New Teammate Paperwork - Sunshine House

We are so excited you’re joining our team!

New Teammate Paperwork

Welcome!

Our Vision: Partnering with families to create a better world.

Our Mission: Providing high-quality care and education - every child, every family, every day.

Dear New Teammate, Welcome to the team! We’re thrilled you’re joining The Sunshine House family, and we can’t wait for you to get started. At The Sunshine House, we’ve built a supportive, team environment with a healthy work/life balance. Most importantly, each teammate has an opportunity to make a meaningful impact in a child’s life each day. This New Teammate Paperwork package contains all new employee forms required by the state, federal government, and our company. Yes, we agree it’s lengthy! But unfortunately, we are required to collect this information. Please review and return all completed forms to your Center Director as soon as possible. We understand that choosing the right work “home” is an important decision. And we thank you for choosing The Sunshine House! My door is always open. If you have any questions, please let me know. I’m here to help! Sincerely,

Darlene Cole Director of Human Resources The Sunshine House Our Vision: Partnering with families to create a better world.

Our Mission: Providing high-quality care and education – every child, every family, every day.

New Employee Information Sheet

New Hire Rehire Anticipated Start Date: __________________________

Legal Name (as shown on Social Security card or Permanent Resident card):

________________________________________________________________________

Social Security # ____________________________________

Address: _______________________________________________________________________

_______________________________________________________________________________

Email Address (please write clearly!) _________________________________________________

Phone # ___________________________________________

Gender _________________________ Birthdate ___________________________

Marital Status _______________________ Ethnicity/Race _______________________

(for EEOC reporting purposes only)

Job Title (Infant, Toddler, Twos etc.)__________________________ Lead or Assistant ? (circle one)

How many hours will the employee normally work each week? _______________________

Regular or Temporary? (Circle one) FT (30 or more hours) or PT ( less than 30 hours)? (Circle one)

Reports to _____________________________________________ Center # _________

Pay Rate ______________ 3 digit Region Code __________

Employee should review ALL above information for accuracy before signing:

Employee Signature Date

Manager Signature Date

***Please upload completed form to [email protected] . Must include W-4 and state tax forms, payroll choice document, copy of Driver’s License, social security card, and Regional approval email

1

Employment Application

The Sunshine House is an Equal Opportunity Employer that recruits and hires qualified candidates without regard to race, religion, sex, sexual orientation, age, national origin, ancestry, citizenship, disability, or veteran status.

Applicant Information

Full Name: Date: Last First M.I.

Address: Street Address City State ZIP Code

Phone: Email

Date Available: Social Security No.: Desired Salary:$

Position Applied for:

How were you referred to us? (write employee name, website, other source)

YES NO If no, are you authorized to work in the U.S.?

YES NO

YES NO If yes, when?

YES NO

Are you a citizen of the United States?

Have you ever worked for this company?

Have you ever been convicted of a felony or misdemeanor?

Are you able to lift up to 30 pounds, bend, stoop and stand as needed for this job?

Are you able to observe, hear and respond to children’s needs, emergencies and conflicts that might occur?

I understand that I may be asked to move to different age group classrooms as needed.

Are you able to interact with children both physically and verbally throughout the day?

Do you have the agility to move from a seated position to a standing position quickly to respond to emergency situations?

YES NO

YES NO

YES NO

YES NO

YES NO

2

Education

High School: Address:

From: To: Did you graduate?YES NO

Diploma:

College: Address:

From: To: Did you graduate?YES NO

Degree:

Other: Address:

Certifications

Certification: Date

Certification: Date

References Please list three professional references.

Full Name: Relationship:

Company: Phone:

Address:


Company: Phone:

Address:


Company: Phone:

Address:

Previous Employment

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary:$ Ending Salary:$

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES NO

3

Company: Phone:



Responsibilities:



Company: Phone:



Responsibilities:



Military Service

Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: Date:

4

DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

[The Sunshine House] (“the Company”) may obtain information about you for employment purposes from a third party consumer reporting agency. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history. The scope of this notice and authorization is all-encompassing, however, allowing The Sunshine House to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by [Employer] by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by [Employer], and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records will be provided upon request.

Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by an outside organization acting on behalf of The Sunshine House, and/or The Sunshine House itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: You also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □

Signature: Date:

The Sunshine House Employee Policy Guide 47 Revised September 2016

Employee Policy Guide Acknowledgment The Employee Policy Guide describes important information about The Sunshine House. I understand I should consult my Manager or Human Resources department regarding any questions not answered in the Policy Guide.

I have entered into my employment relationship with The Sunshine House voluntarily and acknowledge that there is no specified length of employment. Accordingly, either I or The Sunshine House can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

The current Employee Policy Guide, which I can access online in ADP, supersedes any and all prior practices, oral or written representations, or statements regarding the terms and conditions of my employment with The Sunshine House. By distributing this Policy Guide, the Company expressly revokes any and all previous policies and procedures that are inconsistent with those contained herein.

I understand that, except for the employment-at-will status, any and all policies and practices may be changed at any time by The Sunshine House, and the Company reserves the right to change my hours, wages and working conditions at any time. All such changes will be communicated through official notices, and I understand that revised information may supersede, modify or eliminate existing policies.

I understand and agree that nothing in the Employee Policy Guide creates or is intended to create a promise or representation of continued employment, and that employment at The Sunshine House is employment at will, which may be terminated at the will of either The Sunshine House or me. Furthermore, I acknowledge this Employee Policy Guide is neither a contract of employment nor a legal document.

I have been shown how to access the Employee Policy Guide in ADP, and may review it online or print it as needed. I understand that it is my responsibility to read and comply with the policies contained in the Policy Guide and any revisions made to it.

________________________________________ ____________________

Employee's Signature Center # / Department

________________________________________ ____________________

Employee's Name (Print) Date

131106-Sunshine-Employee Guide.indd 49 7/18/14 2:57 PM

1. ERISA Summary Plan Description2. Premium Only Plan Section 125 Summary Plan Description3. Summary of Benefits & Coverage4. Medical Carrier Certificate of Coverage5. Dental Carrier Certificate of Coverage6. Vision Carrier Certificate of Coverage7. Basic Life & AD&D Certificate of Coverage8. Voluntary Life & AD&D Certificate of Coverage9. Short Term Disability Certificate of Coverage10. Annual Notices

By signing this document I confirm, understand & agree that I have the ability to access these documents at any computer, including at my work location or I can request a paper copy from Human Resources at any time. Also, by signing this document, I agree that I am not receiving the paper copies at this time. I understand that if there are any changes to these documents or amendments that I will be notified by The Sunshine House in a timely manner and advised how I can obtain the documents.

Employee Signature_____________________________________ Date:______________________

Electronic Form Notification Acknowledgment

As an employee of The Sunshine House you are provided benefits through The Sunshine House Benefits Group Health & Welfare plan. With the benefit offerings there are documents that you are required to receive. The Sunshine House makes every effort to provide you with these documents in the format you would like. The following documents are available to you at this time in ADP Vantage. These documents are also available to you by paper distribution should you choose.

