(a)carostaff.com/wp-content/uploads/Application.pdf · Solutions, Inc (CSSI). This is a binding...

CAROLINAS STAFFING SOLUTIONS, INC. Policies and Procedures

The Policies and Procedures outlined below describe what is expected of temporary employees placed by Carolinas Staffing Solutions, Inc (CSSI). This is a binding contract between Carolinas Staffing Solutions, Inc. and You (Employee). Please initial each line after you have read and completely understand each statement.

I understand that failure to complete a job assignment without reasonable cause will go against company policy and result in separation of employment. This includes but is not limited to the following: quitting a position without giving a 48 hour notice to CSSI, no show, no call, disorderly or improper conduct while on the job causing reason for dismissal.

APPLICATION In filing this application with CSSI, I hereby certify that the information set forth on my application is true and complete. I understand that if I am employed, any false information and/or omission on this application will be grounds for termination.

AVAILABILITY I understand I must be telephone accessible, and have reliable transportation and I must call office twice weekly to update my availability.

JOB ASSIGNMENTS All job assignments are considered temporary. However, as discussed below, some maybe offered as a “temporary-to-permanent” position. When I accept a job assignment, it is with the understanding that I will be completing it. When an emergency or illness arises whereby I cannot meet my assigned work schedule, I must provide a doctor’s excuse for my absence and must call CSSI (either the office number or emergency number) and the supervisor at my assigned work place. Failure to do so may be grounds for immediate termination and/or an indication of quitting. When an accepted assignment is not completed without prior approval from CSSI, my employment record will reflect that I have voluntarily quit. When an assignment ends, I understand I must call my CSSI office for my next assignment or to be placed on the availability list. Failure to do so or failure to accept my next job assignment will indicate that I voluntarily terminated my employment status with CSSI and, therefore; I will not be eligible for unemployment benefits. I understand that both poor performance and poor attendance will also prevent my eligibility for unemployment benefits.

TEMP-TO-PERMANENT POSITIONS Some assignments maybe offered as “temporary-to-permanent” position. When accepting a “temporary-to-permanent” position, I understand I am still an employee of CSSI until the contract hours requirements are met. I must work a minimum of 480/520 hours (depending upon Employer) with one Employer before being released by CSSI and placed on Employer’s payroll. If the assignment ends prior to contract hours requirements being met and the Employer contacts me to return to work, I understand I must contact CSSI immediately and complete my contract hours as a CSSI employee. I do hereby agree not to work for any Client or anyone associated with the Company that Carolinas Staffing Solutions, Inc. has referred me to without first notifying CSSI and that I or the Company will be charged a fair and equitable fee.

TIME The workweek is from Monday through Sunday. Timesheets maybe dropped off, faxed, or emailed by the Employer. All timesheets must be in by 5:00PM on Monday following the week worked. I understand it is my responsibility to assure timecard(s) is signed by authorized supervisor and sent to CSSI. I understand that CSSI will not recognize or pay for any hours worked by me without a timecard signed by the Employer. I understand that if my time is not received by noon Monday, I will not be paid, and time will be added to following week, however; no overtime is accrued.

PAYDAY Pay day is on Friday, following the calendar work week. Upon hire, I acknowledge that I must complete and provide both direct deposit forms given to me in my new hire paperwork, along with a form from my bank or voided check in order to be paid on time. There is no option to stop payment.

STATEWIDE CRIMINAL BACKGROUND CHECK I understand a state/national criminal background check will be performed prior to me being sent to a job when required by the prospective Employer. All fees associated with the background check will be deducted from my first pay. The fees associated with testing are NC $25.00 and SC is $35.00. Criminal background checks will not keep me from being placed through CSSI; however, certain positions may not be available depending upon my record. A copy of the criminal background check is available upon request. These Rates are subject to change depending on state.

DRUG AND ALCOHOL TESTING I understand I may be required to undergo drug/alcohol testing to comply with either a potential Employer’s or Workers Compensation requirements. I understand the results may be disclosed with

the potential Employer and included in my personnel folder. For NC staff, all fees associated with a drug screen will be paid for by CSSI unless I request a retest or fail the required drug testing for Worker’s Compensation Claims. For SC staff all fees associates with the drug screen will be deducted from my pay, 5 Panel $10.00 or 10 Panel $20.00. These rates are subject to change depending on lab fees associated with testing.

EMPLOYMENT VERIFICATION I understand CSSI may verify information provided about previous Employers including reasons for termination.

ALCOHOL AND DRUGS CSSI has a very strict SUBSTANCE ABUSE POLICY and by signing this form I consent to submit to random drug testing. Use of alcohol and drugs while on a job site are prohibited at all times. I understand that failure to comply with this agreement will be grounds for my immediate termination.

