Employment Eligibility Verification

Employment Eligibility Verification USCIS JFoKm-I-9 OMB No. 1615-0047 Expires 03/31/2016 Department of Homeland Security U.S. Citizenship and Immigr...
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Employment Eligibility Verification

USCIS JFoKm-I-9 OMB No. 1615-0047 Expires 03/31/2016

Department of Homeland Security U.S. Citizenship and Immigration Services

HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire 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 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name')

Middle Initial Other N ames Used (if any)

First Name (Given Name)

Apt. Number

Address (Street Number and Name)

City or Town

State

. Date of Birth (mm/dd/yyyy) U.S. Social Security Number E-mail Address '

'

Zip Code

Telephone Number

1 1

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. lattest, under penally of perjury, ihatl am (check one of the following); I I A citizen of the United States Qj A noncitizen national of the United States (See instructions) Q A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) (See instructions)

. Some aliens may write "N/A" in this field.

For aliens authorized to work, provide your Aiien Registration Number/USCIS Number OR Form 1-94 Admission Number 1. Alien Registration Number/USCIS Number 3-D Barcode Do Not Write in This Space

OR 2. Form I-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States,.Include the following;. Foreign Passport Number Country of Issuance:

,

_

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Date (mm/dd/yyyy):

Signature of Employee:

Preparerand/orTranslator Certifrcation (To be completed and signed if Section 11s prepared by a person other than the employee.) . ' I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct Signature of Preparer or Translator:

Last Name (Family Name) Address (Street Number and Name)

Date (mm/dd/yyyy): First Name (Given Name) City or Town

Employer Completes Next fage Form 1-9 03/08/13 N

State

Zip Code

| Page 7 of9

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 examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: -List A Identity and Employment Authorization Document Title:

OR

UstB Identity Document Title:

AND

ListC Employment Authorization Document Title:

Issuing Authority:

Issuing Authority:

Issuing Authority:

Document Number

Document Number

Document Number

Expiration- Date (tfany)'(mm/dd/yvyy):

'Expiration Date (ifany)'(mm/dd/yyyy):

'Expiration Date (if~any)*(mm/a"d7yyyy):

Document Title: Issuing Authority: Document Number Expiration Date

(ifany)(mm/dd/yyyy): 3-D Barcode Do Not Write in This Space

Document Title: Issuing Authority: Document Number. Expiration Date (ifany)(mm/dd/yyyy):

Certification I attest, under penalty of perjury, that (1) I have examined the documents) presented by the above-named employee, (2) the above-listed documents) 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. (See Instructions for exemptions.)

The employee's first day of employment (mm/dd/yyyy):. Signature of Employer or Authorized Representative

Date (mm/dd/yyyy)

Title of Employer or Authorized Representative Accounting Supervisor

Last Name (Family Name) Stanley

First Name (Given Name) Brenda

Employer's Business or Organization Name Tidewater Fleet Supply LLC

Employer's Business or Organization Address (Street Number and Name) City or Town 3666 Progress Rd.

Norfolk

State

Zip Code

VA

23502

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) As New-Name- (if applicable) Last Name (Family -Name) First Name (G/ye/> Warns) Middje Initial^ B. Date of Rehire (if applicable} (mm/dd/yyyy)-:

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. DocumentTitle:

'DocumenfNurriben

"Expiration Date (ifany^mm/dd/yyyy):

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 documents), the documents) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative:

Form 1-9 03/08/13 N

Date (mm/dd/yyyy):

Print Name of Employer or Authorized Representative:

Page 8 of9

LISTS OF ACCEPTABLE DOCUMENTS All 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.

LISTS Documents that Establish Identity

LIST A

Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551) 3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machinereadable immigrant visa 4, Employment Authorization Document that contains a photograph (Form I-766)

LISTC Documents that Establish Employment Authorization AND

OR

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 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 3. School ID card with a photograph

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and 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. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form 1-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

4. Voter's registration card 5, U.S. Military card or draft record

6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are

unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record

A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION Certification of Birth Abroad issued by the Department of State (Form FS-545) Certification of Report of Birth issued by the Department of State (Form DS-1350) Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal Native American tribal document U.S. Citizen ID Card (Form 1-197) Identification Card for Use of Resident Citizen in the United States (Form 1-179) Employment authorization document issued by the Department of Homeland Security

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274), Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Form 1-9 03/08/13 N

Page 9 of9

Disclosure of Withholding Order Confidential Virginia law requires that we ask all new employees to disclose whether or not they are subject to a wage withholding order under Section 20-79.1 or 63.1-2503. If you owe child support which is required to be deducted from your pay, the law requires that we begin deducting it immediately in accordance with the terms of the Order. Please certify your status below. This information will be kept confidential. I CERTIFY THAT: I am not subject to a wage withholding order. Date

Signature

I am subject to a wage withholding order and I will provide the Company with a copy of the Order so that the proper deductions may be made from my wages. Date

Signature

Vehicle Operator’s Agreement I understand that I will be operating vehicles as part of my job. I also understand that Tidewater Fleet Supply LLC (The Company) considers my safety and the safety of others to be paramount. Therefore, I agree to comply with the following rules: 1. I will not operate any vehicle unless I have a valid, current driver’s license appropriate for the vehicle I am operating. 2. If my license is suspended or revoked for any reason, I will notify The Company immediately and I will not operate a vehicle until it is reinstated. 3. If I receive a ticket or citation for a moving violation of any kind, whether on or off the job, I will immediately notify The Company of this fact. 4. I will not operate any vehicle if I have drugs or alcohol in my system. If I am taking prescription drugs which might impair my ability to drive safely, I will not operate a vehicle and will notify my supervisor immediately. 5. I will not use drugs or alcohol at any time before or during my work day nor will I carry drugs or alcohol in the vehicle. 6. I will not carry any passenger unless I am authorized to do so in advance. 7. I will wear a seat belt at all times while I am operating or riding in a Company vehicle and I will remind those riding with me of this requirement. 8. I will comply with all speed limits and traffic regulations. 9. I understand and agree that I will be personally responsible for paying any traffic citations that I receive as well as for damage to a Company vehicle which is not covered by insurance. 10. I authorize The Company to check my driving record from time to time to ensure that I am complying with this policy. Violation of any of these rules may result in immediate termination. I have read and understand this policy and I will comply with it. Signed: Printed Name:

Date:

Tidewater Fleet Supply

The following employee benefit programs have been offered and explained to me:

Accept Health Insurance: Optima Equity 3000 PPO Optima Equity 3000 HMO Dental Insurance: Anthem Dental Short Term Disability: American Fidelity Long Term Disability: American Fidelity