Notification Regarding Payroll Deductions

The Sunshine House is required by law to make certain deductions from your paycheck. Among these are your federal, state and/or local income taxes and your contribution to Social Security. These deductions will be itemized on your paycheck or statement. The amount of the deductions will depend on your earnings and on the information you furnish on your W-4 form. If you wish to modify this information, please complete and submit a new current year W-4 form. We advise you to annually review your federal and state withholding information. Any other mandatory deductions made from your paycheck, such as court-ordered wage garnishments, will be honored whenever the Company is ordered to make such deductions.

Wage Garnishments- When an employee’s wages are garnished by a court order, The Sunshine House is legally bound to withhold the amount indicated in the garnishment order from the employee’s paycheck. The Sunshine House will, however, abide by federal and state guidelines that protect a certain amount of an employee’s income from being subject to garnishment.

Errors in Pay- Every effort is made to avoid errors in your paycheck. If you believe an error has been made, please contact your Manager or the Payroll department immediately. The issue will be researched and every effort will be made to ensure any necessary correction is made promptly. The company reserves the right to offset errors resulting in overpayment to the employee as allowed by state law.

Childcare Deductions- I understand that I am responsible for paying weekly tuition rates less the applicable discount through bi-weekly payroll deductions. It is my responsibility to notify payroll immediately if any changes must be made. If I leave the employment of Sunshine House with an outstanding balance, I understand that it will be deducted from my final paycheck and, if the earnings are not sufficient to pay the balance owed, I am still obligated to pay the outstanding balance and agree to do so.

Background Checks - The company may deduct fees incurred for fingerprints and/or background checks if an employee leaves the company, either voluntarily or involuntarily, during his/her first 90 days of employment.

NOTE: Wages are paid bi-weekly on Friday (by direct deposit, auto-pay debit card or standard check), including the final paycheck, except in states where required by law to be paid earlier. If an employee elects to be paid by check (sent via standard postal mail) we cannot guarantee the arrival of the check by a specific day.

By my signature below, I acknowledge that I have read and understand these statements regarding required payroll withholding and other possible deductions to my paycheck.

_____________________________________________________ ____________________________

Employee Signature Date

[ ] Savings [ ] Checking

22

FAMILY HANDBOOK RECEIPT ACKNOWLEDGMENT

I acknowledge receipt of The Sunshine House Early Learning Academy Family Handbook. I have reviewed these policies, and understand and agree to abide by the policies set forth in the Family Handbook. I understand I will be notified, in writing, of any changes or updates to these policies.

Employee Name (please print) ___________________________ Date _____________

Employee Signature _____________________________________________________

Give this form to your employer. Keep the worksheets for your records. The SCDOR may review any allowances and exemptions claimed. Your employer may be required to send a copy of this form to the SCDOR.

1 First name and middle initial Last name

Address

City State ZIP

Single

2 Social Security Number

3 Married Married, but withhold at higher Single rate.

If Married filing separately, check Married, but withhold at higher Single rate.

4 Check if your last name is different on your Social Security card.

For a replacement card, contact the Social Security Admin at 1-800-772-1213 .

5 Total number of allowances (from the applicable worksheet on page 3) . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Additional amount, if any, to withhold from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2022. Check the box for the exemption reason and write Exempt on line 7.

7Under penalty of law, I certify that this information is correct, true, and complete to the best of my knowledge.

Part I: Employee Information

Part II: Employer Information

Employee’s signature (required) Date

8 Employer’s name and address 9 First date of employment 10 Employer identification number (EIN)

STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE

SC W-4 (Rev. 10/25/21)

3527

2022SOUTH CAROLINA EMPLOYEE'S

WITHHOLDING ALLOWANCE CERTIFICATE

1350

dor.sc.gov

INSTRUCTIONS

Employee instructions Complete the SC W-4 so your employer can withhold the correct South Carolina Income Tax from your pay. 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. Determine the number of withholding allowances you should claim for withholding for 2022 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. Consider completing a new SC W-4 each year and when your personal or financial situation changes. This keeps your withholding accurate and helps you avoid surprises when you file your South Carolina Individual Income Tax return. For the latest information about South Carolina Withholding Tax and the SC W-4, visit dor.sc.gov/withholding. Exemptions: You may claim exemption from South Carolina withholding for 2022 for one of the following reasons:

For tax year 2021, you had a right to a refund of all South Carolina Income Tax withheld because you had no tax liability, and for tax year 2022 you expect a refund of all South Carolina Income Tax withheld because you expect to have no tax liability. Under the Servicemembers Civil Relief Act, you are claiming the same state of residence for tax purposes as your military servicemember spouse. You are only in South Carolina, or a bordering state, to be with your military spouse who is serving in the state in compliance with military orders. Provide your employer with a copy of your current military ID card and a copy of your spouse's latest Leave and Earnings Statement (LES). Your military ID card must have been issued within the last four years. The assignment location on the LES must be in South Carolina or a bordering state. Enter your spouse's state of domicile on the line provided.

If you are exempt, complete only line 1 through line 4 and line 7. Check the box for the reason you are claiming an exemption and write Exempt on line 7. Your exemption for 2022 expires February 15, 2023. If you are a military spouse and you no longer qualify for the exemption, you have 10 days to update your SC W-4 with your employer. Filers with multiple jobs or working spouses: You will need to file an SC W-4 for each employer. If you have more than one job, or if you are married filing jointly and your spouse is also working, you may want to consider only claiming allowances on the SC W-4 for the highest earning job and/or adding additional withholding on line 6 to ensure you are having enough withheld.

Complete box 8 and box 10 if sending to the SCDOR. Complete box 8, box 9, and box 10 if sending to the State Directory of New Hires.

For tax year 2021, I had a right to a refund of all South Carolina Income Tax withheld because I had no tax liability, and for tax year 2022 I expect a refund of all South Carolina Income Tax withheld because I expect to have no tax liability.

I elect to use the same state of residence for tax purposes as my military servicemember spouse. I have provided my employer with a copy of my current military ID card and a copy of my spouse's latest Leave and Earning Statement (LES). State of domicile:

SC W-4 (2022) Page 2

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 the SC1040ES, Individual Declaration of Estimated Tax, or adding additional withholding from this job's wages on line 6. Otherwise, you may owe additional tax. Find the SC1040ES with instructions at dor.sc.gov/forms. The fastest, easiest way to pay Estimated Tax payments is using our free, online tax portal, MyDORWAY, at dor.sc.gov/pay. Select Individual Income Tax Payment to get started. Do not mail a paper copy of the SC1040ES if you pay online. Employer instructions Complete box 8 through box 10, as necessary. Employees do not complete this section.

New hire reporting: You must report newly-hired employees within 20 days after the employee's first day of work. For more information, see SC Code Section 43-5-598 and 42 USC Section 653a or visit newhire.sc.gov. Box 8: Enter your name and address. If you are sending a copy of this form to the State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9: If you are sending a copy of this form to the 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 you rehired the employee after they had been separated from your service for at least 60 days, enter the rehire date. Box 10: Enter your Employer Identification Number (EIN).