SAFETY I understand as an employee of CSSI I must wear all required safety equipment and follow all safety procedures on the job site, at all times & no climbing over 6 feet. I understand working on any job site, except for clerical/restaurant positions, I am required to wear steel toe /leather boots.

ACCIDENT/WC PROCEDURES I understand if I have an accident while on the job assignment, it must be immediately reported to my onsite supervisor and then to CSSI’s Shallotte/Whiteville office before I leave the job site. I understand at that time, I will be sent to a designated medical facility. If the designated facility is closed or my injury is so serious the designated facility cannot treat me, I understand I must inform CSSI before proceeding to a hospital. I understand I must undergo a drug test prior to treatment. I understand I will be responsible for the medical bill if the designated medical facility or hospital does not contact our office prior to treatment for submittal of drug testing and treatment.

DEDUCTIONS I agree to allow CSSI to deduct from my pay, any amount owed for items supplied to me by the client I

was assigned to including but not limited to uniforms, badges, keys, safety equipment, cell phones etc… In addition

any cash that was collected and due to the client during my assignment that was unaccounted for will also result in a

payroll deduction. I agree that any amount that is owed at the time of my termination regardless if voluntary or not, will

be deducted from my last paycheck. I authorize CSSI to retain the entire amount of my last paycheck in compliance

with the law. I understand that deductions will be made after any mandatory taxes.

UPDATING RECORD I understand it is my responsibility to keep my address and tax information current. W-2’s are mailed to the last address on file.

CELL PHONES I understand cell phones are to be used only on breaks and lunch. I understand using my cell phone during working hours can lead up to and including termination.

CONFIDENTIALITY OF CLIENT INFORMATION I understand I agree to hold confidential all information to which I may have access of or about Clients of CSSI. I understand I will not divulge any information of documents regarding Clients to unauthorized persons or agencies. I understand that this is not time limited, and confidentiality will be protected without regard to my relationship with CSSI. I acknowledge that failure to adhere to this agreement may subject me to civil action for the collection of monetary damages.

ACKNOWLEDGEMENT: I have read and understand the foregoing Policies and Procedures and agree to act in accordance with them as a condition of my employment through Carolinas Staffing Solutions, Inc. (CSSI). I understand CSSI has established the foregoing policies, procedures, and working conditions to ensure fair and consistent treatment to all employees. I further understand acknowledgement of these Policies and Procedures is not a guarantee of employment through CSSI. _________________________________________ (CSSI REPRESENTATIVE) ________________________________________ __________________________________ (Applicant Signature) (Date)

POST-OFFER MEDICAL QUESTIONNAIRE Employee Name: ______________________________________

Social Security Number: ________________________ Date of Birth: _____/______/_____ Gender: ☐ Male ☐ Female Height: ____________ Weight: ____________

PERSONAL HEALTH HISTORY 1. Have you ever had or been treated for any of the following conditions or diseases?

Herniated Disc ☐ YES ☐ NO

Knee injury ☐ YES ☐ NO

Surgical removal of disc or spinal fusion ☐ YES ☐ NO

Back injury ☐ YES ☐ NO

Hernia or rupture ☐ YES ☐ NO

Diseased process of the spine ☐ YES ☐ NO

Neck injury, pain, or problems ☐ YES ☐ NO

Chest Pain ☐ YES ☐ NO

Shoulder injury ☐ YES ☐ NO

Arthritis or rheumatism ☐ YES ☐ NO

Arm/hand injury ☐ YES ☐ NO

Wrist problems ☐ YES ☐ NO (including Carpal Tunnel Syndrome)

Repetitive motion disorders ☐ YES ☐ NO

Broken bones ☐ YES ☐ NO

Ankylosis ☐ YES ☐ NO Immobility of any major, weight-bearing joints (ankles, knees, hips)

Tendonitis ☐ YES ☐ NO

Head injury ☐ YES ☐ NO

Amputations ☐ YES ☐ NO Epilepsy, fainting spells, or dizziness ☐ YES ☐ NO

Hip injury ☐ YES ☐ NO Foot injury ☐ YES ☐ NO

NOTICE TO OFFEREES: In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any required medical examination or follow up. GINA DISCLOSURE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. EMPLOYEE AFFIRMATION: I herewith affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows: (1) to determine whether I currently have the physical qualifications necessary to perform the essential functions of the job that has been offered; (2) to determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and (3) to determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job. The conditional job duties have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.