_

American Fidelity Supplemental Policies Accident Insurance Term Life Insurance Cancer Insurance Legal Resources

Signature

Date

Decline

Tidewater Fleet Supply Health Care Rates August 1, 2014 - July 31, 2015

Health Savings Account-PPO Optima Equity Plus $3000/$6000/90% s Tiered @ $10/30/50/100 AD Monthly Bi- Weekly Employee Employee / Employee / Employee / Employee /

313.70 439.17

Child Children Spouse Family

$

627.39 658.76 909.72

144.78 202.69 289.56 304.04 419.87

Optima Equity Vantage $3000/$6000/90% Drugs Tiered @ $10/30/50/100 AD Monthly Bi- Weekly $

36.20 166.50 253.37 267.85 383.67

Health Savings Account Optima Equity Plus $3000/$6000/90% Drugs Tiered @ $10/30/50/100 AD Bi- Weekly Monthly Employee Employee / Child Employee / Children

Bi- Weekly 14.52 32.52 32.52 29.63 49.44

31.46 70.47

70.47

64.19

240.95 332.74

107.12

Health Savings Account-HMO

Optima Equity Plus $3000/$6000/90% Drugs Tiered @ $10/30/50/100 AD Bi- Weekly Monthly

Employee / Family

Monthly

114.74 160.63 229.48

......

Health Savings Account

78.43 360.75 548.97 580.34 831.30

248.60 348.04 497.20 522.06 720.94

Than;

'

Employee Employee / Child Employee / Children Employee / Spouse

Anthem Dental

Health Savings Account-HMO

Anthem Dental

Optima Equity Vantage $3000/$6000/90% Drugs Tiered @ $10/30/50/100 AD Monthly Bi- Weekly $

62.15 269.62

418.78 443.64 642.52

Monthly

Bi- Weekly

28.68 124.44 193.28

15.73 54.74 54.74

204.75 296.55

48.46

25.26 22.37

91.39

42.18

Health Savings Account-HMO Optima Equity Vantage $3000/$6000/90% Drugs Tiered @ $10/30/50/100 AD Monthly Bi- Weekly

78.43

36.20

62.15

28.68

109.79

50.67

87.01

7.26 25.26

Anthem Dental @ 1/3

Monthly

Bi- Weekly 10.49

4.84

40.16

23.49

10.84

$

156.85

72.39

124.30

57.37

23.49

10.84

Employee / Spouse

164.69

76.01

130.52

60.24

Employee / Family

227.43

104.97

180.24

83.19

21.40 35.71

9.88 16.48

Health Care Rates 2014-2015 2014-2015 Health Ins Rates

7/22/2014

Benefits to Prefect Your Income and Family

NBDfil Benefits & Insurance

American Fidelity Assurance Company IA member of the American Fidelity Group j

Disability Benefits - "Paycheck Protection' Short Term Disability > American Fidelity Assurance > No Rate Change, three age bands > Accident: On the 7th Day of Total Disability > Illness/Surgery: On the 7th Day of Total Disability > 60% of Gross Monthly Income > 26 week benefit period for Accident, Illness or Surgery > NO PRE-EX/Guarantee Issued up to $3,000/monthly benefit (For new employees hired within last 12 months) To Learn More about the Disability Insurance: Please meet with Ben Hoffman, VADA Insurance

Disability Benefits - "Paycheck Protection' Long Term Disability > American Fidelity Assurance > No Rate Change, three age bands > Benefits begin after 180 days > Benefits pay up to Age 65 for an Accident > Benefits pay up for 5 years for an Illness or Surgery > 60% of Gross Monthly Income up to a max of $6,000/month > NO PRE-EX/Guarantee Issued up to $3,000/monthly benefit (For new employees hired within last 12 months) To Learn More about the Disability Insurance: Please meet with Ben Hoffman, VADA Insurance

Life Insurance - "Protecting Loved Ones

PP

Term Life Insurance > > > > > > >

American Fidelity Assurance 10 Year, 20 Year & 30 Year Term Policies Ages 18-50: Up to $200,000 Ages 50+: $100,000 or less Individual policies with 4 simple medical questions 100% portable Spouse Rider and Dependent Child(ren) Riders are available

To Learn More about the Term Life Insurance: Please meet with Ben Hoffman, VADA Insurance

Accident Solution Plan You can neuer plan for an accident to happen, but you can plan for the protection against high costs of accidental injuries or death > American Fidelity Assurance > 24 Hour Coverage > > > >

Benefits are paid based on treatment for injury as a result of an accident $150 ER benefit, $1,000 Hospital Admission, $150 Medical Imaging Benefits paid based upon fractures, lacerations, concussions, etc... 100% portable

> >

Spouse and Family Coverage is also available Sample rates: Employee: $3.99/week Family: $7.80/week To Learn More about the Accident Solution Plan: Please meet with Ben Hoffman, VADA Insurance

Cancer Protection Plan Limited Benefit Specified Disease Cancer Indemnity Insurance >

American Fidelity Assurance

>

In the US, men have slightly less than a 1 in 2 lifetime risk of developing cancer; for women, the risk is a little more than 1 in 3*.

>

This plan is designed to help cover expenses if you are diagnosed with Cancer. With more than 25 built-in policy benefits, this plan provides benefits for the treatment of cancer, transportation, hospitalization, etc... $60 Diagnostic and Preventative Care Benefit each year 100% portable Spouse and Family Coverage is also available

> > >

"'American Cancer Society: Cancer Facts and Figures 2013, pg1.

To Learn More about the Cancer Protection Plan: Please meet with Ben Hoffman, VADA Insurance

Emergency Contact Information

In order to maintain our personnel files, please provide the following information. Please print or write clearly. When complete, return the form to your HR Representative. Employee Name Employee Nickname Address

Home Phone No. Mobile/Cell Phone No. (if applicable)

Spouse’s Name Emergency Contact Address

Home Phone No.

Work Phone No.

Thank you for your assistance in maintaining our employee records.

r==\ Fleet Supply"

Short Term Disability 1. This policy supplements but does not replace the Leave Without Pay Disability Policy stated in the Employee Handbook. 2. Tidewater Fleet Supply LLC has made arrangements with American Fidelity Assurance Company to provide short-term (26 weeks maximum) disability insurance to our employees. 3. This coverage is available on the same basis as our Group Health & Dental Plan. a) Full-time employees are eligible to participate on the first day of the month after they have been employed sixty (60) calendar days. b) Full-time employees work at least thirty-two (32) hours per week. 4. Full-time employees may elect to enroll in the short-term disability program, subject to the conditions in 3 above. An employee may elect to cover up to 60% of their normal income. An amount less than 60% may also be elected. 5. Tidewater Fleet Supply LLC will pay for two-thirds (66%) of the cost of this coverage. 6. In general, the coverage is for the 7th day of accident or the 7th day of illness and continues for a maximum of twenty-six (26) weeks. You must be under a doctor's care. The complete terms and conditions are contained in the insurance document. 7. The short-term disability program is voluntary. You are not required to participate. Should you choose to participate and later change your mind, you may stop participation during open enrollment only or upon termination of employment. 8. This program represents the only short-term disability payment to any employee. There will be no other payment from Tidewater Fleet Supply LLC other than the two-thirds (66%) of the premium.

