Office of Human Resources & Risk Management - UCAuca.edu/hr/files/2017/06/GAEmploymentPacket.pdfOffice of Human Resources & Risk Management University of Central Arkansas Wingo Hall,

Office of Human Resources & Risk Management University of Central Arkansas

Wingo Hall, Suite 106 Conway, AR 72035-5003

To: Graduate Assistants

From: UCA Office of Human Resources

Subject: Employment Packet

Welcome to UCA. We are pleased that you have elected to work here. Attached are forms and

policies that require your review and signature. Your assistance in properly completing these

forms and following the policies will make your employment with UCA a more positive and

productive experience for everyone involved. When completed, return the original forms to

your department.

Please make sure that you have the proper personal identification to present to the department

for copying and attaching to the I-9 Employee Eligibility form. Also, UCA must report payroll

earnings to the Social Security Administration and, therefore, you must present your social

security card to the department for copying and forwarding to Human Resources.

Employees are paid on the 15th and the 31

st of the month, or the last working day before those

dates. All employees are required to be paid using direct deposit. If all forms are not

completed and the originals submitted to Human Resources, we will be unable to record the

necessary tax and identification information and your payroll will be delayed until that

information is provided.

Thank you for your cooperation in completing these forms. If you have any questions or need

further information, please don’t hesitate to call us at 450-3181 or contact us by e-mail at

[email protected].

Graduate Assistant Employment Packet

Index

Form/Document Order of Placement

Welcome Letter 1

Employee Packet Index 2

Graduate Assistant Employment Packet Acknowledgement 3

Statement of Mission and Purpose 4

Concurrent Employment Information 5

UCA Employment Application 6

Employee Disclosure 10

Personnel Data Sheet 16

Form I-9, Employment Eligibility Verification Instructions 17

Form I-9, Employment Eligibility Verification Form 32

Equal Employment Opportunity Statement 35

Employee Notification of Debt Collection 35

University Firearms Policy 35

State Vehicle Authorization Program and Form 36

Direct Deposit Policy and Authorization Form 39

Sexual Harassment Board Policy 41

Drug-Free Workplace Policy 45

Sexual Harassment & Drug-Free Workplace Acknowledgement 46

Social Security Card Acknowledgement 47

Supplemental Retirement Acknowledgement 48

Statement of Selective Service Status 49

Student Right to Know Information 50

W-4 Employee Federal Withholding Allowance Certificate 51

W-4 Nonresident Alien Supplemental Form 55

AR4EC Employee State Withholding Allowance Certificate 57

UNIVERSITY OF CENTRAL ARKANSAS

Graduate Assistant Employment Packet Acknowledgement

By signing below, I acknowledge that I have received materials concerning the following:

Statement of Mission and Purpose

Concurrent Employment Information

UCA Employment Application

Employee Disclosure Certification

Personnel Data Sheet

Form I-9, Employment Eligibility Verification

Employee Disclosure Notification

Equal Employment Opportunity Statement

Employee Notification of Debt Collection

University Firearms Policy

State Vehicle Authorization Form

Direct Deposit Authorization Form

Sexual Harassment Board Policy and Sexual Harassment Policy

Acknowledgement

Drug Free Workplace Memo, Policy and Policy Acknowledgement

Social Security Card Acknowledgement

Supplemental Retirement Acknowledgement

Statement of Selective Service Status

Student Right to Know Information

W-4 Employee Federal Withholding Allowance Certificate

AR4EC Employee State Withholding Allowance Certificate

______________________________________ ________________________

Signature Date Print Name

___________________________________

Department

REMINDER: The attached forms that require signatures must be completed and

returned to the Office of Human Resources (along with the PAF completed by the

department) before payroll can be processed.

UNIVERSITY OF CENTRAL ARKANSAS Statement of Mission and Purpose

The University of Central Arkansas (UCA), a state-wide comprehensive university, seeks to deliver the best undergraduate education in Arkansas as well as excellent graduate programs in selected disciplines. The University offers a variety of undergraduate and graduate programs in the liberal and fine arts, in the basic sciences, and in technical and professional fields in addition to its historical emphasis in the field of education. UCA strives to maintain the highest academic quality and to ensure that its curriculum remains current and responsive to the needs of those it serves. The University’s mission is expressed in its commitment to the personal, social, and intellectual growth of its students; its support for the advancement of knowledge; and its service to the community as a public institution.

The University implements its mission through its emphasis on certain central purposes:

To deliver excellent curricula in general education, in degree programs at the

undergraduate and graduate levels, and in continuing education.

To support its programs with personnel of the highest quality and with optimal resources

and facilities.

To create a campus community that supports students in their personal, social, and

intellectual growth.

To enhance interaction and understanding among diverse groups and to cultivate global

perspectives.

To foster learning and the advancement of knowledge through research and other

scholarly and creative activities.

To serve the public in ways appropriate to the mission and resources of the University.

Rev 3/14/18

UNIVERSITY OF CENTRAL ARKANSAS

CONCURRENT EMPLOYMENT INFORMATION

NOTE: This form must be completed by the employee and attached to each Personnel Action Form requesting

appointment or change.

Name ______________________________ Employee ID # ____________________

CAUTION: Under Arkansas Code 6-63-307 (b) Any employee knowingly violating the provisions of this section shall be subject to

immediate termination and shall be barred from employment by any agency or institution of the State of Arkansas for a period of not less

than three (3) years or until such employee shall repay to the State of Arkansas any sums received by such employee in violation of this

section, together with interest at a rate of ten percent (10%) per annum.

Will you be employed during the period of this PAF in any other roles or assignments with UCA or with other State

Agencies or Institutions? (Including additional teaching assignments, part-time work and temporary project assignments.)

NO If no, please provide signature and date here:

Signature ________________________________ Date _______________

IF NO, THIS FORM IS COMPLETE AND READY TO SUBMIT WITH PAF.

----------------------------------------------------------- *OR* ----------------------------------------------------------

____ YES Please provide specific information and signatures below. Attach additional sheet if necessary.

Please list your UCA teaching schedule as well as your concurrent employment schedule.

Work location, Employment Work Schedule Assignment

Dept/Employer Period Days/ Hours Salary

Example:

UCA Music 1/15/18 – 5/11/18 MWF 9-11, TuTh 8am-1pm $50,000

UALR Music 1/15/18 – 5/11/18 MWF 2-4 pm $ 5,200

I understand that concurrent employment must be approved by the State Office of Personnel

Management prior to my beginning employment.

Signature __________________________________________ Date ___________________

As Chair/Dean/Dept. Mgr., I acknowledge that I am aware that the above-mentioned person is employed elsewhere and that

there is no conflict with the assigned work schedule at UCA.

Chair/Dean Signature __________________________________ Date ___________________

The University of Central Arkansas is an Equal Opportunity Employer, and therefore does not discriminate on the basis ofrace, color, religion, national origin, sex, gender, age, or disability.

Please answer all questions which apply to you. If they do not apply, mark them N/A. Please print or type.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Position for which you are applying (please give title & dept.): _______________________________________________

Employment StatusHave you ever been employed by UCA or another Arkansas State Agency or Institution? ..................................... ❐ Yes ❐ NoIf yes, list the employer and your name at that time. _______________________________________________________Are you a Veteran? ................................................................................................................................................................ ❐ Yes ❐ NoIf yes, check type of discharge ................................❐ Honorable ❐ DishonorableHave you been convicted of, or pled quilty or no contest to a crime (civilian or military) in the past five years? ........ ❐ Yes ❐ NoAre you required by federal or state law to register as a sex offender? ..................................................................... ❐ Yes ❐ NoA “yes” answer to either/both of the above will not automatically exclude you from employment consideration.List professional license(s) relevant to position for which you are applying. Give type of license, license number, date ofexpiration, and state. _______________________________________________________________________________

________________________________________________________________________________

May we contact your current employer? ..............❐ Yes ❐ NoMay we contact your former employer(s)? ...........❐ Yes ❐ No

ReferencesPlease list three (3) persons not related to you, who have knowledge of your work qualifications, are not previous orcurrent employer(s), and can serve as a reference for you.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

NepotismDo you have any relatives employed by the University of Central Arkansas or other State agencies? ................ ❐ Yes ❐ NoIf yes, complete the remainder of this section. (This question is being asked for the sole purpose of ensuring compliancewith any applicable law or policy concerning nepotism.)

________________________________________________________________________________________________

________________________________________________________________________________________________

UNIVERSITY OF CENTRAL ARKANSASApplication for Employment

201 Donaghey Ave.Conway, AR 72035

(501)450-5000www.uca.edu

Last Name First Name Middle Name

Complete Mailing Address City State Zip Code

Home Phone Number Work Phone Number Message or Other Phone Number

Name Address Telephone

1

2

3

Name Relation Agency/Dept. employed by

Educational History

High School Received: ❐ Diploma ❐ G.E.D. ❐ Certificate: Type Awarded:________________________If None, Highest Grade Completed ________________________________________________________

List below post secondary schools, colleges, universities, trade/vocational, or others attended:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________NOTE: For hours completed indicate whether semester hours, quarter hours, clock hours, etc.

