i9 – Fellow Travelers

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Date Address business

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

►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.)

Name *

First

Middle

Last

Other Last Names Used (if any)

Address

Address Line 1

Address Line 2

City

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 the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States
2. A noncitizen national of the United States (See Instructions.)
3. A lawful permanent resident (Enter USCIS or A-Number.)
4. A authorized to work

until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

Form I-94 Admission Number

Foreign Passport Number and Country of Issuance

Signature

Clear Signature

Today's Date (mm/dd/yyyy)

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instruction.

List A

List B

List C

Document Title 1

A. Document Title 1

B.Document Title 1

C. Document Title 1

Issuing Authority

A. Issuing Authority

B. Issuing Authority

C. Issuing Authority

Document Number (if any)

A.Document Number (if any)

B. Document Number (if any)

C. Document Number (if any)

Expiration Date (if any)

A. Expiration Date (if any)

B. Expiration Date (if any)

C.Expiration Date (if any)

Document Title 2 (if any)

A. Document Title 2 (if any)

Additional Information

Check here if you used an alternative procedure authorized by DHS to examine documents

Issuing Authority

A. Issuing Authority

Document Number (if any)

A. Document Number (if any)

Expiration Date (if any)

A. Expiration Date (if any)

Document Title 3 (if any)

A.Document Title 3 (if any)

Issuing Authority

A.Issuing Authority

Document Number (if any)

A. Document Number (if any)

Expiration Date (if any)

A.Expiration Date (if any)

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears 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.

First Day of Employment (mm/dd/yyyy):

Last Name, First Name and Title of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Clear Signature

Today's Date (mm/dd/yyyy)

Employer's Business or Organization Name

Employer's Business or Organization Address

Address Line 1

Address Line 2

City

State

Zip Code

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

LISTS OF ACCEPTABLE DOCUMENTS

Supplement A,
Preparer and/or Translator Certification for Section 1

Department of Homeland Security

U.S. Citizenship and Immigration Services.

Name from Section 1.

First

Middle

Last

Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9.

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

Clear Signature

Name

First

Middle

Last

Date (mm/dd/yyyy)

Address

Address Line 1

Address Line 2

City

State

Zip Code

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

Clear Signature

Name

First

Middle

Last

Date (mm/dd/yyyy)

Address

Address Line 1

Address Line 2

City

State

Zip Code

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

Clear Signature

Name

First

Middle

Last

Date (mm/dd/yyyy)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Supplement B,
Reverification and Rehire (formerly Section 3)

Department of Homeland Security

U.S. Citizenship and Immigration Services

Name from Section 1.

First

Last

Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274)

Date of Rehire (if applicable)

New Name (if applicable)

First

Middle

Last

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title

Document Number (if any)

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

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Clear Signature

Additional Information (Initial and date each notation.)

Today's Date (mm/dd/yyyy)

Check here if you used an alternative procedure authorized by DHS to examine documents

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Date of Rehire (if applicable)

New Name (if applicable)

First

Middle

Last

Document Title

Document Number (if any)

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

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Clear Signature

Additional Information (Initial and date each notation.)

Today's Date (mm/dd/yyyy)

Check here if you used an alternative procedure authorized by DHS to examine documents

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Date of Rehire (if applicable)

New Name (if applicable)

First

Middle

Last

Document Title

Document Number (if any)

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

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Clear Signature

File Upload

Drag & Drop Files, Choose Files to Upload

File Upload

Drag & Drop Files, Choose Files to Upload

Additional Information (Initial and date each notation.)

Today's Date (mm/dd/yyyy)

Check here if you used an alternative procedure authorized by DHS to examine documents

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

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.)

List A

List B

List C

Document Title 1

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 2 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 3 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any)

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

LISTS OF ACCEPTABLE DOCUMENTS

Supplement A, Preparer and/or Translator Certification for Section 1

Department of Homeland Security

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.

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.

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.

Supplement B, Reverification and Rehire (formerly Section 3)

Department of Homeland Security

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Supplement A,
Preparer and/or Translator Certification for Section 1

Supplement B,
Reverification and Rehire (formerly Section 3)