GROUP APPLICATION

AMERICAN FIDELITY ASSURANCE COMPANY 2000 N. Classen Blvd Oklahoma City, Oklahoma 73106

1. PROPOSED INSURED INFORMATION: Age Date of Birth Mo Day Yr

First Name

Last Name Sex MD F D

Soc Sec Number

Residence Address: Number & Street (Not a P.O. Box)

Requested Eff Date Mo Day Yr

Zip

Home Phone # Country of Citizenship

City

Mailing Address (if different than Residence)

Suffix

Date of Employment Mo Day Yr

Work Phone #

State

City

Full Middle Name

State

Zip

Total

Dnannnnc Dnnnnnoc

Employer/MCP # Salary: $ Occupation Employer Name Annual Q Monthly |_] 25741 Tidewater Fleet Supply Are you currently able to perform the duties of your occupation? Yes No D Applicant's E-mail Address: 2. BENEFITS APPLIED FOR: Billing Persons Plan PREMIUM: Product New/Chg Distribution ID Covered1 Plan Code Amount Employee Employer Mode 017935-D4 Z STND S/T Disb STND z 017806-D31 L/T Disb

1z=lndividuat; y=lndividual & Spouse; x=lndividual, Spouse & Child(ren); v=lndividual & Children; s=Spouse TOTAL 3. BENEFICIARY: ' ' ~~ "" ~~~~ " ~ First Name Middle Name Last Name Relationship to Insured Country of Citizenship

4. ELECTION: I hereby enroll, add or change, as checked above, group insurance coverage(s) for which I am eligible. I authorize my employer to deduct my contributions, if any, from my pay. _____ 5. ACKNOWLEDGMENT: I understand and agree that: . The information in this application will be used to determine my eligibility for insurance; the statements and answers shown in this application (first page and, if applicable, the second page) are true and complete; the Company may rely upon such answers as the basis of my contract; and no coverage will take effect until the application is approved by the Company, the first premium is received, and a Certificate is issued. . If applying for disability income coverage, OTHER INCOME I AM ENTITLED TO RECEIVE WILL, IF APPLICABLE, REDUCE MY MONTHLY BENEFIT. I SHOULD READ MY CERTIFICATE FOR MORE DETAILED INFORMATION REGARDING HOW OTHER INCOME WILL REDUCE MY BENEFIT. • "Pre-Existing Conditions" may not be covered; and I should read my Certificate for a more detailed explanation of the Pre-Existing Condition exclusion, if any. • BROCHURE(S)# APSB-21986(VA) HAS/HAVE BEEN EXPLAINED TO ME, AND I HAVE RECEIVED A COPY/COPIES; OR, I HAVE HAD ACCESS TO AND THE OPPORTUNITY TO PRINT THE BROCHURE(S). (Please initial): | 6. FRAUD NOTICE: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an Insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.

AGENT SIGNATURE (where required by law) Agent # A1264VA

SIGNATURE (Applicant)

Date

GROUP APPLICATION

AMERICAN FIDELITY ASSURANCE COMPANY 2000 N, Classen Blvd Oklahoma City, Oklahoma 73106

PROPOSED INSURED'S NAME: HEALTH HISTORY: 7, Within the past 5 years, have you received a diagnosis, taken medication and/or had treatment by a member of the medical profession for any of the following: Cancer (other than basal or squamous cell skin cancer), heart and/or circulatory disorder, peripheral vascular disease (PVD), stroke or transient ischemic attack, liver or kidney disorder/disease (excluding stones), pulmonary disease, diabetes requiring insulin, rheumatoid arthritis, epilepsy, ulcerative colitis, Crohn's disease, organ transplant, systemic lupus erythematosus, disorder of blood cells or blood clotting disorder, seizures, Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or Human Immunodeficiency Virus (HIV)', Chronic Fatigue''Syndrome (CFS), fibromyalgia, alcohol or drug addiction or abuse, or neurological disorder (excluding headaches or migraines).

Yes D No D

8, Within the past 12 months, have you: Received advice from a medical provider, taken medication, incurred an expense, undergone tests, or received treatment (including, but not limited to, spinal manipulation, physical therapy, or counseling) for a condition related to: (a) your back, neck or spine; (b) a mental or nervous condition; or (c) had surgery recommended that has not yet been performed or received a referral for surgery consultation? 9, Are you currently pregnant?

Yes Ct No O

Yes Q No Q

1-0-. The undersigned applicant and agent, if applicable, certify that the applicant has read, or had read to him, the completed application and that the applicant realizes that any false statement or misrepresentation in the application may result in loss of coverage under the policy. I also understand that additional investigation could occur at time of claim and any misrepresentation contained herein relied on by the Company may be used to reduce or deny a claim and/or void the coverage if such misrepresentation materially affects the acceptance of the risk.

Date

Agent Signature

A126WA

Applicant Signature

Tidewater Fleet Supply Short Term Disability Policy #G-108-105 Rate Factor

Annual Income

$ $ $ $ $ '$ $ $ $ $ $ .$. $ $ $ $ $ $ $ $ $ $ $ $. $ $ $ $ $ $ $ $ $ $ $ "$• $ $ $ $ $ $

per $100:

8/1/2004

Rates as of :

4,000.00 5,000.00 6,000.00 7,000.00 8,000.00 9,000.00 10,000.00 11,000.00 12,000.00 13,000.00 14,000.00 1-5,000,00 16,000.00 17,000.00 18,000.00 19,000.00 20,000.00 21,000.00 22,000.00 23,000.00 24,000.00 25,000.00 26,000.00 27,000.00 28,000.00 29,000.00 30,000.00 31,000.00 32,000.00 33,000.00 34,000.00 35,000.00 36,000.00 37,000.00 38,000.00 39,000.00 40,000.00 41,000.00 42,000.00 43,000.00 44,000.00 45,000.00

