHOLD
IF THE TAXABLE INCOME IS COMPUTED TAX IS
OVER BUT NOT OVER OF AMOUNT OVER PLUS
$0 $17,099 ... 1.10% $0 $0.00
$17,099 $40,512 ... 2.20% $17,099 $188.09
$40,512 $52,224 ... 4.40% $40,512 $703.18
$52,224 $64,632 ... 6.60% $52,224 $1,218.51
$64,632 $76,343 ... 8.80% $64,632 $2,037.44
$76,343 $389,627 ... 10.23% $76,343 $3,068.01
$389,627 $467,553 ... 11.33% $389,627 $35,116.96
$467,553 $779,253 ... 12.43% $467,553 $43,945.98
$779,253 $1,000,000 ... 13.53% $779,253 $82,690.29
$1,000,000 and over 14.63% $1,000,000 $112,557.36


IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FTB:

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES

1-800-852-5711 (voice)
1-800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free)

1-916-845-6500


The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, CCR, section 4340-1, and the California Revenue and Taxation Code, including section 18624. The Information Practices Act of 1977 requires that individuals be notified of how information they provide may be used. Further information is contained in the instructions that came with your last California resident income tax return.


Form W-4 (2019)

Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

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. You may claim exemption from withholding for 2019 if both of the following apply.

• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and

• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.

If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions

these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.

Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning.

Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P.

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

Specific Instructions

Personal Allowances Worksheet

Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.

Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total


---------- Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. ----------


Form W-4
Department of the Treasury
Internal Revenue Service

Employee’s Withholding Allowance Certificate
> Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074
2019


Note: If married filing separately, check “Married, but withhold at higher Single rate.”

7. I claim exemption from withholding for 2019, 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.


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.



income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter “-0-” on lines E and F if you use Worksheet 1-6.

Deductions, Adjustments, and Additional Income Worksheet

Complete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Two-Earners/Multiple Jobs Worksheet

Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you

don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate.

Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

Instructions for Employer

Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary.

New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9,

and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/css/employers.

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows.

Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders.

Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date.

Box 10. Enter the employer’s employer identification number (EIN).


Personal Allowances Worksheet (Keep for your records.)


D Enter “1” if:

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

F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).

For accuracy, complete all worksheets that apply.

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.
• If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 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 above.


Deductions, Adjustments, and Additional Income Worksheet


Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage income not subject to withholding.

2. Enter:

$24,400 if you’re married filing jointly or qualifying widow(er)
• $18,350 if you’re head of household
• $12,200 if you’re single or married filing separately


Two-Earners/Multiple Jobs Worksheet


Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

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.


Table 1
Married Filing Jointly All Others
If wages from LOWEST
paying job are—
Enter on
line 2 above
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $5,000 0 $0 - $7,000 0
5,001 - 9,500 1 7,001 - 13,000 1
9,501 - 19,500 2 13,001 - 27,500 2
19,501 - 35,000 3 27,501 - 32,000 3
35,001 - 40,000 4 32,001 - 40,000 4
40,001 - 46,000 5 40,001 - 60,000 5
46,001 - 55,000 6 60,001 - 75,000 6
55,001 - 60,000 7 75,001 - 85,000 7
60,001 - 70,000 8 85,001 - 95,000 8
70,001 - 75,000 9 95,001 - 100,000 9
75,001 - 85,000 10 100,001 - 110,000 10
85,001 - 95,000 11 110,001 - 115,000 11
95,001 - 125,000 12 115,001 - 125,000 12
125,001 - 155,000 13 125,001 - 135,000 13
155,001 - 165,000 14 135,001 - 145,000 14
165,001 - 175,000 15 145,001 - 160,000 15
175,001 - 180,000 16 160,001 - 180,000 16
180,001 - 195,000 17 180,001 and over 17
195,001 - 205,000 18
205,001 and over 19

Table 2
Married Filing Jointly All Others
If wages from HIGHEST
paying job are—
Enter on
line 7 above
If wages from HIGHEST
paying job are—
Enter on
line 7 above
$0 - $24,900 $420 $0 - $7,200 $420
24,901 - 84,450 500 7,201 - 36,975 500
84,451 - 173,900 910 36,976 - 81,700 910
173,901 - 326,950 1,000 81,701 - 158,225 1,000
326,951 - 413,700 1,330 158,226 - 201,600 1,330
413,701 - 617,850 1,450 201,601 - 507,800 1,450
617,851 and over 1,540 507,801 and over 1,540

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to

cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You aren’t required to provide the information requested on a form that’s 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.


Corporate Office

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