Work HistoryList all prior work experience, including military service, use additional sheet(s) of paper if needed. If you wish to includea resume’ instead of completing the work history section, make sure all the requested information is included.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Carefully review the following before signing this applicationCheck over your answers to make sure that all questions have been completed properly. If the job you are applying for requires acollege degree or certification, a copy of your transcript, certificate, or license may be required as a condition of employment.

I hereby declare that, to the best of my knowledge and my ability, the information on this application is true and factual, therefore, Iunderstand that false, misleading, or incomplete statements could lead to my rejection as an applicant or dismissal as an employee.

I also understand that I will be required to provide proof of eligibility to work in the United States pursuant to the Immigration Reformand Control Act of 1986 as a condition of any employment, and that some jobs may require special background checks, driver’s safetyrecord, security clearance, physical fitness exams, or compliance with other specific agency hiring policies prior to my employment,or as a condition of employment; and that failure to meet these requirements may lead to my rejection as an applicant for, or termina-tion from that job. I understand that my application may be subject to disclosure as a public record under the Arkansas Freedom ofInformation Act. I understand that the University is an at-will employer consistent with Arkansas Law. I understand that my employ-ment may be subject to review and approval through the State Department of Finance & Administration or other agencies in compli-ance with the Governor’s Executive Order 98-04 or with other rules and regulations.

_______________________________________________ ____________________________________________Signature of applicant Date of signature (Day/Mo/Yr)

Please submit application & supplementary materials to: University of Central Arkansas, Office of Human Resources,

Wingo Hall, Suite 106, 201 Donaghey Ave., Conway, AR 72035

From To Hours Completed Degree/Diploma Name and Location Mo/Yr Mo/Yr Major/Minor (See note below) Awarded Date Graduated

From To Current or most recent Employer Name/Address Mo/Yr Mo/Yr

Supervisor’s Name Telephone No.

Title & Job Duties Reason for leaving:

Salary begin:

Salary end:

From To Past Employer Name/Address Mo/Yr Mo/Yr

Supervisor’s Name Telephone No.

Title & Job Duties Reason for leaving:

Salary begin:

Salary end:

Disclosure Requirements

Governor’s Executive Order 98-04, Governor’s Policy Directive #8, and ACA §21-8-304 require that the following informationbe disclosed to be considered for employment with the State of Arkansas.

1. Are you one of the following:❐ current member of the AR General Assembly?❐ current constitutional officer?❐ current state employee?❐ former member of the AR General Assembly?❐ former constitutional officer?❐ former state employee?

2. Is your spouse, brother, sister, parent, and/or child of you or your spouse one of the following:❐ current member of the AR General Assembly?❐ current constitutional officer?❐ current state employee?❐ former member of the AR General Assembly?❐ former constitutional officer?❐ former state employee?

3. ❐ None of the above applies.

Some business relationships may prohibit an agency from hiring you. If any block is checked in #1 or #2 above, you will berequired to disclose additional information if you are selected for an interview to determine whether your employmentwould be prohibited or would require approval.

I understand that, should I become an employee of the State of Arkansas, I will be required to disclose any benefit ob-tained from a state contract by a business in which I have a financial interest, pursuant to ACA§19-11-706, and will besubject to civil, criminal, and/or administrative remedies if I fail to report such benefits.

I understand that, should I become an employee of the State of Arkansas, I will be restricted both during and after stateemployment from certain activities concerning procurement and selling to the state, pursuant to ACA§19-11-709, and willbe subject to civil, criminal, and/or administrative remedies if I violate any of these restrictions.

_______________________________________________ ____________________________________________Signature of applicant Date of signature (Day/Mo/Yr)

Equal Employment DataThis section is designed to collect information which will be used in the completion of various state and federal reportsand will not be used in the processing of, or remain part of your application. The completion of this section is voluntary.

Applicant’s Name____________________________________________________________________________________

Position Applied For __________________________________________________________________________________

Date of Birth _________________________________________________________________________ ❐ Male ❐ Female

Check the one listed below which you consider yourself to be:❐ Caucasian (not of Hispanic origin) ❐ Asian ❐ Other _______________________❐ African American ❐ Pacific Islander❐ American Indian ❐ Hispanic

Are you a U. S. Citizen? ........................................................................................................................................................ ❐ Yes ❐ NoIf no, you must visit International Programs (Torreyson Library) for review of your I-9 and W4 forms before beginning work on campus.Are you a veteran? ................................................................................................................................................................ ❐ Yes ❐ No

Please indicate the method by which information concerning this vacancy was obtained. If announcement was read in apublication, please list title of publication. _______________________________________________________________

________________________________________________________________________________________________

Please mail to: Director, Affirmative Action

University of Central Arkansas

Wingo Hall, Suite 106

201 Donaghey Avenue

Conway, AR 72035

Campus Safety and Security

The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act requires that institutions ofhigher education publicly disclose an annual security report. This information is published annually by the University ofCentral Arkansas and is available in the UCA Student Handbook, in the publication “Safety, Security & Health” available atthe offices of the UCA Police Department and the Office of Human Resources, or by accessing the Police Departmentweb-site at www.uca.edu/ucapd. This information is also available upon request by contacting the UCA Police Depart-ment at 501-450-3111.

University of Central Arkansas Police Department201 Donaghey Ave.Conway, AR 72035(501) 450-3111

For further information or assistance, please contact the UCA Office of Human Resources at 501-450-3181.

STATE OF ARKANSAS

Department of Finance and Administration EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT OF FAMILY MEMBERS FORM

I understand to be eligible for employment with the State of Arkansas, I must comply with Governor’s Executive Order 98-04, ACA §21-1-401-408, and ACA §25-16-1001-1007. I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a relative specifically under ACA §25-16-1002. If I am hired and it can be proven I falsely disclosed or failed to disclose information I could be subject to criminal, civil and/or administrative remedies. I assert that I have answered the above questions to the best of my knowledge.

F-3/F-4 Rev. 06/27/12

1. Yes No Are you a current state employeeA?

2. Yes No Are you a former

B state employee

A? 3. Yes No Are you a current Constitutional Officer

C? 3a. Yes No If “Yes”, were you employed prior to your election into office? 3b. ► If “Yes,” give date elected 4. Yes No Are you the spouse of a current Constitutional Officer

C? 4a. ► If “Yes,” give spouse’s name

position/office 4b. Yes No If “Yes”, is your expected salary above $37,649? 5. Yes No Are you the spouse of a former

B Constitutional Officer

C?

5.a ► If “Yes,” give spouse’s name position/office 6. Yes No Are you or your spouse a former

B General Assembly member

D? 6a. ► If “Yes,” give spouse’s name position/office 6b. Yes No If “Yes”, within the 24 months prior to your leaving office or your spouse leaving office, was the position for

which you are being considered created by legislative action, or if the maximum salary level increased by more than 15%, was this authorized by legislative action?

7. Yes No Are you a relative

E of the Public OfficialF in charge of the agency

G in which you are applying? 7a. ► If “Yes,” give relative’s

E name position/office relationship 8. Yes No Are you a relative

E of a state employeeA, state board or commission member or are you a relative

E (other

than the spouse) of a Constitutional OfficerC or an Arkansas General Assembly member

D? 8a. ► If “Yes,” give relative’s

E name position/office relationship 9. Yes No If you checked “Yes” in #8 above, does this relative

E work within the state agencyG in which you are

applying? 9a. Yes No If “Yes”, is the position for which you are applying in the direct line of supervision of your relative

E or will the position be a supervisory employee of the relative

E.

- - Applicant Name (Please Print) Signature of Applicant Date Social Security Number

This form is to be completed by all interviewed applicants for a position. Definitions for the symbols in questions 1 – 9 below. Please read before continuing.

A State Employee any employee of any state agency employed in a regular salary position or extra-help position not to include contract labor.

B Former is defined as within the last 24 months.

C Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner, General Assembly member.

D General Assembly member: member of the Arkansas Senate or the Arkansas House of Representatives.

E Relative includes: husband, wife, mother, father, stepmother, stepfather, mother-in-law, father-in-law, sister, brother, stepsister, stepbrother, half-sister, half-brother, sister-in-law, brother-in-law, daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, aunt, uncle, first cousin, niece or nephew.

F Public Official: constitutional officers; members of the Arkansas General Assembly; the executive head of any agency, department, board, commission, institution, bureau, or council of the state.

G Agency or State Agency: every agency, board, commission, department, division, institution, and other office of state government located within the executive branch of government and under the control of the Governor.

STATE OF ARKANSAS

Department of Finance and Administration EMPLOYEE DISCLOSURE/CERTIFICATION AND EMPLOYMENT OF FAMILY MEMBERS FORM

INSTRUCTIONS FOR HIRING OFFICIAL:

Please check each table below with the disclosure statement and proceed accordingly for the position finalist(s) prior to a job offer.

No Approval Required √ if

applies

Answered “Yes” or Answered “No”

Question 1 and/or 2 Questions 1-9a * Hiring Official must complete information below and forward with hire packet to HR.