All employers reporting South Carolina wages or withholdings must submit the W-2s directly to the SCDOR. Submitting the W-2s to the Social Security Administration does not meet this requirement. The fastest, easiest way to submit W-2s is using our free, online tax portal, MyDORWAY, at MyDORWAY.dor.sc.gov. Sign into your existing account or create an account to get started. Once you've logged in, select the More tab, then click Upload W-2s listed under the Other section. Find the Withholding Tax Tables and the Withholding Tax Formula at dor.sc.gov/withholding. Worksheet instructions Personal Allowances Worksheet: Complete the worksheet on page 3 to determine the number of withholding allowances to claim.

Line C: Head of household - Generally, you may claim the 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 a qualifying individual. For more information on filing status, refer to IRS Pub. 501 at irs.gov. Line E: Dependents - The total number of dependents claimed on your South Carolina return must equal the number of dependents claimed on your federal return. This includes qualifying children and qualifying relatives. Enter the total number of eligible dependents. Line F: Dependents under the age of 6 - Enter the number of dependents from line E who have not reached the age of six by December 31, 2022.

Enter the total from line G of this worksheet on line 5 of the SC W-4. Deductions, Adjustments, and Additional Income Worksheet: Complete this optional worksheet 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.

Reduce withholding: Complete this worksheet to determine if you are 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 reduce your withholding, your refund at the end of the year will be smaller, but your paycheck will be larger. Increase withholding: You can also use this worksheet to determine 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.

Enter the total from line 10 of this worksheet on line 5 of the SC W-4.

SC W-4 (2022) Page 3

Personal Allowances Worksheet

A Enter 1 for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter 1 if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BC Enter 1 if you will file as head of household. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CD Enter 1 if: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

You are single, or married filing separately, and have only one job; or You are married filing jointly, have only one job, and your spouse doesn’t work; or Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

D

E Dependents: Enter the number of dependents you will claim on your 2022 federal return . . . . . . . . . . . EF Dependents under the age of 6: Enter the number of dependents from line E who are under the age

of 6 as of December 31, 2022. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F

G Add line A through line F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GFor 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 the above situation does not apply, stop here and enter the number from line G on line 5 of the SC W-4 on page 1.

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.

1

Enter an estimate of your 2022 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. For more information, see IRS Pub. 505 at irs.gov. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter the 2022 federal standard deduction amount based on your filing status. . . . . . . . . . . . 2 $

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

4 Enter an estimate of your 2022 adjustments to income and any additional standard deduction for age or blindness. For more information, see IRS Pub. 505 at irs.gov. . . . . . . . . 4 $

5 Add line 3 and line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 $

6 Enter an estimate of your 2022 nonwage income not subject to withholding (such as dividends or interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 $

7 Subtract line 6 from line 5. If zero, enter 0. Enter a negative amount in brackets. . . . . . . . . . .

Enter the total from line 10 on line 5 of the SC W-4 on page 1.

7 $

8 Divide line 7 by $4,300. Enter a negative amount in brackets. Round decimals down. . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line G. . . . . . . . . . . . . . . . . . . . 9

10 Add line 8 and line 9. If zero or less, enter 0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SC W-4 Worksheets KEEP FOR YOUR RECORDS

The Family Privacy Protection Act Under the Family Privacy Protection Act, the collection of personal information from citizens by the SCDOR is limited to the information necessary for the SCDOR to fulfill its statutory duties. In most instances, once this information is collected by the SCDOR, it is protected by law from public disclosure. In those situations where public disclosure is not prohibited, the Family Privacy Protection Act prevents such information from being used by third parties for commercial solicitation purposes.

Social Security Privacy Act Disclosure It is mandatory that you provide your Social Security Number on this tax form if you are an individual taxpayer. 42 U.S.C. 405(c)(2)(C)(i) permits a state to use an individual's Social Security Number as means of identification in administration of any tax. SC Regulation 117-201 mandates that any person required to make a return to the SCDOR must provide identifying numbers, as prescribed, for securing proper identification. Your Social Security Number is used for identification purposes.

EMPLOYEE REFERENCE CHECK FORM

Applicant Name:

Position applied for:

I authorize all past employers, schools, persons and organizations having relevant information or knowledge (whether favorable or unfavorable) to provide it to The Sunshine House. I specifically waive any other required written notification. I hereby release The Sunshine House, its officers, employees and agents and any employers, schools, persons, and organizations from all liability in responding to inquiries in connection with my application for employment with The Sunshine House.

Applicant's Signature Date

Reference Check Information Company Name Telephone Number

Supervisor/Contact Name Title

Dates of Employment Position Title Starting Salary Ending Salary

Please Provide Information Regarding the Applicant's Performance In the Following Areas: Attendance

Work Habits:

Employee/supervisor relations:

Employee/peer relations:

Specific duties:

Are there any problems, concerns or reasons you may know that would prohibit this applicant from caring for young children? If so please explain.

Do you have any concerns about this applicant working as the only adult in a classroom of young children? If so, please explain.

Why did the applicant leave your company?

Would you recommend this person for rehire? Yes No Why or why not?

Additional comments:

Reference check completed by:

Name Title Date

EMPLOYEE REFERRAL FORM (Center Level Employees Only)

Employee Name: Center Number/Location: _

Date:

Name of applicant referred:

Start date of new employee: / /

Was applicant hired as full-time center employee? YES / NO (Please circle)

Was applicant hired as a Center Director? YES / NO (Please circle)

Did applicant list the employees name on The Sunshine House Application? YES / NO (Please circle)

Relationship to Employee (friend, family member, or other (please specify):

Please include a copy of the candidate’s application to confirm referral

Signature of Employee Date:

Signature of Director Date:

(PAYROLL USE ONLY) Date received in Payroll: / /

Teammate Referral Payout

Payout 1: $50.00 (paid out after day 1 employment is confirmed)

(Payroll Signature/date)

Payout 2: $50.00 (paid out after 90 days of employment)


Director Referral Payout

Payout 1: $100.00 (paid out after day 1 employment is confirmed)


Payout 2: $100.00 (paid out after 90 days of employment)


Must be a current employee to receive referral payment. Only full-time referred positions are eligible. Center Directors are not eligible for referring

center staff, but are eligible for referring Center Directors. Benefits may vary by position. The Sunshine House is an Equal Opportunity Employer.

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

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

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

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

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

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

Refer to the instructions for more information about acceptable receipts.

South Carolina Department of Social ServicesChild Care Regulatory ServicesMEDICAL STATEMENT

To be completed by staff, volunteers, and emergency personnel:

Name: SSN:

Home Address:

Date of Birth: Male Female Telephone:

Statement of your present health in your own words:

Have you ever had or do you now have any of the following:

If any item is checked “Yes”, please explain:

Please provide appropriate information below regarding freedom from tuberculosis (TB):NEW EMPLOYEE: Enter below date of written evidence from a physician or health resource attesting you are free fromcommunicable TB.