Monthly Benefit $ 200.00 $ 250.00 $ 300.00 $ 350.00 $ 400.00 '$ 450.00 $ 500.00 $ 550.00 $ 600.00 $ 650.00 $ 700.00 •$- 750,00$ 800.00 $ 850.00 $ 900.00 $ 950.00 $1,000.00 $1,050.00 $1,100.00 $1,150.00 $1 ,200.00 $1,250.00 $1 ,300.00 $1. ,350,00$1,400.00 $1 ,450.00 $1,500.00 $1 ,550.00 $1,600.00 $1,650.00 $1,700.00 $1,750.00 $1,800.00 $1,850.00 $1,900.00 $t ,950VOO $2 ,000.00 $2,050.00 $2,100.00 $2,150.00 $2,200.00 $2,250.00

Monthly Premium 4.80 $ 6.00 $ 7.20 $ 8.40 $ 9.60 $ 10.80 $ 12.00 $ 13.20 $ 14.40 $ 15.60 $ 16.80 $ 18,00•$19.20 $ 20.40 $ 21.60 $ 22.80 $ 24.00 $ 25.20 $ 26.40 $ 27.60 $ 28.80 $ 30.00 $ 31.20 $ •$- 32.4033.60 $ 34.80 $ 36.00 $ 37.20 $ 38.40 $ 39.60' $ 40.80 $ 42.00 $ 43.20 $ 44.40 $ 45.60 $ •$46.80 48.00 $ 49.20 $ 50.40 $ 51.60 $ 52.80 $ 54.00 $

American Fidelity Short Long Term Disibility Short Term

Employee Deduction Bl-Weekly 0.75 $ 0.94 $ 1.13 $ 1.32 $ 1.51 $ 1.69$ 1.88 $ 2.07 $ 2.26 $ 2.45 $ 2.64 $ .$. 2.82 3.01 $ 3.20 $ 3.39 $ 3.58 $ 3.77 $ 3.95 $ 4.14 $ 4.33 $ 4.52 $ 4.71 $ 4.90 $ 5.08 $ 5.27 $ 5.46 $ 5.65 $ 5.84 $ 6.03 $ 6.21 $ 6.40 $ 6.59 $ 6.78 $ 6.97 $ 7.16 $ 7.34 '$ 7.53 $ 7.72 $ 7.91 $ 8.10 $ 8.29 $ 8.47 $

$

2.40

Employee Deduction Monthly 1.63 $ 2.04 $ 2.45 $ 2.86 $ 3.26 $ 3.67 $ 4.08 $ 4.49 $ 4.90 $ 5.30 $ 5.71 $ $. 6.1-2 6.53 $ 6.94 $ 7.34 $ 7.75 $ 8.16 $ 8.57 $ 8.98 $ 9.38 $ 9.79 $ 10.20 $ 10.61 $ .$. 11,02 11.42 $ 11.83 $ 12.24 $ 12.65 $ 13.06 $ 13.4& $ 13.87 $ 14.28 $ 14.69 $ 15.10 $ 15.50 $ 15.91 $ 16.32 $ 16.73 $ 17.14 $ 17.54 $ 17.95 $ 18.36 $

7/30/2014

Tidewater Fleet Supply Short Term Disability Policy SG-108-105

Annual income $ $ $ $ $ $ $ $ $ $ $ $. $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Rate Factor per $100:

8/1/2004

Rates as of :

Monthly

Benefit 46,000.00 47,000.00 48,000.00 49,000.00 50,000.00 51,000,00. 52,000.00 53,000.00 54,000.00 55,000.00 56,000.00 57,000.00 58,000.00 59,000.00 60,000.00 61,000.00 62,000.00 63,000,0064,000.00 65,000.00 66,000,00 67,000.00 68,000.00 •69,000.00 70,000.00 71,000.00 72,000.00 73,000.00 74,000.00 75,000.00 76,000.00 77,000.00 78,000.00 79,000.00 80,000.00 81,000.00 82,000.00 83,000.00 84,000.00 85,000.00 86,000.00 87,000.00

$2,300.00 $2,350.00 $2,400.00 $2,450.00 $2,500.00 $2,550,00 $2,600.00 $2,650.00 $2,700.00 $2,750.00 $2,800.00 $2,850.00 $2,900.00 $2,950.00 $3,000.00 $ 3,050.00 $3,100.00 $.3,150,00 $ 3,200.00 $ 3,250.00 $3,300.00 $3,350.00 $3,400.00 $ 3,450.00 $3,500.00 $3,550.00 $3,600.00 $3,650.00 $ 3,700.00 $3,750.00 $3,800.00 $3,850.00 $3,900.00 $3,950.00 $4,000.00 $4,050.00 $4,100.00 $4,150.00 $4,200.00 $4,250.00 $4,300.00 $4,350.00

Monthly Premium 55.20 $ 56.40 $ 57.60 $ 58.80 $ 60.00 $ 61-.20 •$ 62.40 $ 63.60 $ 64.80 $ 66.00 $ 67.20 $ 68.40 $ 69.60 $ 70.80 $ 72.00 $ 73.20 $ 74.40 $ 75,60 $ 76.80 $ 78.00 $ 79.20 $ 80.40 $ 81.60 $ 82.80 $ 84.00 $ 85.20 $ 86.40 $ 87.60 $ 88.80 $ 90.00 $ 91.20 $ 92.40 $ 93.60 $ 94.80 $ 96.00 $ 97.20 $ 98.40 $ 99.60 $ $ 100.80 $ 102.00 $ 103.20 $ 104.40

American Fidelity Short Long Term Disibility Short Term

Employee Deduction Bi-Weekly 8.66 $ 8.85 $ 9.04 $ 9.23 $ 9.42 $ .$. 9.60 9.79 $ 9.98 $ 10.17 $ 10.36 $ 10.55 $ 10.73 $ 10.92 $ 11.11 $ 11.30 $ 11.49 $ 11.68 $ 1-1,86. $ 12.05 $ 12.24 $ 12.43 $ •12.62 $ 12.80 $ 12.99$ 13.18 $ 13.37 $ 13.56 $ 13.75 $ 13.93 $ 14.12 $ 14.31 $ 14.50 $ 14.69 $ 14.88 $ 15.06 $ 15.25 $ 15.44 $ 15.63 $ 15.82 $ 16.01 $ 16.19 $ 16.38 $

$

2.40

Employee Deduction Monthly 18.77 $ 19.18 $ 19.58 $ 19.99 $ 20.40 $ 20,84 •$• 21.22 $ 21.62 $ 22.03 $ 22.44 $ 22.85 $ 23.26 $ 23.66 $ 24.07 $ 24.48 $ 24.89 $ 25.30 $ 25.70 •$• 26.11 $ 26.52 $ 26.93 $ 27.34 $ 27.74 $ 28.1-5$ 28.56 $ 28.97 $ 29.38 $ 29.78 $ 30,19 $ 30.60 "$ 31.01 $ 31.42 $ 31.82 $ 32.23 $ 32.64 $ 33.05 $ 33.46 $ 33.86 $ 34.27 $ 34.68 $ 35.09 $ 35.50 $