Approval by HR Manager Only √ if

applies

Answered “Yes” Answered “No”

Question 4 Question 1 and 4b Question 5 Question 1 Question 6 Question 6b Question 8 Question 9 Question 9a * Submit the form to your agency Human Resource Manager for approval with the hire packet .

Approval by appropriate Legislative Branch and Governor

√ if applies

Answered “Yes” Answered “No”

Question 3 and 3a Question 4 and 4b Question 1 Question 4 and 1 Question 4b Question 5 * Submit the form to the Office of Personnel Management (OPM) for review and submission to the Governor, and if approved, to the Personnel Subcommittee.

Cannot be Hired √ if

applies

Answered “Yes” Answered “No”

Question 3 Question 3a Question 6 and 6b Question 7 Question 9 and 9a * The applicant cannot be hired if one or more of the items above apply.

This form must be completed by the Hiring Official (Supervisor) for the position finalist(s) prior to a job offer.

Agency/Institution Hiring Official Position Applied for

Position #

Pay Grade

Salary

I certify that the applicant meets the education and experience qualifications required to perform the duties of the position for which they are being considered.

F-3/F-4 Rev. 06/27/12

Signature of Agency/Institution Hiring Official Date Phone Number

Approved

Disapproved Signature of Agency/Institution Human Resource Manager Agency Number Date

Hiring Official must check that the applicant completed all required information and answered all questions before signing form. *Ensure the date elected for 3b is after employment date. *Ensure the salary for 4b is correct. *Ensure spouse is a former

B Constitutional Officer

C.

Please initial to confirm: ______

Hiring Official must check that the applicant completed all required information and answered all questions before signing form.

Please initial to confirm: ______ Hiring Official must check that the applicant completed all required information and answered all questions before signing form. *Ensure the salary for 4b is correct. *Ensure the information for 6b is correct. Please initial to confirm: ______

Hiring Official must check that the applicant completed all required information and answered all questions before signing form.

*Ensure 3a was answered before signing below. *Ensure the information for 6b is correct. *Ensure the information for 9a is correct.

Please initial to confirm: ______

STATE OF ARKANSAS Department of Finance and Administration

Employee Disclosure Requirements/Restrictions Notice

Employee Disclosure Requirements Notice

Employees must report any benefit obtained from a state contract by a business in which the employee has a financial interest. Ark. Code Ann. § 19-11-706. The employee must report this benefit to the Director of the Department of Finance and Administration. A state employee has a “financial interest” in a business if he/she:

has received within the past year, or is presently or in the future entitled to receive, more than one thousand dollars ($1000) per year, as a result of ownership of any part of the business or any involvement in the business; or

owns more than a five percent (5%) interest in the business; or holds a position in the business such as an officer, director, trustee, partner, employee, or the like, or holds any position of

management. Any employee who knows or should have known of such benefit and fails to report the benefit to the director is in breach of the ethical standards of Ark. Code Ann. § 19-11-706. Employee Disclosure Restriction Notice State employees are restricted from employment under certain conditions, both during the time they are employed by the state and after they leave state employment. Ark. Code Ann. § 19-11-709. These restrictions include:

employment of a current state employee involved in procurement by any party contracting with the state; former employees from representing anyone other than the state under certain conditions in matters which the employee

participated personally and substantially or which were within the former employee’s official responsibility; partners of a current or former state employee from representing anyone other than the state under certain conditions; selling to the state after termination of employment under certain conditions.

Any current or former state employee who violates any of these employment restrictions is in breach of the ethical standards of Ark. Code Ann. § 19-11-709. Penalties for Non-Compliance with Ark. Code Ann. § 19-11-706 or § 19-11-709 In addition to civil and administrative remedies, Ark. Code Ann. § 19-11-712 allows the Director of the Department of Finance and Administration to impose against any employee who fails to comply with Ark. Code Ann. § 19-11-706 or § 19-11-709, after notice and an opportunity for a hearing, any one or more of the following:

oral or written warnings or reprimands; forfeiture of pay without suspension; suspension with or without pay for specified periods of time; and termination of employment.

Pursuant to Arkansas Code Annotated § 19-11-702, any employee who shall knowingly violate either of these restrictions shall be guilty of a felony and upon conviction shall be fined in any sum not to exceed ten thousand dollars ($10,000) or shall be imprisoned not less than one (1) nor more than five (5) years, or shall be punished by both.

I certify that I have read this Notice and the Ark. Code Ann. §§ 19-11-706, 19-11-702, 19-11-709 and 19-11-712 on the reverse side. The Rule promulgated to enforce Executive Order 98-04 contain additional information regarding this reporting requirement at Section 13 & 14, posted by the agency in a conspicuous place. I understand that it is my responsibility to comply with the requirement to report as explained in Ark. Code Ann §§ 19-11-706 & 19-11-709, this Notice and the rule.

Agency Name Hiring Official

Name of Employee (Please Print) Social Security Number

Signature of Employee Date

See back for Arkansas Code Annotated §§ 19-11-702, 19-11-706, 19-11-709 and 19-11-712

F-5/F-6

EXCERPTS FROM ARKANSAS CODE ANNOTATED §19-11

SUBCHAPTER 7 19-11-702. Penalties. Any employee or nonemployee who shall knowingly violate any of the provisions of this subchapter shall be guilty of a felony and upon conviction shall be fined in any sum not to exceed ten thousand dollars ($10,000) or shall be imprisoned not less than one (1) nor more than five (5) years, or shall be punished by both. 19-11-706. Employee disclosure requirements. (a) Disclosure of Benefit Received from Contract. Any employee

who has or obtains any benefit from any state contract with a business in which the employee has a financial interest shall report such benefit to the Director of the Department of Finance and Administration. However, this section shall not apply to a contract with a business where the employee's interest in the business has been placed in a disclosed blind trust.

(b) Failure to Disclose Benefit Received. Any employee who knows or should have known of such benefit and fails to report the

benefit to the director is in breach of the ethical standards of this section. 19-11-709. Restrictions on employment of present and former employees. (a) Contemporaneous Employment Prohibited. It shall be a

breach of ethical standards for any employee who is involved in procurement to become or be, while such an employee, the employee of any party contracting with the state agency by which the employee is employed.

(b) Restrictions on Former Employees in Matters Connected with Their Former Duties.

(1) Permanent Disqualification of Former Employee Personally Involved in a Particular Matter. It shall be a breach of ethical standards for any former employee knowingly to act as a principal or as an agent for anyone other than the state in connection with any:

(A) Judicial or other proceeding, application, request for a ruling, or other determination;

(B) Contract; (C) Claim; or (D) Charge or controversy

in which the employee participated personally and substantially through decision, approval, disapproval, recommendation, rendering of advice, investigation, or otherwise while an employee, where the state is a party or has a direct and substantial interest.

(2) One-Year Representation Restriction Regarding Matters

for Which a Former Employee Was Officially Responsible. It shall be a breach of ethical standards for any former employee, within one (1) year after cessation of the former employee's official responsibility in connection with any:

(A) Judicial or other proceeding, application, request for a ruling, or other determination;

(B) Contract; (C) Claim; or (D) Charge or controversy

knowingly to act as a principal or as an agent for anyone other than the state in matters which were within the former employee's official responsibility, where the state is a party or has a direct or substantial interest.

(c) Disqualification of Partners. (1) When Partner Is a State Employee. It shall be a breach of ethical standards for a person who is a partner of an employee

knowingly to act as a principal or as an agent for anyone other than the state in connection with any:

(A) Judicial or other proceeding, application, request for a ruling, or other determination; (B) Contract; (C) Claim; or (D) Charge or controversy

in which the employee either participates personally and substantially through decision, approval, disapproval,

recommendation, the rendering of advice, investigation, or otherwise, or which is the

subject of the employee's official responsibility, where the state is a party

or has a direct and substantial interest. (2) When a Partner Is a Former State Employee. It shall be a breach of ethical standards for a partner of a former employee knowingly to act as a principal or as an agent for anyone other than the state where such former employee is barred under subsection (b) of this section.

(d) (1) Selling to State After Termination of Employment Is Prohibited. It shall be a breach of ethical standards for any former employee, unless the former employee's last annual salary did not exceed ten thousand five hundred dollars ($10,500), to engage in selling or attempting to sell commodities or services to the state for one (1) year following the date employment ceased. (2) The term "sell", as used in this subsection, means signing a bid, proposal, or contract; negotiating a contract; contacting any employee for the purpose of obtaining, negotiating, or discussing changes in specifications, price, cost allowances, or other terms of a contract; settling disputes concerning performance of a contract; or any other liaison activity with a view toward the ultimate consummation of a sale although the actual contract therefore is subsequently negotiated by another person. (e) (1) This section is not intended to preclude a former employee from accepting employment with private industry solely because his employer is a contractor with this state. (2) This section is not intended to preclude an employee, a former employee, or a partner of an employee or former employee from filing an action as a taxpayer for alleged violations of this subchapter. 19-11-712. Civil and administrative remedies against employees who breach ethical standards. (a) Existing Remedies Not Impaired. Civil and administrative remedies against employees which are in existence on July 1, 1979, shall not be impaired. (b) Supplemental Remedies. In addition to existing remedies for breach of the ethical standards of this subchapter, or regulations promulgated thereunder, the Director of the Department of Finance and Administration may impose any one (1) or more of the following:

(1) Oral or written warnings or reprimands; (2) Forfeiture of pay without suspension; (3) Suspension with or without pay for specified periods of time; & (4) Termination of employment.