CURRENT EMPLOYEE: Check below if you are required to have additional tuberculosis tests.No more TB tests required TB tests required every

I CERTIFY THAT THE ABOVE INFORMATION SUPPLIED BY ME IS TRUE AND COMPLETE TO THE BEST OF MYKNOWLEDGE.

DSS Form 2901 (OCT 07) Edition of JUL 82 is obsolete.

Last First Middle

Date of Verification

Signature Date

Number Street City State Zip

Illness/ConditionVision Problems Rupture or Hernia

HemorrhoidsSugar or Albumen in UrineJaundiceDiabetesHeart ProblemsBone, Joint or other DeformityBack ProblemsTumor, Growth or CancerNervous ConditionDrug or Narcotic HabitAdverse Reaction to MedicationAlcoholismIllnesses or injury not mentioned aboveLoss of consciousness

Ear, Nose, Throat ProblemsHearing LossFrequent/Severe HeadachesDizziness or Fainting SpellsHead InjuryEpilepsy or SeizuresShortness of Breath or Lung ProblemsSpitting up BloodTuberculosisSkin DiseasePain or Pressure in ChestHigh Blood PressureFrequent IndigestionStomach, Liver or Intestinal ProblemsHave you ever been refused employment or been unable to hold a job for reasons of health?Have you ever been denied life insurance?Have you ever been rejected for or discharged from military service for physical, mental or other reasons?

Yes No Illness/Condition Yes No

South Carolina Department of Social Services Child Care Licensing

NAME: ________________________________________________DOB: ________________

Type of Activity in Child Care (Check all applicable) Caring for children Desk Work Adult Member of Household Food Preparation Driver of Vehicle Facility Maintenance____________________________________________________________________________

THIS SECTION TO BE COMPLETED BY HEALTH CARE PROVIDER WHO DOES HEALTH ASSESSMENTS

PART I – MEDICAL HISTORY – Does this person have any of the following medical problems? Yes No

History of myocardial infarction, angina pectoris, coronary insufficiency? History of epilepsy? Diabetes? Current drug or alcohol dependency? Disabling emotional disorder? Does this person have any special medical or mental problems which might interfere with the health of the children or that might prohibit this person from providing adequate care for the children? If yes, explain on reverse of form. Speech disorder? Significant physical findings/chronic medical condition or physical impairment? Other special medical problem or chronic disease which requires restriction of activity, medication or which might affect his/her work role? If so, specify on reverse of form.

PART II – AS SHOWN BY PHYSICAL EXAMINATION, DOES THE INDIVIDUAL HAVE: Yes No

At least 20/20 combined vision, corrected by glasses if needed? Normal hearing? Normal blood pressure? Date of Examination ___________________

PART III – COMMUNICABLE DISEASES – Does this person have a communicable disease which would prohibit him/her from working in a child care facility?

Yes No If yes, please comment: _________________________________________________

____________________________________________________________________________________

Tuberculosis Certification Must be completed within 12 months prior to employment. TB Certification must be documented on the DHEC 1420, School Employee Certificate of Evaluation of TB according to SC DHEC Regulation 61-22 DHEC 1420 can be obtained at SCDHEC.gov

Immunization Status Facility staff are at risk of exposure to childhood diseases. Prospective employees who will work with infants should have a review of their immunization status. Employees are also at risk of exposure to live virus, such as polio and CMV, and one-time adult dose of TDAP. Immunization status reviewed: Yes No

Comments: __________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________ Print Name & Address of Health Care Provider Telephone Number

_________________________________________________________________________________________________________ Signature of Health Care Provider Date Signed

HEALTH ASSESSMENTS MUST BE OBTAINED AT LEAST EVERY FOUR (4) YEARS AFTER INITIAL ASSESSMENT

DSS FORM 2926 (MAY 19) Edition of JUN 09 is obsolete.

Staff Health Assessment

School Employee Certificate of Evaluation for Tuberculosis

____________________________________________ ________________________________________________________________Name: Last First M.I. Residence Address City County

_____________________________________________________________________________________________ ___________________________Worksite, e.g. public or private school, kindergarten, nursery, or daycare facility for infants and children Date employed

TE

ST R

ESU

LT

S

TUBERCULIN SKIN TEST ____________Date Given

5 TU Mantoux Method____________ mm _______________

Date Interpreted

CHEST X-RAY

Date _______________

Interpretation:

REMARKS

IGRA ____________ □ T Spot □ QFT Date Collected

Results ________________________

DIS

POSI

TIO

N

________ No tuberculosis infection per 5 TU PPD o r I G RA r es u l t s 1

________ Tuberculosis infection, no evidence of disease_________ Preventive treatment s t a r t e d a nd completed ___________________.

_______ Preventive treatment started ___________________but not completed 2

________ Preventive treatment not prescribed/refused 2

History of tuberculosis disease. Treatment started _____________ and completed _______________.

________ Current tuberculosis disease

_______ Non-contagious as of _________________ and medically cleared to start/resume school employment on ______________.1No further routine screening required unless additional screenings required by employer. 2Remains at lifelong risk of developing tuberculosis.

CE

RT

IFI

-CA

TIO

N _______ This is to certify that I have examined the person named herein for tuberculosis and report my findings as indicated above pursuant to the Code of Laws of South Carolina, 1976.

____________________________________________________________________________ _________________________Physician’s Signature Date

DHEC 1420 (07/2017) DISPOSITION: This form shall be retained in the files of the current employer or individual following evaluation and certification.

SCHOOL EMPLOYEE CERTIFICATE OF EVALUATION FOR TUBERCULOSIS: This form may be used for school employees who need documentation of tuberculosis evaluation. It should be maintained in the current employer’s file for school employees.

CODE OF LAWS OF SOUTH CAROLINA, 1975. SECTION 44-29-150. No person will be initially hired to work in any public or private school,kindergarten, nursery, or day care center for infants and children until appropriately evaluated for tuberculosis according to guidelinesapproved by the Board of Health and Environmental Control. Re-evaluation will not be required for employment in consecutive years unlessotherwise indicated by such guidelines.

SECTION 44-29-160. Any person applying for a position in any of the public or private schools, kindergartens, nurseries, or day care centersfor infants and children of the State shall, as a prerequisite to employment, secure a health certificate from a licensed physician certifying thatsuch person does not have tuberculosis in an active stage.

SECTION 44-29-170. The physician shall make the aforesaid certificate on a form supplied by the Department of Health and EnvironmentalControl, whose duty it shall be to provide such forms upon request of the applicant.

