IIMST UCTIOMS FO CQMPLET1MG MEW HIRE PAPERWORK

PLEASE READ ALL INSTRUCTIONS FOR COMPLETION

**DO NOT PRINT DOUBLE SIDED** USE BLUE OR BLACK INK ONLY

1. ADDITIONAL INFORMATION SHEET:® Must be LEGIBLE. PLEASE PRINT.© Make sure that you have checked the CAN or CA NOT be given to the public box at the bottom of the page.

2. SOCI L SECURITY FO M SS - 1945:© Make sure your NAME and Social Security # is listed at the top of this form.

© You must retain a copy of this form for your records

3. INSU CE OTIFIC TIO FORM:© You may view benefits information at WWW.katvisd.org -Departments -Risk Management - Benefits for

additional information.

© Your health coverage is effective the first of the month following your first day of employment.

4. W-4 Forms:

© It is OT a requirement that you complete the Personal Allowances Worksheet attached.

© Make sure your NAME and Social Security number is listed at the top of this form

© You must retain a copy of this form for your records.

5. UTHO IZ TIO FO DIRECT DEPOSIT (OPTIO L):

® Pay card o tion: Your first pay will be a paper check and will need to be picked up in the Payroll Department ofFinancial Services ESC Room 2510. Because it takes 7-10 business days to receive the pay card. Subsequent pay

will go to the pay card. Payroll can be reache at 281-396-2334.

® Direct Deposit option: Your first pay will be direct deposit into your account. Please complete this form bychecking NEW and filling in ALL appropriate information and attaching a VOIDED CHECK.

6. EMPLOYME T FTER ETI EMENT CK OWLEDGE E T FORM© To be completed by RETIREES ONLY.

NOTE:FINGERPRINTING:

• Fingerprinting is mandatory and must be completed prior to the New Hire meeting. (* *NOTE: If youhave already completed fingerprinting, please disregard this notice).

SUB to Employee

KATY I DEPENDE T SCHOOL DISTRICT

Additional Information Sheet

Full Name (please print)

Last Name First Name Middle Name(DO NOT USE INITIALS)

Social Security Number Date of Birth

/ /IViale Female

Address

P. 0. Box or Street City ST ZipPhone umber

(. Jhomecell

Marital Status

M W

The United States Department of Education (USDE) requires all state and local education institutions tocollect data on ethnicity and race for students and staff. This information is used for state and federalaccountability reporting, as well as for reporting to the Office of Civil Rights (OCR) and the EqualEmployment Opportunity Commission (EEOC). (Please complete both Part 1 and Part 2.)

School district staff, and parents or guardians of students enrolling in school, are requested to providethis information. If you decline to provide this information, please be aware that the USDE requiresschool districts to use observer identification as a last resort for collecting the data for federal reporting.

Part 1 - Ethnicity (choose only one}

Hispanic/Latino(a person of Cuban, Mexican, Puerto Rican,South or Central American or other Spanishculture or origin, re ardless of race

Not Hispanic/Latino

Must complete Part 2

Part 2 - Race (choose one or more) p

American Indian or Alaska Native(a person having origins in any of the original peoples of North or South America(including Central America), and who aintains a tribal affiliation or communityattachment)Asian(a erson having origins in any of the original peoples of the Far East, SoutheastAsia or the Indian subcontinent including, but not limited to, Cambodia, China, India,Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)Black or African American(a person having origins in any of the black racial groups of Africa)Native Hawaiian or other Pacific Islander(a person having origins in any of the original peoples of Hawaii, Gua , Samoa orother Pacific Islands)White(a person having origins in any of the original peoples of Europe, the Middle East orNorth Africa)

Statement of Confidentiality

According to the Open Records Act (effecti e 9/1/85) the home addresses, home telephone numbers (including formerhome addresses and telephone numbers), social security numbers and any information that reveals whether the personhas family members are confidential if the individual has, in writing, opted to keep this information closed. As anemployee of KISD, you may indicate whether you wish this information to be released by completing the appropriate boxbelow. Failure to complete either box below .indicates that you have no objection to having this information released.You can file a new form at any time to reflect a change in your choice concerning confidentiality.