7/30/2014

Tidewater Fleet Supply Short Term Disability Po Key #6-108-105

Monthly

Annual Income

$ $ $ $ $ $ $ $ $ $ $ $• $ $ $ $ $ $ $ $ $ $ $ •$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Rate Factor per $100:

8/1/2004

Rates as of:

Benefit 88,000.00 89,000.00 90,000.00 91,000.00 92,000.00 93,000,00 94,000.00 95,000.00 96,000.00 97,000.00 98,000.00 9S,OOO.OQ 100,000.00 101,000.00 102,000.00 103,000.00 104,000.00 105,000.00 106,000.00 107,000.00 108,000.00 109,000.00 110,000.00 I'TIYOiDO.UO 112,000.00 113,000.00 114,000.00 115,000.00 116,000.00 117,000.00 118,000.00 119,000.00 120,000.00 121,000.00 122,000.00 123,000.00 124,000.00 125,000.00

$4,400.00 $4,450.00 $4,500.00 $4,550.00 $4,600.00 $4,650.00 $4,700.00 $4,750.00 $4,800.00 $4,850.00 $4,900.00 •$4,950,00 $5,000.00 $5,050.00 $5,100.00 $5,150.00 $5,200.00 $-5,250:00 $5,300.00 $5,350.00 $5,400.00 $5,450.00 $5,500.00 $'5,550.UQ $ 5,600.00 $5,650.00 $5,700.00 $5,750.00 $5,800.00 $5,850.00 $5,900.00 $5,950.00 $6,000.00 $6,050.00 $6,100.00 $6,150.00 $6,200.00 $ 6,250.00

Monthly Premium $ 105.60 $ 106.80 $ 108.00 $ 109.20 $ 110.40 $ 111.60 $ 112.80 $ 114.00 $ 115.20 $ 116.40 $ 117.60 •$ 148.SO$ 120.00 $ 121.20 $ 122.40 $ 123.60 $ 124.80 "$ 126.00' $ 127.20 $ 128.40 $ 129.60 $ 130.80 $ 132.00 '$• 133.20 $ 134.40 $ 135.60 $ 136.80 $ 138.00 $ 139.20 $ 140.40 $ 141.60 $ 142.80 $ 144.00 $ 145.20 $ 146.40 $ 147.60 $ 148.80 $ 150.00

American Fidelity Short Long Term Disibility Short Term

Employee Deduction Bi-WeekJy 16.57 $ 16.76 $ 16.95 $ 17.14 $ 17.32 $ 17.51 $ 17.70 $ 17.89 $ 18.08 $ 18.27 $ 18.45 $ 18.64 •$• 18.83 $ 19.02 $ 19.21 $ 19.40 $ 19.58 $ 19.77 $ 19.96 $ 20.15 $ 20.34 $ 20.53 $ 20.71 $ 2D.9D "$ 21.09 $ 21.28 $ 21.47 $ 21.66 $ 21.84 $ 22.03 $ 22.22 $ 22.41 $ 22.60 $ 22.79 $ 22.97 $ 23.16$ 23.35 $ 23.54 $

$

2.40

Employee Deduction Monthly 35.90 $ 36.31 $ 36.72 $ 37.13 $ 37.54 $ 37.94 $ 38.35 $ 38.76 $ 39.17 $ 39.58 $ 39.98 $ 40,39 -$40.80 $ 41.21 $ 41.62 $ 42.02 $ 42.43 $ 42.84 $ 43.25 $ 43.66 $ 44.06 $ 44.47 $ 44.88 $ 45.29 "$ 45.70 $ 46.10 $ 46.51 $ 46.92 $ -47.33 $ 47.74 $ 48.14 $ 48.55 $ 48.96 $ 49.37 $ $ • 49.78 50.18 $ 50.59 $ 51.00 $

7/30/2014

Tidewater Fleet Supply Short Term Disability Policy #G-108-105

Rates as of:

Annual Income

Rate Factor per $100:

8/1/2004

Monthly Benefit

Employee Deduction Bi-Weekly

Monthly Premium

American Fidelity Short Long Term Disibility Short Term

.

4

$

2.40

Employee Deduction Monthly

7/30/2014

Tidewater Fleet Supply Long Term Disability Policy # G-1tre-T05

Rates as of :

Annual Income

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ? $ $ $ $ $ $ $ $ $ $ $ -$ $ $ $ $ $ $ $ $ $ $ $

4,000.00 5,000.00 6,000.00 7,000.00 8,000.00 9,000.00 10,000.00 11,000.00 12,000.00 13,000.00 14,000.00 15,000.00 16,000.00 17,000.00 18,000.00 19,000.00 20,000.00

2T.rjoa.oa 22,000.00 23,000.00 24,000.00 25,000.00 26,000.00 27.000-.00 28,000.00 29,000.00 30,000.00 31,000.00 32,000.00 33,000.00 34,000.00 35,000.00 36,000.00 37,000.00 38,000.00 39,000.00 40,000.00 41,000.00 42,000.00 43,000.00 44,000.00

Rate Factor per $100:

8/1/2004

Monthly Benefit $ 200.00 $ 250.00 $ 300.00 $ 350.00 $ 400.00 $ 450.00 $ 500.00 $ 550.00 $ 600.00 $ 650.00 $ 700.00 $ 750.00 $ 800.00 $ 850.00 $ 900.00 $ 950.00 $1,000.00 $1,050;oo $1,100.00 $1 ,150.00 $1,200.00 $1,250.00 $1,300.00 $1,350.00 $1 ,400.00 $1,450.00 $1,500.00 $1,550.00 $1 ,600.00 $-1,650.00$1,700.00 $1,750.00 $1,800.00 $1,850.00 $1,900.00 $1,950.00 $2 ,000.00 $2 ,050.00 $2 ,100.00 $2 ,150.00 $2 ,200.00