SUMMARY OF GUIDELINES OF THE DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL. (Regulation 61-22) As aprerequisite to employment, and as a condition for continued employment, all employees shall be evaluated for tuberculosis by a licensedhealth care provider and shall provide written certification from a licensed physician that the person does not have TB disease.Tuberculosis evaluations must be completed no more than one year prior to employment. Tuberculosis evaluations shall be conducted utilizing Approved TB Screening Tests. Certification of tuberculosis evaluation, including disposition and preventive treatment, shall be documented on DHEC 1420 and retained in the files of the school, kindergarten, nursery or day care center for infants and children where the person works. These forms shall be subject to review by DHEC. If the evaluation reveals TB disease, then the individual shall be excluded from working in any school, kindergarten, nursery or day care center for infants and children until a licensed physician certifies thatthe individual no longer has TB in an active stage. Any employee with a positive Approved TB Screening Test or with a history of latent TBinfection or TB disease shall be further evaluated by a licensed health care provider with chest x-ray or additional testing. Any employee with a positive Approved TB Screening Test or with a history of latent TB infection or TB disease shall be further evaluated by a licensedhealth care provider. If the evaluation reveals no TB disease, then no exclusion and no further routine screening shall be required. Anemployee who would otherwise be exempt from routine annual screening for tuberculosis may be required to undergo non routine screening if there is epidemiologic or clinical evidence that such employee may have been exposed to TB bacteria or become infected with TB or mayhave moved from having latent TB infection to TB disease as evidenced by the observation of signs and symptoms suggestive oftuberculosis.

DHEC 1420 (07/2017)

South Carolina Department of Social Services Child Care Licensing

CONSENT TO RELEASE INFORMATION AND COMPLIANCE STATEMENT

The SC Child Care Licensing Law, Section 63-13-40 D(1-2) et seq., Code of Laws states that in order to be employed by or to provide caregiver services at a childcare facility licensed, registered, or approved under this sub-article, a Central Registry and Database check must be conducted by DSS to determine any abuse or neglect perpetrated by the person upon a child. However, as stated in Section 63-13-40 D(3), Code of Laws, a person may be provisionally employed or may provisionally provide caregiver services before the Central Registry check is completed if the person executes a sworn statement on a form provided by DSS that he or she is not on the Central Registry or in the Database for having perpetrated abuse or neglect upon a child.

Name of Child Care Facility: ________________________________ Name of Director/Operator: ____________________________________

Street Address of Facility: ______________________________________ City: ____________________ State: ______ Zip Code: _________

County: _________________ Facility Permit/ App ID Number _____________ Check One: NEW Staff Member RENEWAL Staff

(Optional) I want to receive results for this check by facility’s e-mail address on file. Contact your Regional Office if any changes to email address

Print or Type: Do not use initials. Spelling of the entire name is required to avoid processing delays.

Full Name: _________________________________________________________________ DOB: ______________ Sex: _____________ Last First Middle

Maiden/Former Name: _________________________________ Race: _______________ Complete SSN (No X’s): __________________

Current Address: _________________________________________________________________________________________________

Lists other addresses that you have lived at in the past 5 years, including dates of each residency: _______________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

This serves as my consent to authorize SC DSS Child Care Licensing to conduct a search of the Central Registry and Database of Child Abuse and Neglect and National Sex Offender Registry on myself. I understand that the information may prove unfavorable to me. I agree to hold any source of information, SC DSS and its staff harmless from liability associated with the release of information I have requested using this form. I understand that all information provided on this form will be released to the individual/organization listed above. This consent is effective for a search of the Central Registry and Database of Child Abuse and Neglect and National Sex Offender Registry for the purpose of working in any child care facility in the State. If it appears to me that the information in the Registry has not been updated or is inaccurate, I will notify DSS County Office immediately.

No electronic signatures. Your signature MUST be witnessed. Mail form to SCDSS, Child Care Licensing, P.O. Box 1520, Room 218, Columbia, SC 29202-1520

___________________________________ ___________ _______________________________________ ________________ Signature of Applicant Date Witnessed by Director/Operator/Designee Date

To be completed by authorized DSS employee only. Results of Search of the Child Abuse and Neglect Database, Central Registry and National Sex Offender Registry.

The applicant is not listed as a perpetrator in the Central Registry or Database of Child Abuse and Neglect. The applicant is listed as a perpetrator in the Central Registry. According to state law, being named as a perpetrator prohibits an

individual from being employed in a child care facility. The applicant is listed as a perpetrator in the Database of Child Abuse and Neglect. According to state law, being named as a

perpetrator prohibits an individual from being employed in a child care facility for up to 7 years. The applicant information requires research. An additional 10 days are needed to process this request. The applicant is not listed in the National Sex Offender Registry. (NSOR) The applicant is listed in the National Sex Offender Registry. (NSOR)

Child Abuse and Neglect/ National Sex Offender Registry Check Completed by: _________________________ ______________ Authorized DSS Employee Date

FOR PROVISIONAL EMPLOYMENT ONLY THIS FORM ONLY NEEDS TO BE NOTARIZED IF THE EMPLOYEE IS BEING HIRED PROVISIONALLY AS DEFINED BY SECTION 63-13-40 D(2) AT THE TOP OF THE FORM. I AFFIRM BY THIS SWORN AND SIGNED STATEMENT THAT I AM NOT LISTED IN THE CENTRAL REGISTRY OR DATABASE AS A PERPETRATOR OF CHILD ABUSE AND NEGLECT. Staff’s Signature: ____________________________________________ Staff’s Title: ________________________________________ SWORN TO AND SUBSCRIBED BEFORE ME This ________ day of _______________________, 20 ____, ___________________________________________________ My Commission Expires: ___________________________ Notary Public for South Carolina

DSS Form 2924 (JUNE 21) Edition of SEPT 20 is obsolete.

South Carolina Department of Social Services Office of Inspector General

P.O. Box 1520, Columbia, South Carolina 29202

NON-CRIMINAL JUSTICE APPLICANT PRIVACY RIGHTS NOTIFICATION

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for a job or license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights as outlined below:

• You are entitled to written notification that your fingerprints and associated information (biometrics) will be used to check the criminal history records maintained by the Federal Bureau of Investigation (FBI), when a federal record check is so authorized.

• If you have an FBI criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.

• If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.)

• If you have a FBI criminal history record, procedures for obtaining a change, correction, or update of your record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.

• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal history record.

• You may obtain a copy of your criminal history record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at http://www.fbi.gov/about-us/cjis/background-checks.

• You have the right to expect that officials receiving the results of your criminal history record check will use it solely for the purpose requested and will not disseminate the record outside the receiving departments, related agencies, or other authorized entities.

• In addition, the South Carolina Law Enforcement Division (SLED) will store your fingerprints and provide the SC Department of Social Services (DSS) with notification of any arrests that occur in South Carolina.

______________________________________ _______________________ Print Name Date

______________________________________ Signature

DSS Division/Office/Unit Name

DSS FORM 1081 (FEB 19) Edition of MAR 18 is obsolete.

http://www.fbi.gov/about-us/cjis/background-checks

http://www.fbi.gov/about-us/cjis/background-checks

South Carolina Department of Social Services Office of Inspector General

P.O. Box 1520 , Columbia, South Carolina 29202

PRIVACY ACT STATEMENT

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. The South Carolina Law Enforcement Division (SLED) will store your fingerprints and provide the SC Department of Social Services (DSS) with notification of any arrests that occur in South Carolina.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Additional Information: The requesting agency and/or the agency conducting the application-investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).