My home address, home telephone number (including former home addresses and telephone numbers), socialsecurity number and any information that reveals whether I have family members: (check one)

CAN BE GIVEN to the public CA OT BE GIVE to the public

Signature Date

Updated: April 2013

St tement Concer ing Yo r Employme t in a JobNot Covered by Social Sec rity

Employee Name Employee ID#

Employer Name KATY I.S.D. Employer IP# 74-6001484

Your earnings from ti s job are not covered under Social Security. When you retire, or if you eco e disabled, youmay receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit fro SocialSecurity based on either your own work or the work of your husband or wife, or former husband or wife, yourpension may affect the a ount of the Social Security benefit you receive. Your Medicare benefits, however, willnot be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be

affected.

Windfall Elimination Provision ' ¦ .Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using amodified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As

result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. Forexa ple, if you are ge 62 in 2005, the xi u onthly reduction in your Social Security benefit s a result ofthis provision is $313.50. This amount is updated annually. This rovision reduces, but does not totally eliminate,your Soci l Security benefit. For ddition l infor tion, please refer to Soci l Security Public tion, Windf llEli ination Provision.

Government Pension Of set ProvisionUnder the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which youbecome entitled will be offset if you also receive a Federal, State or local government pension based on workwhere you did not pay Social Security tax. The offset reduces the amount of your Social Sec rity spouse orwidow(er) benefit by two-thirds of the amount of your ension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you areeligible for a $500 widow(e ) benefit, you will receive $100 er month from Social Securit ($500 - $400=$100).Even if your pension is high enough to totally offset your spouse or widow(er) Soci l Security benefit, you are stilleligible for edicare t e 65. For ddition l inform tion, ple se refer to Social Security Publication, Govern entPension Offset.

For More Information , . .Social Security publications and additional information, including information about exceptions to each rovision,are available at www.soda1seenrTtv.gov. Yo may also call toll free 1-800-772-1213, or for the deaf or hard ofhearin call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 th t contains inform tion about the possible effects or theWindfall Elimination Provision and the Govern ent Pension Offset Prov sion on my potenti l future SocialSecurity benefits.

Signature of Emplo ee Date

Form SSA-1945 (12-2004)

I formation abo t Social Security Form SSA-1945Stateme t Concer ing Yo r Employme t in Jo Not Covered y Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protectio Act of 2004] requires Stateand local government employers to provide a statement to employees hired Ja uary 1, 2005 or later in a job notco ered u der Social Security. The statement explains how a pension from that job could affect future Social

Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Yonr Emplo ent in a Job Not Covered by Social Security, is thedocument that employers should use to meet the requirements of the law. The SSA-1945 e plains the potential

ef ects of two provisions in the Social Security law for workers ho also receive a pension based on their work ina job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker sSocial Security retirement or disability benefit. The Government Pension Offs t Provision can affect a SocialSecurity benefit received as a spouse or an e -spouse.

Employers must:

0 Give the statement to the ployee prior to the start of employment;

® Get the e ployee’s signature on the form; and

® Submit a copy of the signed form to the pension aying agency.

So ial Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are vailable online at the Social Security website, www.socialsecuritv.gov/ onnl945.

Paper copies can be requested by email at oplm.os m.rqct.orders@ ssa.gov or by fax at 410-965-2037. Therequest ust include the name, complete address and telephone number of the employer. Forms ill not be sent to

a post office bo . Also, if appropriate, include the name of the person to who the forms are to be delivered. The

forms are available in packages of 25. Please refer to Inventor Control Number (ICN) 276950 hen ordering.

Form SSA-1945 (12-2004)

Lance N. NaumanDirector or Risk Management

Katy Independent School District

Dear Employee:

Welcome to Katy I.S.D. You are receiving this letter because it has been determined that you are eligiblefor benefits as a Katy I.S.D. employee. Several benefits are available to you which include medical, dental,vision, life, disability, FSA, and legal protection plans. Benefit information can be obtained by accessingthe Katy Benefits website at www.katvbenefits.org. This is also the site where you may enroll or you maycall 1-866-222-5473 if you have questions or ish to enroll by phone. You will receive enrollmentinstructions once your employment information is in the Katy I. S. D. benefits system. If you receive vourfirst pa check and are still not able to enroll, please contact the Katy I.S.D.Risk Management Department at 281-396-2241.