$

1.40

Employee Employee Monthly Deduction Deduction Premium Bi-Weekly Monthly 2.80 $ 1.29 $ 2.80 $ 3.50 $ 1.62 $ 3.50 $ 4.20 $ 1.94 $ 4.20 $ 4.90 $ 2.26 $ 4.90 $ 5.60 $ 2.58 $ 5.60 $ 6.30 $ 2.91 $ 6.30 $ 7.00 $ 3.23 $ 7.00 $ 7.70 3.55 7.70 $ $ $ 8.40 $ 3.88 $ 8.40 $ 9.10 4.20 $ 9.10 $ $ 4.52 $ 9.80 $ 9.80 $ 10.50 $ 4.85 $ 10.50 $ 11.20 $ 5.17 $ 11.20 $ 11.90 $ 5.49 $ 11.90 $ 12.60 $ 5.82 $ 12.60 $ 13.30 $ 6.14 $ 13.30 $ 14.00 $ 6.46 $ 14.00 $ 14.70 $' 6.78 $ T4.70 $ 7.11 $ 15.40 $ 15.40 $ 16.10 7.43 $ 16.10 $ $ 16.80 $ 7.75 $ 16.80 $ 17.50 $ 8.08 $ 17.50 $ 18.20 $ 8.40 $ 18.20 $ 1-8.90 $ 8.72 $ 18.90$ 19.60 $ 9.05 $ 19.60 $ 20.30 $ 9.37 $ 20.30 $ 21.00 $ 9.69 $ 21.00 $ 21.70 $ 10.02 $ 21.70 $ 22.40 $ 10.34 $ 22.40 $ -$. 23.10- -$10,66 •$23,1-0. 23.80 $ 10.98 $ 23.80 $ 24.50 $ 11.31 $ 24.50 $ 25.20 11.63 25.20 $ $ $ 25.90 $ 11.95 $ 25.90 $ 12.28 $ 26.60 $ 26.60 $ 27.30 $ 12.60 $ 27.30 $ 28.00 12.92 $ $ 28.00 $ 28.70 $ 13.25 $ 28.70 $ 29.40 $ 13.57 $ 29.40 $ 30.10 $ 13.89 $ $ 30.10 30.80 $ 14.22 $ $ 30.80

American Fidelity Short Long Term Disibility Long Term

7/30/2014

Tidewater Fleet Supply Long Term Disability Policy #G-108-105

Rates as of : Annual Income $ $ $ $ $ $ $ $ $ $ $ $• $ $ $ $ $ '$ $ $ $ $ $ $. $ $ $ $ $ $ $• $ $ $ $ $ $ $ $ $ $

45,000.00 46,000,00 47,000.00 48,000.00 49,000.00 50,000.00 51,000.00 52,000.00 53,000.00 54,000.00 55,000.00 55,000.00 57,000.00 58,000.00 59,000.00 60,000.00 61,000.00 62,000.00 63,000.00 64,000.00 65,000.00 66,000.00 67,000.00 ea.QOO.OQ69,000.00 70,000.00 71,000.00 72,000.00 73,000.00 74,000.00 75,000.00 76,000.00 77,000.00 78,000.00 79,000.00 80,000,0081,000.00 82,000.00 83,000.00 84,000.00 85,000.00

Rate Factor per $100:

8/1/2004

Monthly

Benefit $2,250.00 $2,300.00 $2,350.00 $ 2,400.00 $2,450.00 $2,500.00 $2,550.00 $2,600.00 $2,650.00 $2,700.00 $2,750.00 $-2,800.00 $2,850.00 $2,900.00 $2,950.00 $3,000.00 $ 3,050.00 $3,100.00 $3,150.00 $ 3,200.00 $3,250.00 $3,300.00 $3,350.00 $3,400.00 $3,450.00 $3,500.00 $3,550.00 $3,600.00 $3,650.00 $3,700.00 $3,750.00 $3,800.00 $3,850.00 $3,900.00 $ 3,950.00 $-4,000.00 $4,050.00 $4,100.00 $4,150.00 $4,200.00 $4,250.00

Monthly Premium $ 31.50 $ 32.20 $ 32.90 $ 33.60 $ 34.30 $ 35.00 $ 35.70 $ 36.40 $ 37.10 $ 37.80 $ 38.50 $ 39120 $ 39.90 $ 40.60 $ 41.30 .$ 42.00 $ 42.70 $ 43.40 $ 44.10 $ 44.80 $ 45:50 $ 46.20 $ 46.90 •$- 47.60 $ 48.30 $ 49.00 $ 49.70 $ 50.40 $ 51.10 $ 51.80 $ 52.50 $ 53.20 $ 53.90 $ 54.60 $ 55.30 $ 56,00 $ 56.70 $ 57.40 $ 58.10 $ 58.80 $ 59.50

American Fidelity Short Long Term Disibility Long Term

Employee Deduction Bi-Weekly 14.54 $ 14.86 $ 15.18 $ 15.51 $ 15.83 $ 16.15 $ 16.48 $ 16.80 $ 17.12 $ 17.45 $ 17.77 $ raoff $ 18.42 $ 18.74 $ 19.06 $ 19.38 $ 19.71 $ 20-.03 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

20.35 20.68 21.00 21.32 21.65 21.97 22.29 22.62 22.94 23.26 23.58 23.91

24.23 24.55 24.88 25.20 25.52 25.85 26.17 26.49 26.82 27.14 2746

$

1.40

Employee Deduction Monthly 31.50 $ 32.20 $ 32.90 $ 33.60 $ 34.30 $ $ .35.00 35.70 $ 36.40 $ 37.10 $ 37.80 $ 38.50 $ 39120 $• 39.90 $ 40.60 $ 41.30 $ 42.00 $ 42.70 $ 43.40$ 44.10 $ 44.80 $ 45.50 $ 46.20 $ 46.90 $ $ 47.6048.30 $ 49.00 $ 49.70 $ 50.40 $ 51.10 $ 51.80 $ 52.50 $ 53.20 $ 53.90 $ 54.60 $ 55.30 $ 56,00 •$56.70 $ 57.40 $ 58.10 $ 58.80 $ 59.50 $ 7/30/2014

Tidewater Fleet Supply Long Term Disability

Policy #G-108-105 Rates as of :

$ $ $ $ $ ~$ $ $ $ $ $ '$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ '$ $ $ $ $

Annual Income 86,000.00 87,000.00 88,000.00 89,000.00 90,000.00 91,000.00 92,000.00 93,000.00 94,000.00 95,000.00 96,000.00 97,000.00 98,000.00 99,000.00 100,000.00 101,000.00 102,000.00 103,000,00 104,000.00 105,000.00 106,000.00 107,000.00 108,000.00 109,000.00 110,000.00 111,000.00 112,000.00 113,000.00 114,000.00 115,000.00 116,000.00 117,000.00 118,000.00 119,000.00 120,000.00 121,000.00 122,000.00 123,000.00 124,000.00 125,000.00

Rate Factor per $100:

8/1/2004

Monthly Benefit $4,300.00 $4,350.00 $4,400.00 $4,450.00 $4,500.00 $4,550.00 $4,600.00 $4,650.00 $4,700.00 $4,750.00 $4,800.00 $4,-850.00 $4,900.00 $4,950.00 $5,000.00 $5,050.00 $5,100.00 $-5,150,00$5,200.00 $5,250.00 $5,300.00 $5,350.00 $5,400.00 $ 5,450.00 $5,500.00 $5,550.00 $5,600.00 $5,650.00 $5,700.00 $-5,750,00$5,800.00 $5,850.00 $5,900.00 $5,950.00 $6,000.00 $6,050.00 $6,100.00 $6,150.00 $ 6,200.00 $6,250.00