_______________________________________ ______________________ Print Name Date

_______________________________________ Signature

DSS Division/Office/Unit Name

DSS FORM 1083 (FEB 19). Edition of MAR 18 is obsolete.

EMPLOYEE COPY

All Full-Time employees who are regularly scheduled to work at least 30 hours per week, and their eligible dependents, may participate in the company benefits program if they choose.

All Part-Time employees who are regularly scheduled to work 17-29 hours/week are eligible for Minimum Essential Benefit coverage with Century Medical, Dental, Vision and Voluntary Supplemental coverage options.

If hired between: Your benefits will begin on:

Important Note: If you do not enroll within 30 days of your hire date the enrollment window will be closed and you will not be able to elect benefit coverages for the current benefit year. November is the next open enrollment period to make benefit elections for the next plan year. Once you choose to enroll in the SSH benefits program (or decline to enroll), you may not change your election(s) unless you experience a Qualifying Event. A Qualifying Event is one that would ordinarily cause an individual to change their health coverage. Qualifying Events include: marriage, divorce, death, birth or adoption of a child or if your spouse loses their insurance coverage elsewhere.

HOW TO ENROLL

To make your benefit elections, log on to the ADP website at: https://adpvantage.adp.com. First time users will use registration code: SSHOUSE1-Register, enter name, last 4 digits of social security number and date of birth (MM/DD) and hit confirm. Complete the registration process. Once logged in to ADP, go to Myself > Benefits > Enrollments. Click on the hyperlink New Hire – MM/DD/YYYY (your hire date would be here). If you decide not to complete your benefits at this time, you will see the message “You have until midnight on MM/DD/YYYY to make your elections”.

_______________________________________ _________________________________ Employee Signature Date **If you need assistance please contact 864-990-1820 x773 or [email protected].

January 1 – 31 April 1 February 1 – 28 May 1

March 1 – 31 June 1 April 1 – 30 July 1 May 1 – 31 August 1 June 1 - 30 September 1 July 1 - 31 October 1

August 1 - 31 November 1 September 1 - 30 December 1

October 1 - 31 January 1 November 1 - 30 February 1 December 1 – 31 March 1

HR COPY

All Full-Time employees who are regularly scheduled to work at least 30 hours per week, and their eligible dependents, may participate in the company benefits program if they choose.

All Part-Time employees who are regularly scheduled to work 17-29 hours/week are eligible for Minimum Essential Benefit coverage with Century Medical, Dental, Vision and Voluntary Supplemental coverage options.

If hired between: Your benefits will begin on:

Important Note: If you do not enroll within 30 days of your hire date the enrollment window will be closed and you will not be able to elect benefit coverages for the current benefit year. November is the next open enrollment period to make benefit elections for the next plan year. Once you choose to enroll in the SSH benefits program (or decline to enroll), you may not change your election(s) unless you experience a Qualifying Event. A Qualifying Event is one that would ordinarily cause an individual to change their health coverage. Qualifying Events include: marriage, divorce, death, birth or adoption of a child or if your spouse loses their insurance coverage elsewhere.

HOW TO ENROLL

To make your benefit elections, log on to the ADP website at: https://adpvantage.adp.com. First time users will use registration code: SSHOUSE1-Register, enter name, last 4 digits of social security number and date of birth (MM/DD) and hit confirm. Complete the registration process. Once logged in to ADP, go to Myself > Benefits > Enrollments. Click on the hyperlink New Hire – MM/DD/YYYY (your hire date would be here). If you decide not to complete your benefits at this time, you will see the message “You have until midnight on MM/DD/YYYY to make your elections”.

_______________________________________ _________________________________ Employee Signature Date **If you need assistance please contact 864-990-1820 x773 or [email protected].

January 1 – 31 April 1 February 1 – 28 May 1

March 1 – 31 June 1 April 1 – 30 July 1 May 1 – 31 August 1 June 1 - 30 September 1 July 1 - 31 October 1

August 1 - 31 November 1 September 1 - 30 December 1

October 1 - 31 January 1 November 1 - 30 February 1 December 1 – 31 March 1

https://adpvantage.adp.com/

**IMPORTANT -- READ BEFORE COMPLETING THE FOLLOWING FORMS**

1. You must sign and date, IN BLUE INK, the original and each copy that you submit.

2. Type or print your answers in ink (if your form is not legible, it will not be accepted).

3. All questions on this form must be answered. If no response is necessary or applicable, indicate thison the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date,estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

4. Any changes that you make to this form after you sign it must be initialed and dated by you. Undercertain limited circumstances, you may modify the form consistent with your intent.

5. You must use the State codes (abbreviations) listed when you fill out this form. Do not abbreviate thenames of cities or foreign countries.

6. The 5-digit postal ZIP code is needed to speed the processing of your investigation.

7. All telephone numbers must include the three-digit area code.

8. All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers toindicate months. For example, June 10, 1978, should be shown as 06/10/1978.

9. Whenever "City (Country)" is shown in an address block, provide in that block the name of thecountry when the address is outside the United States.

10. If you need additional space to list your residence or employment history, or to include periods ofself-employment, unemployment, or educational experience, you may use a blank piece of paper thatlists the question reference number next to the additional information. Each blank piece of paper youuse must contain your name and Social Security Number at the top of the page.

DSS Form 1706 (JAN 20) Edition of NOV 19 is obsolete.

Child Care and Development Block Grant (CCDBG) Act Criminal Background Check Questionnaire Title 42 U.S.C., §9858 (f) – Criminal Background Checks South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment

Please follow all instructions carefully or your form cannot be processed timely. Be sure to sign and date the Certification Statement on Page 5 and the Release Form on Page 6. If you have any questions, please contact your immediate supervisor or the assigned background investigator.

Purpose of this Form

In accordance with Title 42 United States Code (U.S.C.) §9858 (f) – Criminal Background Checks; U.S. Department of Health and Human Services (DHHS), Title 45 Code of Federal Regulations (C.F.R.), Subchapter A, Section 98.43 – Child Care and Development Fund (CCDF) (a.k.a. the Child Care and Development Block Grant (CCDBG) Act); South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment; and states shall have requirements, policies and procedures to require all licensed, regulated and registered child care providers; as defined under Title 42 U.S.C. §9858 (f)(i)(2) and South Carolina Code of Laws, Section §63-13-40 (A), to conduct a comprehensive criminal background check upon all current and prospective employees who are employed by a child care provider for compensation or whose activities involve unsupervised access to children who are cared for by the child care provider.

The information obtained from this form is used as the basis for this criminal background check. Providing this information is not voluntary for positions with unsupervised access to children. The required investigation cannot be completed, or completed in a timely manner, if each item of information requested is not provided in full. The CCDF requires child care service providers to complete criminal background checks at least once every five (5) years.

Authority to Request this Information

The South Carolina Department of Social Services is authorized to ask for this information under Title 42 U.S.C. §9858 (f) – Criminal Background Checks; Title 45 C.F.R., Subchapter A, Section 98.43 – Child Care and Development Fund (CCDF) (a.k.a. the Child Care and Development Block Grant (CCDBG) Act); and South Carolina Code of Laws, Section §63-13-40 (A).