You are eligible to participate in any of the available benefits effective on the first day of the monthfollowin the first day worked or first day benefits eligible. If the first day worked or benefits eligible isthe first day of the month, your benefits will be effective on that day. The date you enroll does notdetermine the effective date of benefits.

You must enroll within one month of your eligibility date in order to participate in any benefits. You areresponsible for premiums from the effective date as defined in the para raph above, which could be priorto your actual enrollment date. If you do not enroll within the first month of eligibility you will only haveBasic Life and Employee Assistance Program coverage which is provided by the District with no cost to theemployee. In most cases, the Basic Life amount is $20,000.

If you leave the District as a benefits eligible employee and are rehired into a benefits eligible positionwithin 31 days of the date your benefits termed, the same benefits will be reinstated with no lapse incoverage. If you are rehired during a predetermined ACA (Affordable Care Act) eli ibility period, you willbe eligible for benefits for the remainder of that eligibility period regardless of your position.

After reading this letter, please si n below.

I understand that I am responsible for my enrollment by the date specified above.

Signature

Print Name

Regards,

Jo Ann TiltonInsurance Coordinator

Date

Social Security

Katy Independent School District • 6301 South Stadium Lane • PO Box 15 • K ty, Tex s 77492-0159281-396-2241 • Fax: 281-644-1900 • lancennaum n@katyisd.org

Form ApprovedOMB No. 1210-0149(expires 11 -30-2013)

New ealth Ir suranee Marketplace CoverageO tions and Your ealth Coverage

P RT A: General InformationWhen key parts -of the health care law take effect in 201 4, there will be a new way to buy health insurance: the HealthInsurance Marketplace. To assist you as you evaluate options for you and your family, this not ce provides some basic

infor ation about the new Marketplace nd employment-based health coverage offered by your employer.

What is the Health Insurance Marke place?The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. TheMarketplace 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 E loney on my Health Insurance Premiums in th 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 Healt Coverage Affect Eligibility for Premium Savings t roug the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligiblefor a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may beeligible for a ta 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 st ndards. 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 householdincome 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 youremployer, 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 ta 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 orcontact Benefits Outlook at www.KatvBenefits.ora: 866-222-5473 ;

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through theMarketplace and its cost. Please visit HealthCare.gov for more information, including an online pplication for healthinsurance coverage and contact information for a Health Insurance Marketplace in your area.

EMPLGYIVIENTINFORMATION O LY

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 Bs Information bout Health Coverage Offered by Your EmployerThis section contains information about any health coverage offered by your employer. If you decide to complete anapplication for coverage in the Marketplace, you will be asked to provide this information. This information is numberedto correspond to the Marketplace application.

3. Employer name

Katy Independent School District4. Employer Identification Number (EIN)

74-60014845.. Em loyer address 6. Employer phone number• PO Box 159 281-396-60007. City 8. State 9. ZIP code

Katy TX 7749210. Who can we contact about employee health coverage at this job?

a" Benefits Outlook - www.KatyBenefits.org

11. Phone number (if different.from above)

281-396-224112. Email address

N/A

Here is so e basic infor ation about health coverage offere by this employer:o As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

Regular employee (active or on a benefits-eligible leave approved by the district) and you are an active, contributingmember of Teacher Retirement System (TRS). You may also participate if you are retired from TRS and rehired by thedistrict into a benefits-eligible position.

a With respect to dependents:[7] We do offer coverage. Eligible dependents are:

Legal spouse (unless legally separated); child under age 26; unmarried child of any age, who is incapable ofself-support because of mental disability or physical handicap if declared as such before age 26; child who qualifies asyour dependent under the terms of a qualified medical child support order.