(c) Right to Recover from Employee Value Received in Breach of Ethical Standards. The value of anything received by an employee in breach of the ethical standards of this subchapter, or regulations promulgated thereunder, shall be recoverable by the state as provided in § 19-11-714, which refers to recovery of value transferred or received in breach of ethical standards. (d) Due Process. Notice and an opportunity for a hearing shall be provided prior to imposition of any of the remedies set forth in subsection (b) of this section.

STATE OF ARKANSAS

Department of Finance and Administration

Employee Disclosure Requirements

In Compliance with Governor’s Executive Order 98-04 Arkansas Code Annotated § 19-11-706

Pursuant to Arkansas Code Annotated § 19-11-706, employees are required to disclose any benefit received from any state contract. Specifically:

(a) Any employee who has or obtains any benefit from any state contract with a business in which the employee has a financial interest shall report such benefit to the Director of the Department of Finance and Administration. However, this section shall not apply to a contract with a business where the employee’s interest in the business has been placed in a disclosed blind trust.

(b) Any employee who knows or should have known of such benefit and fails to report the benefit to the director is in breach of the ethical standards of this section.

This employee disclosure shall be made within 30 days after the employee has actual or constructive notice of a benefit received or to be received. Such disclosure shall be made by completing this Employee Disclosure Requirements form and forwarding this completed form to: Director Department of Finance and Administration P. O. Box 3278 Little Rock, AR 72203-3278

Employee Name: Agency Name/ Division where employed: Name of Person/Business involved with State Contract: Name of Government Body with which the Business has a Contract: Dollar Amount and Nature of Contract: Nature and extent of the benefit received or to be received:

Employee’s Signature Date F-7

THE FOLLOWING IS A PAGE FROM A SAMPLE EMPLOYMENT

APPLICATION THAT CONTAINS THE CHECKLIST FOR EMPLOYEE DISCLOSURE.

DISCLOSURE REQUIREMENTS

Governor’s Executive Order 98-04, Governor’s Policy Directive #8, and ACA §21-8-304 require that the following information be disclosed to be considered for employment with the State of Arkansas. 1. Are you one of the following:

current member of the AR General Assembly? former member of the AR General Assembly? current constitutional officer? former constitutional officer? current state employee? former state employee?

2. Are any of your relatives one of the following: (Relative is defined as husband, wife, mother, father, stepmother, stepfather,

mother-in-law, father-in-law, brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, sister-in-law, daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, uncle, aunt, first cousin, nephew, or niece)

current member of the AR General Assembly? former member of the AR General Assembly? current constitutional officer? former constitutional officer? current state employee? former state employee?

3. None of the above applies. 4. Certain family or business relationships may prohibit an agency from hiring you. If any block is checked in #1 or #2 above, you

will be required to disclose additional information if you are selected for interview to determine whether your employment would be prohibited or would require approval. I understand, should I become an employee of the State of Arkansas, that I may be reprimanded or terminated for failing to disclose the required information or disclosing incorrect information.

I understand that, should I become an employee of the State of Arkansas, I will be required to disclose any benefit obtained from a state contract by a business in which I have a financial interest, pursuant to ACA §19-11-706, and will be subject to civil, criminal, and/or administrative remedies if I fail to report such benefits. I understand that, should I become an employee of the State of Arkansas, I will be restricted both during and after state employment from certain activities concerning procurement and selling to the state, pursuant to ACA §19-11-709, and will be subject to civil, criminal, and/or administrative remedies if I violate any of these restrictions. I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a relative. If I am hired and it can be proven that I falsely disclosed information in gaining employment that I could be subject to criminal or civil penalties under ACA § 25-16-1004 or § 25-16-1005.

F-8

Rev. 07/14/17

UNIVERSITY OF CENTRAL ARKANSAS Personnel Data Sheet

Please write legibly using blue or black ink

PERSONAL INFORMATION

Employee Name: ________________________________________ SSN: _______________________

Gender: Male ______ Female: ______ Date of Birth: Month __________ Day _____ Year ________

Do you consider yourself to be Hispanic or Latino? Yes ____ No____

In addition, select one or more of the following racial categories to describe yourself: ____ American Indian or Alaska Native ____ Asian ____ Black or African American

____ Native Hawaiian or Pacific Islander ____ White

Mailing Address: ____________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Telephone Number: ________________________________________ Unlisted: Yes ___ No ____

Email Address: ____________________________________________________

UCA LOCATION INFORMATION

Department in which you will be employed: ________________________________________________ Building: __________________________ Room # : _______________ Telephone #: _________________

EDUCATION INFORMATION

Highest Level of Education: High School: ____________Grade Completed: _____ Graduation Date: ______ Year of GED: _____ Associate Degree Institution: _________________ Graduation Date: ______ Major: ______________ Bachelor Degree Institution: __________________ Graduation Date: ______ Major: ______________ Master Degree Institution: ___________________ Graduation Date: ______ Degree: _____________ Doctorate Institution: ______________________ Graduation Date: ______ Degree: _____________ Other: __________________________________________________________________________

EMERGENCY CONTACT INFORMATION

Name: _____________________________ Relationship: ______________________________ Telephone Number: _____________________ Alternate Number: _______________________

Previous State Service (list agency and dates):_____________________________________________

___________________________________________________________________________________

_________________________________ _________________________ Signature Date

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

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

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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

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

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

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

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

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

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

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

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

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

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

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

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

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

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

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

and(2) An endorsement of the alien's

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

a. Foreign passport; and

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

listed above:

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

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

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

4. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

The University of Central Arkansas is an Equal Opportunity Employer, and therefore does not discriminate on

the basis of race, color, religion, national origin, sex, age or disability.

All Human Resources actions including hiring, promotion, transfer, lay-off and termination as well as all

benefits are administered without regard to race, color, religion, national origin, sex, gender, age or disability.

The University is an at-will employer consistent with Arkansas Law.

Questions regarding the University’s Equal Employment practices can be directed to:

Director of Human Resources University Equal Employment Officer

University of Central Arkansas OR University of Central Arkansas

Conway, AR 72035 Conway, AR 72035

(501) 450-3181 (501) 450-3170

_________________________________________________________________________________________

EMPLOYEE NOTIFICATION OF DEBT COLLECTION

I agree that, if issued work uniforms, keys or other equipment which I fail to return or that if I have overdue

UCA traffic tickets or dining hall fees or if I have other unpaid fees or charges, the University may collect such

costs from my payroll check(s) and/or from other payment(s) such as terminal vacation, holiday pay,

overtime/compensatory time payments or related payments which I may receive from the University.

I further understand that the University participates in the Arkansas New-Hire Reporting program (child support

payments program, workers compensation fraud, etc.) and other employment and wage garnishment directives.

Signature:________________________________________ Date:_________________

_________________________________________________________________________________________

UNIVERSITY FIREARMS POLICY

UCA is committed to a safe working environment. Unless authorized by law or specific permission has been

granted in advance by the divisional Vice President and the President, the use, storage or possession of a firearm

on University controlled property or at a University sponsored or supervised event is expressly prohibited and

the employee involved will be subject to immediate termination of employment.

Signature:_______________________________________ Date:__________________

ARKANSAS STATE VEHICLE SAFETY PROGRAM January 2018

AIDRM VSP 01-2018

Form to be filed in Employee file located in Human Resources Division.

DRIVING SAFETY TIPS

Observe Speed Limits and Traffic Laws – Allow sufficient time to reach your destination without

violating speed limits or traffic laws.

Seat Belts – Each driver and all passengers in any motor vehicle operated on State official business

are required by law to wear a properly adjusted and fastened seat belt. Statute: § 27-37-702

Handheld Wireless Telephone – “A driver of a motor vehicle shall not use a handheld wireless

telephone for wireless interactive communication while operating a motor vehicle”, in accordance

with A.C.A. § 27-51-1504. Communicating on the phone takes your attention away from driving,

making you less likely to notice hazardous situations.

Backing Crashes – Most backing accidents are preventable. Whenever possible, park your vehicle

where backing is not required. Know what is beside and behind your vehicle before you begin to

back. Back slowly and check both sides as well as the rear as you back. Continue to look to the rear

until the vehicle has come to a complete stop.

Intersection Crashes – When approaching and entering intersections, be prepared to avoid crashes

that other drivers may cause. Take precautions to allow for the lack of skill or improper driving

habits of other drivers. Potentially dangerous acts include, but are not limited to, speeding, improper

turn movements, and failure to yield the right of way.

Weather Related Crashes – Rain, snow, fog, sleet or icy pavement increase the hazards of driving.