Monthly Premium 60.20 $ 60.90 $ 61.60 $ 62.30 $ 63.00 $ 63.70' $ 64.40 $ 65.10 $ 65.80 $ 66.50 $ 67.20 $ 67.90 '$ 68.60 $ 69.30 $ 70.00 $ 70.70 $ 71.40 $ .$. 72.1072.80 $ 73.50 $ 74.20 $ 74.90 $ 75.60 $ 76.30 $ 77.00 $ 77.70 $ 78.40 $ 79.10 $ 79.80 $ .$. 80.50 81.20 $ 81.90 $ 82.60 $ 83.30 $ 84.00 $ 84.70 $ 85.40 $ 86.10 $ 86.80 $ 87.50 $

American Fidelity Short Long Term Disibility Long Term

$

1.40

Employee Employee Deduction Deduction Bi-Weekly Monthly 27.78 60.20 $ $ 28.11 $ 60.90 $ 28.43 $ 61.60 $ 28.75 $ 62.30 $ 29.08 $ 63.00 $ 29.40 $• '$ 63.70 29.72 $ 64.40 $ 30.05 $ 65.10 $ 30.37 $ 65.80 $ 30.69 $ 66.50 $ 31.02 67.20 $ $ 31.34 $ 67.90$ 31.66 68.60 $ $31.98 $ 69.30 $ 32.31 $ 70.00 $ 32.63 $ 70.70 $ 32.95 $ 71.40 $ 33.28 -$72.10. $33.60 $ 72.80 $ 33.92 $ 73.50 $ 34.25 $ 74.20 $ 34.57 74.90 $ $ 34.89 75.60 $ $ 35.22 $ 76.30 $ 35.54 $ 77.00 $ 35.86 $ 77.70 $ 36.18 $ 78.40 $ 36.51 $ 79.10 $ 36.83 $ 79.80 $ .$37.15 .$. 80,5037.48 $ 81.20 $ 37.80 $ 81.90 $ 38.12 $ 82.60 $ 38.45 $ 83.30 $ 38.77 $ 84.00 $ 39-09 $ 84.70$ 39.42 $ 85.40 $ 39.74 86.10 $ $ 40.06 86.80 $ $ 40.38 $ 87.50 $

7/30/2014

CBIZ Payroll Agreement for Employee Direct Deposit Version 12.01.07 Company ID

Company Name

Employee ID

Employee Name

Institution Name Routing # Checking Account Type Deposit Options (SELECT ONLY ONE) Deposit Entire Net Pay Amount Deposit % Institution Name Routing # Checking Account Type Deposit Options (SELECT ONLY ONE) n Deposit Entire Net Pay Amount D Deposit % Institution Name Routing # Checking Account Type Deposit Options (SELECT ONLY ONE) Depos TT Deposit Entire Net Pay Amount Deposit __ °/

Account # Savings TU f~l

D _J 2]

Q

Deposit $ Cancel Direct Deposit

Account # Savings Deposit $ Cancel Direct Deposit

Account # Savings Deposit $ Cancel Direct Deposit

I hereby authorize and release COMPANY, to make payment of any amounts owing to me by initiating credit entries to my account indicated below in the bank named below, herein after called BANK, and I; authorize and request BANK to accept any credit entries initiated by COMPANY to such account and to credit the same to such account without responsibility for the correctoess thereof. I also authorize and request COMPANY to effect repayment to COMPANY for amounts owed it because of a prior erroneous credit initiated to my account if prior to the initiation of the correcting entry COMPANY has sent or delivered to me written notice of the correction and the reason therefore and, the correcting entry is transmitted in such time as to be delivered or made available to BANK before midnight of the tenth day next following settlement for the erroneous entry. It is understood that this agreement may be terminated by me at any time by written notification to COMPANY or BANK Any such notification to COMPANY shall be effective only with respect to entries initiated by COMPANY after receipt of such notification and a reasonable opportunity to act on it Any such notification to file BANK shall be effective only with respect to entries credited to my account by BANK after receipt of such notification and a reasonable time to act on it I recognize, acknowledge and accept that this service is being provided for my convenience. As such I agree to hold COMPANY, CBIZ PAYROLL each, participating bank and NACHA harmless from any claim incident to the operation of this plan, arising from any act or omission by COMPANY and/or CBIZ PAYROLL and their employees, including without limitation any claim based on alleged loss as a result of non-credit of any deposit, and any claim which may be made by any depositor as a result of the rejection of any debits because of insufficient funds arising from the failure to credit deposits to his/her account

Employee Signature * Attach a VOID check (or copy) for each account to this form***

FORM VA-4

COMMONWEALTH OF VIRGINIA DEPARTMENT OF TAXATION

PERSONAL EXEMPTION WORKSHEET 1. If no one else can claim you as a dependent, and you wish to claim yourself, write "1" . 2. If you are married and your spouse is not claimed on his/her own certificate, write "1",. 3. Exemptions for age (a) If you will be 65 or older on December 31, write "1" (b) If you claimed an exemption on line 2 and your spouse will be 65 or older on December 31, write "1" 4. Exemptions for blindness (a) If you are legally blind, write "1" (b) If you claimed an exemption on line 2 and your spouse is legally blind, write "1" 5. Write the number of dependents you will be allowed to claim on your income tax return (do not include your spouse) 6. Total exemptions (add lines 1 through 5)

Detach here and give the certificate to your employer. Keep the top portion for your records. FORM VA-4 Your social security number

EMPLOYEE'S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE Name.

Street address

City

COMPLETE THE APPLICABLE LINES BELOW 1. If subject to withholding, enter the number of exemptions claimed on line 6 of the Personal Exemption Worksheet 2. Enter the amount of additional withholding requested (see instructions) 3. I certify that I am not subject to Virginia withholding. I meet the conditions set forth in the instructions (check here)

Signature

Data

EMPLOYER: Keep exemption certificates with your records. If you believe the employee has claimed too many exemptions, notify the Department of Taxation, P.O. Box 1880, Richmond, Virginia 23282-1880, telephone (804) 367-8038. VA DEPT OF TAXATION

2601064 REV 6/93

FORM VA-4 INSTRUCTIONS Use this form to notify your employer whether you are subject to Virginia income tax withholding and how many exemptions you are allowed to claim. You must file this form with your employer when your employment begins. If you do not file this form, your employer must withhold Virginia income tax as if you had no exemptions.