Federal and State agencies are routinely required to utilize a Social Security Number to identify individuals in agency records; this is to insure the accuracy of those records. This background investigation requires that a detailed search be conducted within all Federal and State criminal and sex offender registries and repositories and that a review be conducted of all Federal and State arrest and conviction information.

The Investigative Process

Criminal background checks are conducted using your responses on this form to develop information to determine eligibility for existing and/or prospective child care providers staff members; as defined under Title 42 U.S.C. §9858(f)(i)(2). The information that you provide on this form will be verified during the investigation. As a normal part of this process, you may becontacted by SCDSS to update, clarify, and/or explain information obtainedduring the background check. It is important that you respond as soon aspossible if contacted.

Instructions for Completing this Form

1. Follow the instructions given to you by the person who gave you theform and any other clarifying instructions furnished by that person toassist you in completion of the form. You must sign and date, in BLUEink, the original and each copy you submit.

2. Type, or print your answers in ink (if your form is not legible, it willnot be accepted).

3. All questions on this form must be answered. If no response isnecessary or applicable, indicate this on the form (for example, enter"None" or "N/A"). If you find that you cannot report an exact date,approximate or estimate the date to the best of your ability and indicatethis by marking "APPROX." or "EST."

4. Any changes that you make to this form after you sign it must beinitialed and dated by you. Under certain limited circumstances, you may modify the form consistent with your intent.

5. You must use the State codes (abbreviations) listed when you fill outthis form. Do not abbreviate the names of cities or foreign countries.

6. The 5-digit postal ZIP codes are needed to speed the processing ofyour investigation.

7. All telephone numbers must include area codes.

8. All dates provided on this form must be in Month/Day/Year orMonth/Year format. Use numbers (1-12) to indicate months. Forexample, June 10, 1978, should be shown as 6/10/78.

9. Whenever "City (Country)" is shown in an address block, also providein that block the name of the country when the address is outside theUnited States.

10. If you need additional space to list your residences, employmenthistory, to include, periods of self-employment, unemployment, oreducational experience; you may use a blank piece of paper that lists thequestion reference number next to the additional information. Ifadditional space is needed to answer other items, use a blank piece ofpaper. Each blank piece of paper you use must contain your name andSocial Security Number at the top of the page.

Disclosure of Information

The information you provide is for the purpose of completing background checks pursuant to State and Federal laws and is protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by both State and Federal Privacy Acts. The information on this form, and information collected during your criminal background investigation shall not be disclosed without your consent, except as permitted by law.

SC Department of Social Services Office of Inspector General CCDBG Criminal Background Check Questionnaire

Child Care and Development Block Grant ActTitle 42 U.S.C., §9858 (f) – Criminal Background Checks

South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment Criminal Background Check Questionnaire


Final Determination on Your Eligibility

The SCDSS will only provide the detailed results of your criminal background check to you. The child care provider will receive your results in the form of a written statement that indicates whether you as an existing or prospective child care staff member are eligible or ineligible for employment. The child care provider will not receive any information regarding your disqualifying crime.

If you are one of those individuals subject to a criminal conviction screening, you will be provided the opportunity to submit additional information within a specified timeframe, in the event a criminal conviction requires clarification or results in an unfavorable outcome, such as ineligibility for employment.

Final decisions resulting in an ineligibility status, will be provided in a written statement to you that will include information related to each disqualifying crime. You will also be given notice of the opportunity to appeal. An ineligible existing or prospective child care staff member will receive instructions about how to complete the appeals process if the child care staff member wishes the accuracy or completeness of the information contained within such member’s criminal background report.

If you, as an existing or prospective child care staff member knowingly and willfully make a materially false statement in connection with this criminal background check, you shall be determined ineligible for employment by a child care provider.

STATE CODES (ABBREVIATIONS)

Alabama AL Hawaii Hl Massachusetts MA New Mexico NM South Dakota SD Alaska AK Idaho ID Michigan Ml New York NY Tennessee TN Arizona AZ Illinois IL Minnesota MN North Carolina NC Texas TX Arkansas AR Indiana IN Mississippi MS North Dakota ND Utah UT California CA Iowa IA Missouri MO Ohio OH Vermont VT Colorado CO Kansas KS Montana MT Oklahoma OK Virginia VA Connecticut CT Kentucky KY Nebraska NE Oregon OR Washington WA Delaware DE Louisiana LA Nevada NV Pennsylvania PA West Virginia WV Florida FL Maine ME New Hampshire NH Rhode Island RI Wisconsin WI Georgia GA Maryland MD New Jersey NJ South Carolina SC Wyoming WY

American Samoa AS Dist. of Columbia DC Guam GU Northern Marianas CM Puerto Rico PR Trust Territory TT Virgin Islands Vi

DSS Form 1706 (JAN 20) Edition of NOV 19 is obsolete. Page 1

SC Department of Social ServicesOffice of Inspector General CCDBGACrimnal Background CheckQuestionnaire

Child Care and Development Block Grant Act Title 42 U.S.C., §9858 (f) – Criminal Background Checks

South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment

Criminal Background Check Questionnaire

C PLACE OF BIRTH - Use the two-letter code for the State. SOCIAL SECURITY NUMBER

Height (feet and inches) E O T H E R IDENTIFYING INFORMATION

F TELEPHONE NUMBERS

Home (include area code) Day Night ( )

Work (include Area Code and extension) Day Night ( ) -

Your Mother’s Maiden Name

Mark the box at the right that reflects your current citizenship status, and follow its instructions.

G1 CITIZENSHIPI am a U.S. citizen, but I was NOT born in the U.S. Answer items b, c and d

I am not a U.S. citizen. Answer items b and e

Persons completing this form should begin with the questions below. FULL NAME

If you have only initials in your name, use them and state “IO”. If you have no middle name, enter “NMN.”

If you are a “Jr.,” “Sr.,” “II,” etc., enter this in the box after your middle name.

B DATE OF BIRTH

Last Name First Name Middle Name Jr., II, etc. Month Day Year

A

City County

D OTHER NAMES USED: Na me

# 1 Na me

# 2

State Country (If not in the United States)

Month/Year

To

Month/Year Name

#3

Month/Year

To

Month/Year

Month/Year

To

Month/Year Name

#4

Month/Year

To

Month/Year

Weight (pounds) Hair Color Eye Color Sex (mark one box)

Female Male

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. Answer items b and d

Enter your Social Security Number before going to the next page

New Hire

G2 FACILITY LICENSE NUMBER________________________________________________________________________________________________________________

__________________________________________________________________________________________________G2 FACILITY NAME __________________________________________________________________________

FACILITY ADDRESS __________________________________________________________________________

STREET ADDRESS __________________________________________________________________________

CITY, STATE, ZIP CODE __________________________________________________________________________

__________________________________________________________________________________________________


H WHERE YOU HAVE LIVED List the places where you have lived, beginning with the most recent (#1) and working back five (5) years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence, do not use a post office box as an address, do not list a permanent address when you were actually living at a school address, etc. For military assignments, be sure to specify your location as closely as possible. For example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas. If additional space is needed, please list on additional paper.