Slow down and be especially alert when driving in adverse conditions. Discontinue use of cruise

control in wet or icy road conditions.

Passing Crashes – When you pass another vehicle, look in all directions, check your blind spots, and

use your signal. As a general rule, only pass one vehicle at a time.

Rear End Crashes – The driver can prevent rear-end collisions in spite of abrupt or unexpected

stops of the vehicle ahead by maintaining a safe following distance at all times. Most crashes can be

avoided by maintaining the “four second rule” and following the vehicle ahead at a distance that

spans at least four seconds. The following distance should be increased when driving in adverse

conditions.

Security – State vehicles shall be locked whenever they are unoccupied.

Engines – The engine of a State vehicle shall always be turned off before the driver exits the vehicle.

AIDRM VSP 01-2018

ARKANSAS STATE VEHICLE SAFETY PROGRAM (January 2018) VSP-1 AUTHORIZATION TO OPERATE

STATE VEHICLES AND PRIVATE VEHICLES ON STATE BUSINESS

The following must be completed and signed before authorization to drive on state business is granted:

AGENCY CODE: 016501 AGENCY: UNIVERSITY OF CENTRAL ARKANSAS EMPLOYEE/DRIVER: _____________________________________________ DATE OF BIRTH: ______/________/________ DRIVER’S LICENSE NUMBER: ________________________________ DRIVERS’S LICENSE STATE: __________________________________ CONTACT PHONE NUMBER: _________________________________ CONTACT EMAIL: __________________________________________ INITIAL EACH OF THE FOLLOWING: ______ I understand that as permitted by Arkansas Code Ann. 27-50-906 (6) (A), the Office of Driver Services will notify

my employer each time a new violation is added to my driving record. I also understand that my employer has access to my driving record through the SVS System (State of Arkansas Website) through Information Network of Arkansas.

______ I understand that because of my driving record I may not be permitted to drive on State business. ______ I will participate in all required Defensive Driving Classes. ______ I will report all accidents and incidents that occur on state business to my employer immediately and to

BancorpSouth at 501-664-9252 (see Section III A). ______ I have read the Driving Safety Tips provided by my employer. ______ I understand that I must maintain liability coverage, as required by State Law, on my private vehicle(s)

that I drive on State business.

______ I pledge to end distracted driving, including but not limited to, use of any communication device while driving. You are hereby authorized to obtain my Traffic Violation Record from the Office of Driver Services as permitted by A.C.A. 27-50-906 and A.C.A. 27-50-908. This record shall include material normally excluded by A.C.A. 27-50-802. Signature of individual appearing below shall constitute consent for the release of such records to the State agency named on this form.

Employee/Driver Signature Date

ARKANSAS STATE VEHICLE SAFETY PROGRAM January 2018

AIDRM VSP 01-2018

FOR NON-RESIDENT DRIVERS ONLY

VSP-2

AUTHORIZATION TO OBTAIN TRAFFIC VIOLATION RECORD FROM DEPARTMENT OF FINANCE AND ADMININSTRATION,

OFFICE OF DRIVER SERVICES Fax completed form to: (501) 682-2075

Agency Code/Name: 016501 - University of Central Arkansas Agency Address: 201 Donaghey Ave., Conway, AR 72035 Agency Contact Person: Phyllis Campbell Email Address: [email protected] Telephone Number: 501-852-2816 You are hereby authorized to obtain my Traffic Violation Record from the Office of Driver Services as permitted by A.C.A. § 27-50-906 and A.C.A. § 27-50-908. This record shall include material normally excluded by A.C.A. § 27-50-802. Signature of individual appearing below shall constitute consent for the release of such records to the State agency named on this form. Driver Signature Date Driver Personnel # (Print) Last Name First Name Middle Initial Drivers License # State Date of Birth

HR Revised 10/19/2011, 4/18/12

UCA Direct Deposit Policy Effective 3/1/10, Revised 10/19/11, 4/18/12

For those employees not on Direct Deposit or using the Pay Card, beginning with the March 31, 2010, pay day Human Resources (HR) will no longer disburse pay checks to the hiring department. Instead, HR will mail the employee’s check to the current mailing address (MA) that is listed in the employee’s MyUCA account. This is a self-service account maintained by the employee. Please check your MyUCA account to ensure your correct address is listed.

In accordance with Arkansas Code 21-5-109, as a condition of employment, a person hired or appointed to a position in any agency in state government on or after August 12, 2005 shall be required to accept payment of salary or wages by electronic warrants transfer. In order to provide UCA employees with the most efficient and reliable way to obtain their wages UCA has chosen to implement this state policy requiring direct deposit as a condition of employment for employees hired on or after March 1, 2010.

• All full-time employees hired on or after March 1, 2010, will be required to complete a direct deposit authorization during the orientation process.

• All part-time employees, graduate assistants and student employees hired on or after March 1, 2010, will be required to complete direct deposit authorization when their initial hiring packet is completed.

• Employees may direct the payroll deposit into as many as three (3) bank accounts by designating either flat dollar amounts or percentages, as long as they total 100% of the net payroll amount.

• A copy of the direct deposit form may be printed from the Human Resources website,

Notice: Only personal checking and/or savings accounts will be accepted. Requests to deposit to Business accounts will not be processed.

www.uca.edu/hr by selecting the Internal Forms link, then look under Payroll – General Payroll Forms for the direct deposit form.

• If the employee does not have a bank account UCA offers a bank-issued payroll card. The Payroll Card packet may be printed from the the Human Resources website, www.uca.edu/hr by selecting the Internal Forms link, then look under Payroll – General Payroll Forms for the Payroll Card packet. (See footnote below)

The setting up of either the direct deposit or the bank-issued payroll card requires UCA to pre-note the information to the employee’s bank. A check will be issued to you while your account is in the pre-note status and mailed to the current mailing address listed on your MyUCA account. Note: Employees that sign up for the bank-issued payroll card must complete pages 1-3 and submit

them, along with a copy of an acceptable photo ID (see list on enrollment form), to Human Resources. The remaining packet contains information provided by the bank that you are required to read and retain.

Please check status: Full-time Faculty ___ Full-time Staff ___ Grad Assist ___

Part-time Faculty ___ Part-time Staff ___ Student ___

Employee Name SSN or Employee ID

Work Phone Home/Cell Phone Department

ADDRESS** first payroll check to be mailed: ____________________________________________________________________________

New enrollment or Bank Change in Current Bank and/or Account Cancel Direct Deposit Participation

**Requires pre-note to bank May require move to Pay Card

I hereby authorize and request UCA to have my net Payroll and AP/Travel reimbursement directly deposited to the designated checking and/or savings account as indicated. I also authorize UCA to initiate any correction (debit) entries to my account, should such entries be necessary. The Financial Institution(s) named below is (are) also authorized to make the same entries to my account(s). This authority is toremain in full force and effective until UCA has received written notification from me of its cancellation. I may give such notice at any time, but I must allow UCA a reasonable time after receipt to act upon it. I understand that UCA is not responsible for the accuracy of the bank information I have provided and inaccurate information will delay the implementation of my direct deposit.

Notice: Only personal checking and/or savings accounts will be accepted. Requests to deposit to Business accounts will not be processed.

Please read this section and completely fill out the required information. If you are making a change, you must complete all account(s) information in order of priority.

Banking Priority - Your net pay for Payroll can be distributed to up to (3) three different accounts even if they are with different banks. Your pay will be distributed to each accountaccording to the order you have listed them below. AP/Travel reimbursement can only be deposited into one account. Example:Priority 1 = $10.00 to one savings account, priority 2 = $100.00 to a checking account, priority 3 would be the remainder of your check to either a checking or savings account.

You must attach a voided check or Bank validated letter/ACH form for each account listed to validate the account information.

Banking C=Checking Write in dollar amount or Write in % amt Payroll A/P Travel

Priority S=Savings per pay period per pay period (P) Check One

1

2

3

**** The total amount of your payroll direct deposit must equal 100% of your net pay. *****

Employee Signature Date

Changes made to account information must be received by the Payroll Office 10 working days prior to your regularly scheduled payday to be effective.

** Set up of new accounts or changes to existing accounts will require the University to Pre-Note the information to the employee's bank.

A check will be issued to the employee while their account is in pre-note status.

Bank Name Bank Routing Number Account Number

UNIVERSITY OF CENTRAL ARKANSAS

Payroll /Account Payable/Travel Direct Deposit Authorization Form

HR revised 03/9/2017

Administrative Policies

Series: 500 Policy Number: 511 Policy Name: Sexual Harassment

Adoption Date: 8/89 Revision Date: 2/98, 5/99 Policy Text:

The University of Central Arkansas Sexual Harassment Policy is as follows:

Sexual harassment by any faculty member, staff member, or student is a violation of both law

and university policy and will not be tolerated at the University of Central Arkansas. Sexual

harassment of employees is prohibited under Section 703 of Title VII of the Civil Rights Act of

1964 and sexual harassment of students may constitute discrimination under Title IX of the

Education Amendments of 1972.