PERSONAL EXEMPTION WORKSHEET You may not claim more personal exemptions on form VA-4 than you are allowed to claim on your income tax return unless you have received written permission to do so from the Department of Taxation. Line 1. You may claim an exemption, for yourself if ho one else claims you as a dependent on their income tax return. Line 2. You may claim an exemption for your spouse if he or she is not already claimed on his or her own certificate. Line 3. If you will be 65 or older at the end of this year, you may claim an additional exemption. The additional exemption for a spouse may be claimed only if you were entitled to an exemption on line 2. Line 4. If you are considered legally blind for federal income tax purposes, you may claim an additional exemption. The additional exemption for a spouse may be claimed only if you were entitled to an exemption on line 2. Line 5. Enter the number of dependents you are allowed to claim on your income tax return. NOTE: A spouse is not a dependent.

FORM VA-4 Be sure to enter your social security number, name and address in the spaces provided. Line 1. If you are subject to withholding, enter the number of exemptions from line 6 of the Personal Exemption Worksheet. Line 2. If you wish to have additional tax withheld, and your employer has agreed to do so, enter the amount of additional tax on this line. Line 3. If you are not subject to Virginia withholding, check the box on this line. You are not subject to withholding if you meet any one of the conditions listed below. Form VA-4 must be filed with your employer for each calendar year for which you claim exemption from Virginia withholding. (a) You had no liability for Virginia income tax last year and you do not expect to have any liability for this year. (b) You expect your Virginia adjusted gross income to be less than $5,000 (single), $8,000 (married, filing a joint or combined return) or $4,000 (married, filing a separate return). .(.c). You live in Kentucky or the District of Columbia and commute on a daily basis to your place of employment in Virginia. (d) You are a domiciliary or legal resident of Maryland, Pennsylvania or West Virginia whose only Virginia source income is from salaries and wages and such salaries and wages are subject to income taxation by your state of domTcTfe. VA DEBT OF TAXATION 2601064 REV 6/93 (back)

Form W-4 (2014) 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 2014 expires February 17,2015. See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: • Is age 65 or older, • Is blind, or • Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credjts, adjustments to income, or two-eamers/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 dependents) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Rling 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.

Non wage 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 iincome, 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 yoTrare ffnWireisideritralieTr, 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 2014. 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 wvm.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.) Enter "1" for yourself if no one else can claim you as a dependent A f • You are single and have only one job; or 1 Enter "1" if: | • You are married, have only one job, and your spouse does not work; or f . . . B *• • Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. ' Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-" may help you avoid having too little tax withheld.) C Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) . . E Enter "1" if you have at least $2,000 of child or dependent care expenses for which you.plan to claim a credit . . . F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. • If your total income will be less than $65,000 ($95,000 if married), enter "2" for each eligible child; then less "1" rf you have three to six eligible children or less "2" if you have seven or more eligible children. Hfyourtotalincomewilltebetween$65,OOOand$84,000($95,OOOand$119,OOOifmarriecf),enterI1nforeacheligiblechild . . . G 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

D E F

For accuracy, complete all worksheets that apply.

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

Form

W-4

Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate

OMB No. 1545-0074

^- Whether you are entitled to daim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Your first name and middle initial

Last name

Home address (number and street or rural route)

2

3 CH Single

14

Your social security number

LJ Married HH Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the "Single" box. City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card, check here. You must caH 1-800-77Z-T2'13 for a replacement caret. >>• | |

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2014, 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 M7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee's signature (This form is not valid unless you sign it) »8

Employer's name and address (Employer: Complete lines 8 and 1 0 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date >9 Office code (optional)

Cat No. 10220Q

10

Employer identification number (EIN)

Form W-4 (2014)

Page 2

Form W-4 (2014)

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 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was bom before January 2,1950) of your income, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income is over $305,050 and you are married filing jointly or are a qualifying widowjer); $279,650 if you are head of household; $254,200 if you are single and not head of household or a qualifying widow(er); or $152,525 if you are married filing separately. See Pub. 505 for details . . . . 2 3 4 5 6 7 -8, 9 1o

f $12,400 if married filing jointly or qualifying widow(er) 1 Enter: j $9,100 if head of household f ^ $6,200 if single or married filing separately •* Subtract line 2 from line 1. If zero or less, enter "-0-" Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505) Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2014 Form W-4 worksheet in Pub. 505.) Enter an estimate of your 2014 nonwage income (such as dividends or interest) . Subtract line 6 from line 5. If zero or less, enter "-0-" .Divide, the amount on line-7 by $3,950 and -enter the result here. Drop any fraction . . , . , . . Enter the number from the Personal Allowances Worksheet, line H, page 1 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Eamers/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

1 2 3 4 5 6 7 8 9 -\Q

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) 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than "3" 3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter "-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 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. Enter the-number from line-2 of this worksheet 4 Enter the number from line 1 of this worksheet 5 Subtract line 5 from line 4 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . Divide line 8 by the number of pay periods remaining in 2014. 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 2014. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1 Married Filing Jointly If wages from LOWEST paying job are— $0 - $6,000 6,001 - 13,000 13,001 - 24,000 • 24,001- - 26,000 26,001 - 33,000 33,001 - 43,000 43,001 - 49,000 49,001 - 60,000 60,001 - 75,000 75,001 - 80,000 80,001 - 100,000 100,001 - 115,000 115,001 - 130,000 130,001 - 140,000 140,001 - 150,000 150,001 and over

Enter on line 2 above

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

6 7 8

Table 2 Married Filing Jointly

All Others If wages from LOWEST paying job are— $0 - $6,000 6,001 - 16,000 16,001 - 25,000 25,001 - 34.OOO 34,001 - 43,000 43,001 - 70,000 70,001 - 85,000 85,001 - 110,000 110,001 - 125,000 125,001 - 140,000 140,001 and over

Enter on line 2 above

0 1 2 3

4 5 6 7 8 9 10

Priuanx/ Arrt anri Parwwr rk RpHnnfinn Arrt NntinA. We ask fnrthfl information nn 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 asingle 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 theirtax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

If wages from HIGHEST paying job are— $0 74,001 130,001 200,001 355,001 400,001

- $74,000 - 130,000 - 200,000 - 355,000 - 400,000 and over

Enter on line 7 above $590

990 1,110 1,300 1,380 1,560

All Others If wages from HIGHEST paying job are— $0 37,001 80,001 175,001 385,001

- $37,000 80,000 - 175,000 - 385,000 and over

Enter on line 7 above $590

990

1,110 1,300 1,560

Ynn arp nnt rpnriirpH tn nrnuiHotfioinfnrma+inn ro/itioo+o/4 nn a fnrm -fK-rtio oi

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