We do not offer coverage.

[71 If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended tobe affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premiumdiscount through the Marketplace. The Marketplace will use your household income, along with other factors,to determine whether you may be eligible for a pre ium discount. If, for example, your wages vary fromweek to week (perhaps you are an hourly employee or you wor on a commission basis), if you are newlyemployed 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 your

onthly premiu s.

EMPLOYMENTINFORMATION ONLY

Form W-4 (2017)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

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

The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

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

Form W-4Department of the Treasury Internal Revenue Service

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

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

OMB No. 1545-0074

20171 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

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

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

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

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

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

Form W-4 (2017) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

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

2 Enter: { $12,700 if married filing jointly or qualifying widow(er)$9,350 if head of household . . . . . . . . . . .$6,350 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

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

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

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

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 07,001 - 14,000 1

14,001 - 22,000 222,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 95,000 10

95,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $8,000 08,001 - 16,000 1

16,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 70,000 570,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

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

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

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

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

Katy Independent School District

AUTHORIZATION AGREEMENT FOR PAYROLL DIRECT DEPOSITPlease fill out one form per deposit account

Type of Transaction

EW / UPDATE - Establish or change direct deposit

CANCEL - Stop my payroll deposit

EMPLOYEE NAME: ___________________ I authorize Katy ISO to transfer my paycheck directly to the financial institution(s) notedbelow for deposit:

SavingsSavingsSavings

Direct Deposit Account NET Amount: NET AMOUNT CheckingDirect Deposit Account 2: $ Amount CheckingDirect Deposit Account 3: $ Amount Checking

Employee's Bank Account Number Transit/ABA Number Routing Number

Financial Institution (Name of Bank)

Please Attach a voided Check or document from bank erifying routing and account number

OR, you can elect to have your pay deposited to a Pay Card:If you do not have or wish to provide checking account info, you may receive your pay on a Prepaid Payment Card.

Your pay is automatically deposited to the card and immediately available for you to access on payday.Just complete the section below:

Payment Card Order Form:NAME:

PHO E NUMBER:

MAILING ADDRESS:

SOCIAL SECURITY NO: DATE OF BIRTH:

This authorization will remain in effect until Katy ISD has received written notification from me that it is to be terminated, or when Katy ISD is notified by your financial institutioi

of a change or I have terminated the Pay Card, as provided in the Terms and Conditions received with the card. Ten days notice is required for an employee to terminate their

direct deposit. If I choose the Pay Card Option, I understand that this card was provided to me as an option by my employer and that there are fees for account maintenance

and card use that will be deducted from the card balance. I herby authorize my employer to act as my agent to submit my application for the Pay Card to the issuing Financial

Institution of the Pay Card, and to the Terms and Conditions governing my use of Pay Card that I will receive at the time I receive my card. If funds or monies to which I am not

entitled are deposited to my account or my Pay Card I authorize my employer to initiate a correcting entry to my account or Pay Card to withdraw funds to correct the error or

overpayment. I further acknowledge that while the District does not anticipate any delays in the receipt of my direct deposit, in the event that a delay does occur, the District

is not responsible for any inconvenience or charges caused by such delay.

The USA PATRIOT Act is a federal law that requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

You will be asked to provide your name, a valid physical US street address, a telephone number, a date of birth, and other information that will allow us to identify you. You

may also be asked to provide documentation as proof of identification. I acknowledge and agree that this authorization may be rejected or discontinued by the issuing

Financial Institution at any time.

Signature Print Name Date

SSN Katy ID Number Campus/Dept.

Revised 5/1/2015

TO BE COMPLETED BY TRS RETIREES ONLY

KATY I DEPENDENT SCHOOL DISTRICT

Employment After Retirement Acknowledgement Form

I agree to read the Teacher Retirement System of Texas (TRS) Employment after Retirement

Guide (www.trs.state.tx.us), prior to my start date, and to abide by the standards, policies, and

procedures defined within or referenced in the document.

As this information is subject to change, I understand that it is my responsibility as a retiree to

stay current on all updates and to comply with any changes in TRS policies and procedures.