The university considers sexual harassment a very serious issue and shall subject the offender to

dismissal or other sanctions following the university's investigation and substantiation of the

complaint and compliance with due process requirements.

Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors or other

verbal or physical conduct of a sexual nature when:

1. submission to such conduct is either explicitly or implicitly made a condition of an individual's

employment with the university or a factor in the educational program of a student;

2. submission to or rejection of such conduct by an individual is used as the basis for an

employment or academic decision affecting such individual;

3. such conduct has the purpose or effect of unreasonably interfering with an individual's right to

achieve an educational objective or to work in an environment free of intimidation, hostility or

threats stemming from acts or language of a sexual nature.

NOTE: Other forms of harassment based upon race, religion, national origin, sex, or age may

have the same impact as sexual harassment. In the absence of other policies addressing these

specific issues, the university encourages the use of the steps and procedures in this policy in

reporting other types of harassment and will generally conduct investigations of those complaints

in the same manner.

Although sexual harassment most frequently occurs when there is an authority differential

between the persons involved (e.g. faculty member and student, supervisor and staff member), it

may also occur between persons of the same status (e.g. faculty and faculty, student and

student, staff and staff). Both men and women may be victims of sexual harassment and sexual

harassment may occur between individuals of the same gender.

Because of the unique situations which exist between students, faculty, supervisors, and staff,

relationships in the workplace and on campus should at all times remain professional. In

particular, due to the professional power differential between faculty and students, faculty are

encouraged to remain professional in all relationships with students.

Sexual harassment may create a hostile, abusive, demeaning, offensive or intimidating

environment. It may be manifested by verbal and/or physical actions, including gestures and

other symbolic conduct. Sexual harassment is not always be obvious and overt; it can also be

subtle and covert. A person who consents to sexual advances may nevertheless be a victim of

sexual harassment if those sexual advances were unwelcome. Previously welcomed advances

may become unwelcome. Examples of sexual harassment may include, but are not limited to, the following:

non-sexual slurs about one's gender

contrived work or study assignments and assigning more onerous or unpleasant tasks

predominately to employees or students of one gender

repeated unwanted touching, patting or pinching

repeated inappropriate social invitations or requests for sexual favors

repeated unwanted discussions of sexual matters

use of sexual jokes, stories, analogies or images which are not related to the subject of

the class or work situation

touching, fondling or deliberate brushing against another person

ogling, leering or prolonged stares at another's body

display or use of sexual graffiti or sexually-explicit pictures or objects sexually suggestive jokes, comments, e-mails, or other written or oral communications

Individuals who are aware of or have experienced an incident of sexual harassment should

promptly report the matter to one of the university officials designated to receive these

complaints. No person shall be subject to restraints, interference or reprisal for action taken in

good faith to report or to seek advice in matters of sexual harassment.

In the course of a complaint investigation the university will attempt to maintain confidentiality

for all parties involved. However, there can be no guarantee of confidentiality and anonymity

based upon the course and scope of the complaint investigation.

A grievant whose complaint is found to be both false and to have been made with malicious intent

will be subject to disciplinary action which may include, but is not limited to, demotion, transfer,

suspension, expulsion or termination of employment.

PROCEDURES FOR SEXUAL HARASSMENT CLAIMS

Employees or students of the university who believe they have been subjected to sexual

harassment are encouraged to use the following procedures to resolve their complaint.

The university will make every effort to adhere to the prescribed time frames of the informal and

formal resolution processes. However, in the event that individuals involved are unavailable or of

other unanticipated occurrences, the Affirmative Action officer, with the concurrence of the

president, may adjust the time frames. Any changes will be immediately communicated to the

complainant and respondent by the Affirmative Action officer and where possible their needs will

be accommodated.

INFORMAL INVESTIGATION AND RESOLUTION

1. Individuals who believe they have been subjected to sexual harassment (complainant) should

report the incident promptly to their immediate supervisor or academic dean or to a departmental

supervisor higher up in the chain of command or directly to the Affirmative Action officer, legal

counsel or assistant vice president for human resources.

The person to whom the complaint is made shall immediately contact the Affirmative Action

officer, legal counsel or assistant vice president for human resources. One or more of these

administrators will determine the course of the informal investigation and resolution. The

department involved and/or the supervisor to whom the complaint was made may be asked to

assist in the informal investigation.

2. If, following investigation, an informal resolution of the matter which is satisfactory to the

complainant, the person against whom the complaint is made (respondent) and the university

(represented by the Affirmative Action officer, the legal counsel or assistant vice president for

human resources) is reached, it shall be considered closed and all parties involved shall be so

advised in writing by the Affirmative Action officer, legal counsel or assistant vice president for

human resources. If a satisfactory resolution has not been reached within ten (10) working days

from the date of the complaint, the complainant, university or respondent may initiate formal

complaint/investigation procedures.

FORMAL INVESTIGATION AND RESOLUTION

1. If the sexual harassment complaint has not been resolved through informal procedures and the

complainant, university or respondent wish to pursue the matter further, he/she must file a

written complaint. The written complaint must be filed with the Affirmative Action officer, legal

counsel or assistant vice president for human resources within twenty (20) working days of the

termination of the informal procedures. The complainant and respondent shall be entitled to have,

at the individual's own expense, an advisor, who may or may not be an attorney, to assist in

preparing the formal complaint.

2. The Affirmative Action officer will notify the parties involved of the sexual harassment

complaint, provide copies of the complaint and advise the parties of the procedures for a formal

investigation and hearing within three (3) working days of receipt of the formal written complaint.

The respondent will then be given five (5) working days to respond in writing to the complaint.

3. Within ten (10) working days of receipt of the formal written complaint the Affirmative Action

officer shall refer the complaint and the respondent's response, if any, to the Sexual Harassment

Complaint Committee.

4. Within five (5) working days of the Committee's receipt of the complaint, the Committee will

meet separately with the complainant and the respondent. The purpose of these preliminary

meetings is to inform the Committee about the case, to insure the complainant and respondent

are fully aware of their procedural rights and to decide upon the nature of the investigation.

Throughout the proceedings the respondent and complainant shall have the right to be

accompanied by an advisor, who may or may not be an attorney. Attorneys will not be provided

at university expense. The legal counsel may be present but shall act only in an advisory capacity

to the Committee.

5. Within five (5) working days of the conclusion of the Committee's preliminary meetings with

the complainant and respondent the Sexual Harassment Complaint Committee will hold a formal

meeting on the matter. Strict judicial rules of evidence shall not be applied. The committee

members may receive any evidence they consider to be relevant.

6. The respondent and complainant, and their advisors, shall have the right to be present at any

time testimony is presented and to be provided copies of all evidence considered by the

Committee. Neither the respondent nor complainant shall have the right to cross-examine

witnesses. Advisors shall not have the right to address or question committee members or

witnesses.

7. A written record of the minutes of the proceedings and recommendations of the Committee

shall be presented to the president within five (5) working days of the Committee's final meeting.

8. A copy of the minutes and recommendations of the Committee shall be presented to both the

complainant and the respondent at the time they are forwarded to the president.

9. Within ten (10) working days of receipt of the Committee's recommendation, the president

shall make a final decision concerning what action if any, to take including disciplinary action after

considering the recommendation of the Committee, and will notify the complainant and

respondent.

Sexual Harassment Complaint Committee:

1. Charge: To serve as the formal committee conducting investigations and making

recommendations according to the guidelines of the University of Central Arkansas Sexual

Harassment Policy.

2. Procedure: The operating procedures of the committee will be consistent with the formal

investigation and resolution process as described in the policy.

3. Membership: The Affirmative Action officer, who will serve as the non-voting chair, the director

of the counseling center as a voting member and six (6) voting members, randomly drawn from

appropriate categories from a twenty-four (24) person membership pool.

The Faculty Senate, the Staff Senate and the Student Government Association will each select

eight (8) members (four (4) male and four (4) female) for the membership pool. A new pool will

be established each September and new members will be selected throughout the year as

necessary to replace members who separate from the university or who are otherwise unable to

serve.

Upon receipt of a written complaint, the chair will arrange for the complainant and the respondent

to draw members for the committee from the corresponding pools. The complainant will first draw

one member, next the respondent will draw one member and the chair will draw two members

each from the appropriate categories.

For example, if the complainant is a student and the respondent is a tenure- track faculty

member, the complainant will draw one member from the student pool, the respondent will draw

one (1) member from the faculty pool and the chair will draw two (2) members from the student

pool and two (2) members from the faculty pool. If the complainant and respondent are both staff

members, each will draw (1) member from the staff pool and the chair will draw four members

from the staff pool.

4. Meetings: On call.

5. Reporting: To the president.

UNIVERSITY OF CENTRAL ARKANSAS DRUG-FREE WORKPLACE POLICY

Drug abuse and use in the workplace are subjects of immediate concern in our society. The problems created by drug abuse are extremely complex and ones for which there are no easy solutions. From a safety perspective, the users of drugs may impair the well-being of all employees, the public at large, and result in damage to state property. Therefore, it is the policy of the State of Arkansas that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance in a state agency’s workplace is prohibited. Any employees violating the policy will be subject to discipline up to and including termination. The specifics of this policy are as follows:

1. State agencies will not differentiate between drug users and drug pushers or sellers. Any employee who gives or in any way transfers controlled substances to another person or sells or manufactures a controlled substance while on the job or on agency premises will be subject to discipline up to and including termination.