Month/Year

#1 To

Month/Year

Present

Street Address Apt. # City (Country) State ZIP Code

Month/Year

#2 To

Month/Year Street Address Apt. # City (Country) State ZIP Code

Month/Year

#3 To


Month/Year

#4 To


Month/Year

#5 To


Month/Year

#6 To


Month/Year

#7 To


Month/Year

#8 To


Month/Year

#9 To


Month/Year

#10 To


Month/Year

#11 To


Month/Year

#12 To





SC Department of Social Services Office of Inspector General CCDBGA Criminal Background Check Questionnaire

Enter your Social Security Number before going to the next page


YOUR POLICE RECORD (Do not include anything that happened before your 18th birthday.) Have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150.

If you answered “Yes,” explain your answer(s) in the space provided.

Yes No

Month/Year Offense Action Taken Law Enforcement Authority/Court (Include City and county/country if outside U.S.) State ZIP Code

Certification That My Answers Are True

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. Enter your Social Security Number before going to the next page

Signature (Sign in BLUE Ink) Date





i CRIMINAL ARREST HISTORY

After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification and sign and date the release on page 6.


AUTHORIZATION FOR RELEASE OF INFORMATION (Please read this authorization to release information carefully, then sign and date it in BLUE ink.)

I Authorize an investigator, or other duly authorized representative, of the South Carolina Department of Social Services (SCDSS), Office of Inspector General pursuant to Federal and State laws, to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, or other sources of information. This information may include, but is not limited to, my residential, employment history, public safety agency contacts or investigations, and/or criminal history record information. I authorize the investigator or duly accredited representative conducting my criminal background check will provide the results of my criminal background check to the child care provider who submitted the request to the SCDSS in the form of a written statement. The statement provided by the SCDSS will indicate whether I, as an existing or prospective child care employee, am eligible or ineligible for employment in accordance with federal and state laws.

This will be accomplished without revealing any disqualifying criminal history information or any other related information regarding that individual pursuant to Title 42 U.S.C. §9858 (f) – Criminal Background Checks; Title 45 C.F.R., Subchapter A, Section 98.43 – Child Care and Development Fund (CCDF) (a.k.a. the Child Care and Development Block Grant (CCDBG) Act); and South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment.

I Further Authorize an investigator or other duly accredited representative of the South Carolina Department of Social Services, Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility to deliver CCDF services, as an employee of a child care provider for compensation or as an individual whose activities involve unsupervised access to children who are cared for by the referenced child care provider. I understand that I may request a copy of such records, as may be available to me under the law.

I Understand that the information released by records custodians and sources of information is for official use by the South Carolina Department of Social Services for the purposes provided in Title 42 U.S.C. §9858 (f) – Criminal Background Checks; Title 45 C.F.R., Subchapter A, Section 98.43 – Child Care and Development Fund (CCDF) (a.k.a. the Child Care and Development Block Grant (CCDBG) Act); and South Carolina Code of Laws, Section §63-13-40 (A) – Background Checks for Employment; and that it may be redisclosed by the South Carolina Department of Social Services only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid from the date signed.

Signature (Sign in BLUE Ink) Date





DSS Form 1706 (NOV 19) Edition of AUG 19 is obsolete.

DSS Form 1706 (AUG 19) Edition of MAR 19 is obsolete.

South Carolina Department of Social Services DSS Form 1706

Child Care and Development Block Grant (CCDBG) Act Criminal Background Check Questionnaire

Instructions

All existing and prospective child care staff members must complete the OIG CCDBGA Criminal Background Check Questionnaire issued to them by the child care provider. The child care provider making the request for the criminal background check must submit the completed and signed criminal background check questionnaire directly to the OIG within (2) business days of making an offer of employment or making a referral to a Live Scan site for fingerprint submittal.

Forms can be sent via email to [email protected] or mailed to:

SCDSS- Office of Inspector General Attn: Criminal Records Unit1628 Browning Road Suite 200-2 Columbia, South Carolina 29210Phone Number: (803) 898-8005


mailto:[email protected]

New Health Insurance Marketplace Coverage

Options and Your Health Coverage Form Approved

OMB No. 1210-0149 (expires 5-31-2020)

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 after-

tax 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 Benefits Manager at 864-990-1820 x 773 .

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

The Sunshine House4. Employer Identification Number (EIN)

57-10001785. Employer address12 Interchange Blvd.

6. Employer phone number

(864) 990-18207. City

Greenville8. State

SC9. ZIP code

2960710. Who can we contact about employee health coverage at this job?

Benefits Manager

11. Phone number (if different from above)

(864) 990-1820 ext. 77312. Email address

[email protected]

Here is some basic information about health coverage offered by this employer:

As your employer, we offer a health plan to:

D All employees. Eligible employees are:

D Some employees. Eligible employees are:

Employees who work 30 hours or more per week are eligible for minimum value coverage.

Employees who work 17 to 29 hours per week are eligible for minimum essential coverage.

Employees who work less than 17 hours per week are not eligible for coverage

With respect to dependents:

D We do offer coverage. Eligible dependents are:

Covered up to age 26

D We do not offer coverage.

D 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 theemployer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower yourmonthly premiums.

South Carolina New Hire Paperwork Check List

Employee Name: _______________________________

Center #_________ Date Uploaded:______________

**Employee documents requiring a signature should not be completed electronicallyAFTER RECEIVING APPROVAL FOR NEW HIRE INFORMATION, ALL FORMS BELOW SHOULD BE PLACED IN ORDER AND UPLOADED TO ADP. A COPY IS ALSO TO BE MAINTAINED IN THE EMPLOYEE’S CENTER FILE

Employee Information Sheet submitted Regional approval of Employee Information Sheet received/included

**Without Regional approval, process cannot move forward** Employment application completed Employee Policy Guide Acknowledgment signed Electronic Notification Acknowledgment signed Payroll Deductions Notification signed Payroll Choice Form completed Family Handbook Acknowledgment Form signed State and Federal W-4 Forms Two acceptable work references received I-9 form and identification documents completed DSS FBI and SLED Background Check letter Copy of High School Diploma/GED (or college degree, if applicable) SC DSS – Medical Statement SC DSS – Staff Health Assessment (TB test must be included) DHEC Certification of Evaluation for Tuberculosis SC DSS – Central Registry Release and Compliance Statement SC DSS Notice of Clearance/Central Registry Letter Evidence of Non-Conviction form Two fingerprint notification forms (DSS Form 1081 and 1083) SAFE (State Applicant Fingerprint Electronic processing) SCDBG Background Check Questionnaire **use BLUE ink** Benefits Eligibility Form Health Insurance Marketplace Coverage Options Order employee name tag through ACES Paperwork should be completed by hand and two approvals received from HR prior to the employee beginning work.

New Teammate Paperwork - Sunshine House

Documents

Transcript of New Teammate Paperwork - Sunshine House