I UNDERSTAND THAT SPECIAL ATTENTIO MUST BE GIVEN TO RESTRICTIONS REGARDINGASSIGNMENTS AND WORK HOURS, AS STIPULATED BY TRS, ESPECIALLY WITH REGARD TOWORKING IN VACANT OR SUPPLEMENTAL POSITIONS AND WORKING IN MULTIPLE SCHOOLDISTRICTS.

I UNDERSTAND THAT ANY VIOLATION OF THESE RESTRICTIONS MAY RESULT IN THEREVOCATION OF MY ANNUITY BY TRS. I ACKNOWLEDGE THAT I AM SOLELY RESPONSIBLE FORANY REPAYMENTS TO TRS THAT MAY RESULT FROM ANY SUCH VIOLATIONS.

I UNDERSTAND THAT I WILL NOT BE EMPLOYED IN ANY CAPACITY BY KATY ISD UNTIL I HAVEBEEN RETIRED FROM ALLTRS-COVERED EMPLOYERS FOR 12 FULL, CONSECUTIVE CALENDARMONTHS.

My signature below affirms that 1 ave retired with TRS, a d I have not worked in any

capacity fo a TRS-cover d employer for 12 full, consecutive calendar months. I also agree to

pay any and all fines, enalties, an any othe member charges i posed by TRS for a y

reaso and hold Katy ISD harmless for any and all existing and/or future charges.

PRI T NAME

SIGNATURE . * *

DATE

* Any further questions or inquiries regarding TRS regulations and guidelines should be directed to:

Teacher Retirement System of Texas (TRS)

1000 Red River Street

Austin, TX 78701-26981-800-223-8778

www.trs.state.tx.us

Katy Independent School District

Human Resources

Texas Departm nt of i suranceDivision of Workers Compensation7551 Metro Center Drive, S ite 100 * A stin, Texas 78744-16 5512-804 4000 tele hone * 512-804-4001 fax w/Jdi.lexas.C'W

Reference Rule 110.101fa) In addition to the posted notice required by subsection (e) of this section, employers, as

defined by Labor Code Section 406.001, shall notify their employees of workers co pensati n insurance coverage tatus, n writing. This additional notice:

(1) shall be provided t the time an employee i hired, me ning when the e ployee i required by federal law to complete both a W-4 form nd an 1-9 form or when abreak in serv ce lia occurred nd the employee is req ired by federal law tocomplete a W-4 form n the fir t day the employee reports back to duty;

(2) shall be provided to each employee, by an em loye who e workers’compensation insura ce coverage i terminated or cancelled, not late tha the 15lhday afte the te on which the termin tion or c ncellation f coverage t keseffect;

(3) shall be provided to each employee, by an employer who obtains workers compensation insura ce cove age, n t later than the !5l1' d y after the d te onwhich coverage t kes ef ect, a necessary to allow the employee to elect to retaincommon law rights under Labo Code Ch pter 406;

(4) shall include the text required in the posted notice (see rule 110.101 (e)(1), (e)(2),(e)(3), (e)(4) for appro riate language); nd

(5) if the empl y is covered by workers’ compens tion in urance (subscriber) orbecomes covered, whether by commercial in urance or through self-insur nce asprovided by the Texas Worker ’ Compensa ion Act (Act), shall include thefol 1 o wi ng statement:

NOTICE TO NEW EMPLOYEES

You m y elect to retain your com on law right of actio if, no later than five daysafter you begin emplo m nt or ithin live d ys fte receivin writte n tic frontthe employer th t t e e ployer lias obtained orkers’ c mpens ti n i sur ncecovera e, u otify you employer in riting that you wi h to retain our com onl w ri ht to recover da ges or per onal inju y. If ou elect to retain yo rcommon law right of ction, y u nnot obt in orkers’ compen ation income or

medic l benefits if u re inju ed.

Katy Independent School District 0 6301 South Stadium L ne 6 PO Box 159 • Katy, Texas 77492-0159281-396-2347 • fax: 281-644-1825 • www.katyisd.org