2. The term “controlled substance” means any drug listed in 21 U.S.C. Section 812 and other federal regulations. Generally, these are drugs which have a high potential for abuse. Such drugs include, but are not limited to, Heroin, Marijuana, Cocaine, PCP, and “Crack”. They also include “legal drugs” which are not prescribed by a licensed physician.

3. Each employee is required by law to inform the agency within five (5) days after he or she is convicted of violation of any federal or state criminal drug statute where such violation occurred on the agency’s premises. A conviction means a finding of guilt (including a plea of nolo contendre) or the imposition of a sentence by a judge or jury in any federal court, state court or other court of competent jurisdiction.

4. The University of Central Arkansas is required to notify the Federal Funding Agency of the conviction of any employee for drug use or abuse who is employed in a position utilizing federal funds or a federal grant within ten (10) days of receiving notice of the conviction from the employee or otherwise receiving actual notice.

5. If an employee is convicted of violating any criminal drug statute while in the workplace, he or she will be subject to discipline up to and including termination. Alternatively, the agency may require the employee to successfully finish a drug program sponsored by an approved private or governmental institution.

6. Abiding by the Drug-Free Workplace Policy is considered a condition of employment for all state employees.

7. This policy is intended to comply with the rules published by the federal office of Management and Budget on January 31, 1989, in the Federal Register, implementing the Drug-Free Workplace Act of 1988 and the Governor’s Executive order 89-2 dated March 30, 1989.

UNIVERSITY OF CENTRAL ARKANSAS

SEXUAL HARASSMENT POLICY

ACKNOWLEDGEMENT:

I, _______________________________, an employee of the University of Central

Arkansas, confirm that I have received information concerning the University of Central

Arkansas policy regarding sexual harassment and other forms of harassment in the workplace. I

realize that sexual harassment or harassment of any kind is strictly prohibited. I also understand

that if I violate this policy, I can be subject to disciplinary actions, up to and including

termination of my employment.

_____________________________________ ________________________

Signature Date

DRUG-FREE WORKPLACE POLICY

ACKNOWLEDGMENT

I, ____________________________________________, an employee of the University of

Central Arkansas, hereby certify that I have received a copy of this agency’s policy regarding

the maintenance of a drug-free workplace. I realize that the unlawful manufacture, distribution,

dispensing, possession or use of a controlled substance is prohibited on this agency’s premises

and violation of this policy can subject me to discipline, up to and including termination. I also

realize that I may be required to successfully complete a drug rehabilitation program conducted

by an approved private or governmental institution. I realize that as a condition to employment

that utilizes federal funding or grants that I must abide by the terms of this policy, and will

notify my employer of any criminal drug conviction for a violation occurring in the workplace

no later than five (5) days after such conviction. I further realize that the Drug-Free Workplace

Act of 1988 mandates that my employer communicate this conviction to the federal funding

agency.

___________________________________________ ____________________

Signature Date

SOCIAL SECURITY CARD COPY

If your social security card information is not being provided as an I-9, List C, document, the

University of Central Arkansas requires a copy of your social security card for payroll purposes.

Please attach a copy to this set of completed documents.

By signing below, I acknowledge that I have read this information and will provide a copy of

my social security card as required.

___________________________________________ ____________________

Signature Date

University of Central Arkansas Supplemental Retirement Acknowledgment

As an employee of the University of Central Arkansas, I acknowledge that I am eligible to participate in employee only contributions to the Optional Retirement Program through a Supplemental Retirement Annuity (SRA) with TIAA or Valic either pretax or Roth (after-tax) or a combination of both. Pretax I understand that by participating in an SRA pretax, I can set aside tax-deferred (salary reduction) monies, to save for retirement. I pay no taxes on my contributions and no taxes on earnings until it is received as income. Roth – after tax You are also eligible to participate in employee only contributions to a Roth after tax Supplemental Retirement (SRA). With the Roth option, your contributions are deducted after your gross income is taxed. Income received upon retirement will be tax-free. I also understand that if I wish to participate in an SRA, I must complete all necessary paperwork. For more information, please contact the office of Human Resources at 501-450-3181.

______________________________________________ ____________________

Signature Date

Disclaimer – TIAA and Valic rules and regulations supersede this document.

STATEMENT OF SELECTIVE SERVICE STATUS

IN COMPLIANCE WITH ACT 228 OF THE 1997 ACTS OF THE

ARKANSAS GENERAL ASSEMBLY

I understand that to be eligible for employment with the State of Arkansas

or eligible for admission to an institution of higher education, I must

register, or be exempt from registration, with the Selective Service System

in accordance with the Military Selective Service Act, 50 U.S.C. Appx §

451 et seq., as specified in Act 228 of the 1997 Acts of the Arkansas

General Assembly. I therefore swear or affirm under penalty of perjury

that I have registered with the Selective Service System, or I am exempted

from such registration because of the following provision(s) of the Military

Selective Service Act or Act 228 of the 1997 Acts of the Arkansas General

Assembly:

I am female,

I am a current member of the armed forces on active duty,

I am under 18 years of age,

I am 26 years of age or over,

I am an exempted resident alien,

Other (specify below).

____________________________________________________________

_______________________________

Name (Please Print)

_________________________________ _____________________

Signature Date

Updated 10/09, HR

STUDENT RIGHT TO KNOW INFORMATION

The federal government requires that certain information be provided to incoming and current University students, prospective students, parents, and current and prospective employees of the University. This information, which comes under the Student Right To Know Act, can be found on UCA’s website. Individuals can go to the UCA website www.uca.edu. Students can access the website information from their personal computer or from any computer lab on campus. Requests can be made to the University department responsible for the information, or to the Dean of Students Office located in Student Health Center, Room 210. Student information available on the UCA website includes:

Family Education Rights and Privacy Act- includes information about students’ educational records, students’ rights to inspect and review records, and procedures for challenging students’ records.

Available Financial Assistance and Direct Loan Deferments for Performed Services- includes information about University, federal and private financial assistance programs; how to make application for aid; eligibility requirements; rights and responsibilities of students who receive aid; and terms for repayment. Also includes information about terms and conditions of deferments for service in the Peace Corps, Domestic Volunteer Service Act, and comparable volunteer service programs.

General Institutional Information- includes information about general registration and other fees, room and board fees, withdrawal and refund policy, requirements for return of Title IV grants or loans, academic programs, academic planning and assessment, University accreditation, disability support services, student handbook, campus directory, international and study abroad programs, and voter registration.

Graduation Rate Information- includes information about four, five, and six year graduation rates at UCA; and how UCA compares with other Arkansas 4-year public institution averages.

Campus Security Report- includes statistics for the previous three years concerning reported crimes that occurred on campus; in certain off-campus buildings or property owned or controlled by the University of Central Arkansas; and on public property within, or immediately adjacent to and accessible from, the campus. The report also includes institutional policies concerning campus security, such as policies concerning alcohol and drug use, crime prevention, the reporting of crimes, sexual assault, and other matters. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act require that institutions of higher education publicly disclose an annual security report. This information is published annually by the University of Central Arkansas and is available in the UCA student Handbook, in the publication “Safety, Security, & Health” available at the offices of the UCA Police Department and the Office of Human Resources, or by accessing the Police Department website at www.ucapd.com. This information is also available upon request by contacting the UCA Police Department at (501) 450-3111.

Athletic Program Participation Rates & Financial Support Data- includes information about varsity teams that compete in intercollegiate athletics, and number of participants for each team; institutional revenues and expenses associated with University athletics; and graduation rates of UCA athletes (by selected sports).

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Notice 1392(Rev. November 2013)

Department of the TreasuryInternal Revenue Service

Supplemental Form W-4 Instructions for Nonresident Aliens

Nonresident aliens must follow special instructions when completing Form W-4, Employee's Withholding Allowance Certificate, for compensation paid to such individuals as employees performing dependent personal services in the United States. Compensation for dependent personal services includes amounts paid as wages, salaries, fees, bonuses, commissions, compensatory scholarships, fellowship income, and similar designations for amounts paid to an employee.

Note. Form W-4, and the other IRS forms and publications referenced in this notice, are available at www.irs.gov/formspubs or by calling 1-800-829-3676.

Are you a nonresident alien? If so, these special instructions apply to you. Resident aliens should follow the instructions on Form W-4.

If you are an alien individual (that is, an individual who is not a U.S. citizen), specific rules apply to determine if you are a resident alien or a nonresident alien for federal income tax purposes. Generally, you are a resident alien if you meet either the “green card test,” or the “substantial presence test,” for the calendar year. Any alien individual not meeting either test is generally a nonresident alien. Additionally, a dual-resident alien who applies the so-called “tie-breaker” rules contained within the Resident (or Residence or Fiscal Residence) article of an applicable U.S. income tax treaty in favor of the other Contracting State is treated as a nonresident alien. See Publication 519, U.S. Tax Guide for Aliens, for more information on the green card test and the substantial presence test.

What compensation is subject to withholding and requires a Form W-4?

Compensation paid to a nonresident alien for performing personal services as an employee in the United States is subject to graduated withholding. Compensation for personal services also includes amounts paid as a scholarship or fellowship grant to the extent it represents payment for past, present, or future services performed as an employee in the United States. Nonresident aliens must complete Form W-4 using the modified instructions provided later, so that employers can withhold the correct amount of federal income tax from compensation paid for personal services performed in the United States. This Notice modifies the instructions on Form W-4 to take into account the restrictions on a nonresident alien's filing status, the limited number of personal exemptions allowed, and the restriction on claiming the standard deduction.

Are there any exceptions to this withholding?

Yes. Nonresident aliens may be exempt from wage withholding on the following amounts.

Compensation paid to employees of foreign employers if such pay is not more than $3,000 and the employee is temporarily present in the United States for not more than a total of 90 days during the tax year.Compensation paid to regular crew members of a foreign vessel.Compensation paid to residents of Canada or Mexico engaged in transportation-related employment.Certain compensation paid to residents of American Samoa, Puerto Rico, or the U.S. Virgin Islands.Compensation paid to foreign agricultural workers temporarily admitted into the United States on H-2A visas.

See Publication 519 to see if you qualify for one of these exemptions.

Nonresident aliens may be exempt from wage withholding on part or all of their compensation for dependent personal services under an income tax treaty. If you are claiming a tax treaty withholding exemption, do not complete Form W-4. Instead, complete Form 8233, Exemption from Withholding on Compensation for Independent (and Certain Dependent) Personal Services of a Nonresident Alien Individual, and give it to each withholding agent from whom amounts will be received. Even if you submit Form 8233, the withholding agent may have to withhold tax from your income because the factors on which the treaty exemption is based may not be determinable until after the close of the tax year. In this case, you must file Form 1040NR, U.S. Nonresident Alien Income Tax Return, (or Form 1040NR-EZ, U.S. Income Tax Return for Certain Nonresident Aliens With No Dependents, if you qualify), to recover any overwithheld tax and to provide the IRS with proof that you are entitled to the treaty exemption. See Form 8233 and the Instructions for Form 8233, Publication 901, U.S. Tax Treaties, and Publication 519 for more information on treaty benefits.

Am I required to file a U.S. tax return even if I am a nonresident alien?

Yes. Nonresident aliens who perform personal services in the United States are considered to be engaged in a trade or business in the United States and generally are required to file Form 1040NR (or Form 1040NR-EZ). However, if your only U.S. trade or business was the performance of personal services and the amount of compensation is less than the

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personal exemption amount for the year (listed in Publication 519), then you may not need to file Form 1040NR (or Form 1040NR-EZ). Also, you do need to file Form 1040NR (or Form 1040NR-EZ) to claim a refund of any overwithheld taxes. See the Instructions for Form 1040NR, or the Instructions for Form 1040NR-EZ, for more information.

Nonresident aliens who are bona fide residents of U.S. possessions should consult Publication 570, Tax Guide for Individuals With Income From U.S. Possessions, for information on whether compensation is subject to wage withholding in the United States.

Will my withholding amounts be different from withholding for my U.S. co-workers?

Yes. Nonresident aliens cannot claim the standard deduction. The benefits of the standard deduction are included in the existing wage withholding tables published in Publication 15 (Circular E), Employer's Tax Guide.

Because nonresident aliens do not qualify for the standard deduction, employers are instructed to withhold an additional amount from a nonresident alien's wages. For the specific amounts to be added to wages before application of the wage tables, see Publication 15.

Note. A special rule applies to students and business apprentices from India who are eligible for the benefits of Article 21(2) of the United States-India income tax treaty, because such individuals may be entitled to claim an additional withholding allowance for the standard deduction. See Publication 519 for more information.

What are the special Form W-4 instructions?Nonresident aliens should pay particular attention to the following lines when completing Form W-4.

Line 2. You are required to enter a social security number (SSN) on line 2 of Form W-4. If you do not have an SSN, you must apply for one on Form SS-5, Application for a Social Security Card.

You can get Form SS-5 at http://www.ssa.gov/ssnumber/ss5.htm or from any Social Security Administration (SSA) office.

Note. You cannot enter an individual taxpayer identification number (ITIN) on line 2 of Form W-4.

Line 3. Check the single box regardless of your actual marital status.

Line 5. Generally, you should claim one withholding allowance. However, if you are a resident of Canada, Mexico, or South Korea, a student or business apprentice from India, or a U.S. national, you may be able to claim additional withholding allowances for your spouse and children. See Publication 519 for more information.

If you are completing Form W-4 for more than one withholding agent (for example, you have more than one employer), figure the total number of allowances you are entitled to claim and claim no more than that amount on all Forms W-4 combined. 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.

Line 6. Write “nonresident alien” or “NRA” on the dotted line. If you would like to have an additional amount withheld, enter the amount on line 6.

Line 7. Do not claim that you are exempt from withholding on line 7 of Form W-4 (even if you meet both of the conditions listed on that line).

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(a) Your spouse for whom you have been claiming an exemption is divorced or legally separated from you, or claims his or her own exemption on a separate certificate, or (b) The support you provide to a dependent for whom you claimed an exemption is expected to be less than half of the total support for the year. OTHER DECREASES in exemptions or dependents, such as the death of a spouse or a dependent, does not affect your withholding until next year, but requires the filing of a new certificate by December 1 of the year in which they occur.

You may claim additional amounts of withholding tax if desired. This will apply most often when you have income other than wages.

You qualify for the low income tax rates if your total income from all sources is:

(a) Single $11,737 to $15,200(b) Married Filing Jointly $19,794 to $24,300 (1 or less dependents) (c) Married Filing Jointly $23,822 to $30,500 (2 or more dependents)(d) Head of Household/Qualifying Widow(er) $16,687 to $21,400 (1 or less dependents) (e) Head of Household/Qualifying Widow(er) $19,892 to $24,300 (2 or more dependents)

STATE OF ARKANSASEmployee’s Withholding Exemption Certificate

AR4EC

Arkansas Withholding Tax Section

P. O. Box 8055 Little Rock, Arkansas 72203-8055

Print Full Name ________________________________________________ Social Security Number ____________________________________

Print Home Address _____________________________________________ City _____________________________State _____ Zip _________

Employee:File this form with your employer. Otherwise, your employer must withhold state income tax from your wages without exemptions or dependents.

Employer:Keep this certificate with your records.

How to Claim Your WithholdingSee instructions below

1. CHECK ONE OF THE FOLLOWING FOR EXEMPTIONS CLAIMED

a. You claim yourself. (Enter one exemption) ......................................................................1a

b. You claim yourself and your spouse. (Enter two exemptions) .........................................1b

c. Head of Household, and you claim yourself. (Enter two exemptions) .............................1c

2. NUMBER OF CHILDREN or DEPENDENTS. (Enter one exemption per dependent) ................. 2

3. TOTAL EXEMPTIONS. (Add Lines 1a, b, c, and 2) If no exemptions or dependents are claimed, enter zero .............................................................. 3

4. Additional amount, if any, you want deducted from each paycheck. (Enter dollar amount) ......... 4

5. I qualify for the low income tax rates. (See below for details) ....................................................... 5 Please check filing status: Single Married Filing Jointly Head of Household

I certify that the number of exemptions and dependents claimed on this certificate does not exceed the number to which I am entitled.

Signature: ______________________________________________________________________________________Date: _________________

For additional information consult your employer or write to:

Number of Exemptions Claimed

Yes No

TYPES OF INCOME - This form can be used for withholding on all types of income, including pensions and annuities.

NUMBER OF EXEMPTIONS – (Husband and/or Wife) Do not claim more than the correct number of exemptions. However, if you expect to owe more income tax for the year, you may increase your withholding by claiming a smaller number of exemptions and/or dependents, or you may enter into an agreement with your employer to have additional amounts withheld. This is especially important if you have more than one employer, or if both husband and wife are employed.

DEPENDENTS – To qualify as your dependent (line 2 of form), a person must (a) receive more than 1/2 of their support from you for the year, (b) not be claimed as a dependent by such person’s spouse, (c) be a citizen or resident of the United States, and (d) have your home as their principal residence and be a member of your household for the entire year or be related to you as follows: son, daughter, grandchild, stepson, stepdaughter, son-in-law or daughter-in-law; your father, mother, grandparent, stepfather, stepmother, father-in-law or mother-in-law; your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law or sister-in-law; your uncle, aunt, nephew or niece (but only if related by blood).

CHANGES IN EXEMPTIONS OR DEPENDENTS – You may file a new certificate at any time if the number of exemptions or dependents INCREASES. You must file a new certificate within 10 days if the number of exemptions or dependents previously claimed by you DECREASES for any of the following reasons:

Instructions

AR4EC (R 12/20/16)