Describe any conditions checked “YES”: ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ________________________________________ ______________________________________

______________________________________ ______________________________________ ______________________________________ ________________________________________ ______________________________________ ________________________________________ ________________________________________

2. Have you had any prior surgeries or sought treatment from a healthcare provider for any of the above injuries and/or

medical conditions? ☐ YES ☐ NO

3. Are you capable of performing the essential duties of this job function? ☐ YES ☐ NO

4. Do you have any injury or condition that requires a reasonable accommodation in order for you to be able to perform the essential duties of this job position? ☐ YES ☐ NO

If yes, what accommodations do you need to perform the job? _______________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________ ___________________________________________________________________________________________________

5. How much weight can you lift comfortably unassisted? ☐ < 15 lbs ☐ 15-25 lbs ☐ 25-39 lbs ☐ ≥ 40 lbs

6. Has a healthcare provider placed any limitation on your ability to sit, stand, push, pull, or lift? ☐ YES ☐ NO

If yes, what are the limitations? _________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

7. Has a healthcare provider limited the amount of weight you can lift? ☐ YES ☐ NO

If yes, list the weight limitation and the date that your healthcare provider issued you the limitation: _________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

8. Are you taking any prescribed drugs that would interfere with your ability to safely perform your job? ☐ YES ☐ NO

If yes, list the medications: _____________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

9. Have you ever been hurt on the job or filed a Workers’ Compensation claim? ☐ YES ☐ NO

If yes: . Date(s): ____________________________________________________________________________________________ Treating physician(s): _________________________________________________________________________________ Body part(s): ________________________________________________________________________________________

My signature certifies that all facts and representations made by me are true, accurate and made willingly and intentionally.

____________________________________ _______________________________ _________________ Signature of Employee Printed Name Date

___________________________________________________________ _________________ Company Representative Date

Form W-42020

Employee’s Withholding Certificate

Department of the Treasury Internal Revenue Service

▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. ▶ Give Form W-4 to your employer.

▶ Your withholding is subject to review by the IRS.

OMB No. 1545-0074

Step 1: Enter Personal Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

(c) Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ▶

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:

Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 ▶ $

Multiply the number of other dependents by $500 . . . . ▶ $

Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $

Step 4 (optional):

Other Adjustments

(a)

Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $

(b)

Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $

Step 5:

Sign Here

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

▲

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

▲

Date

Employers Only

Employer’s name and address First date of employment

Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)

USCIS Form I-9

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

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

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

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

Date of Birth (mm/dd/yyyy)

- -

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

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

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

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

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

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

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

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

Employer Completes Next Page

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

USCIS Form I-9

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

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


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

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

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

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

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

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

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

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

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

4480 Main St Shallotte NC 28470

Carolinas Staffing Solutions, Inc.

Instructions. Use Form NC-4EZ if you:

• Plan to claim the N.C. Standard Deduction• Plan to claim the N.C. Child Deduction Amount (but no other N.C. deductions)• Do not plan to claim N.C. tax credits• Prefer not to complete the extended Form NC-4• Qualify to claim exempt status (See Lines 3 or 4 below)

Important. If you plan to claim N.C. itemized deductions or plan to claim other N.C. deductions (other than the N.C. Child Deduction Amount), you must complete Form NC-4. If you are a nonresident alien, you must complete Form NC-4 NRA. In general, a nonresident alien is an alien (not a U.S. citizen) who has not passed the green card test or the substantial presence test. (See Publication 519, U.S. Tax Guide for Aliens, for more information on the green card test and the substantial presence test.)

Employee’s Signature Date

I certify, under penalties provided by law, that I am entitled to the number of withholding allowances claimed on Line 1 above, or if claiming exemption from withholding, that I am entitled to claim the exempt status on Line 3 or 4, whichever applies.

5. I certify that I no longer meet the requirements for an exemption on Line 3 or Line 4 (Check applicable box)

Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax based on the number of allowances entered on Line 1 and any additional amount entered on Line 2.

Check Here

• This year, I expect a refund of all State income tax withheld because I expect to have no tax liability.

I certify that I am exempt from North Carolina withholding because I meet both of the following conditions:• Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and

3.Check Here

1. Total number of allowances you are claiming (Enter zero (0), or the number of allowances from the table above)

Additional amount, if any, you want withheld from each pay period (Enter whole dollars)2. .00

Check HereI certify that I am exempt from North Carolina withholding because I meet the requirements of theMilitary Spouses Residency Relief Act and I am legally domiciled in a state other than North Carolina.

4.(Enter state of

domicile)

If an exemption on Line 3 or Line 4 applies to you, enter the year the exemption became effective

Employee’s WithholdingNC-4EZ

# of Children under age 17

# of Allowances

Income

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 100 1 2 3 4 4 5 6 7 80 1 1 2 3 3 4 4 5 6

0 0 0 0 1 1 1 1 1 20 0 1 1 2 2 2 3 3 4

0 - 20,000 20,001 - 30,000 30,001 - 40,000

50,001 - 60,000 40,001 - 50,000

60,001 and over 0 0 0 0 0 0 0 0 0 0

# of Children under age 17

# of Allowances

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 100 1 2 3 4 4 5 6 7 80 1 1 2 3 3 4 4 5 6

0 0 0 0 1 1 1 1 1 20 0 1 1 2 2 2 3 3 4

0 - 40,000 40,001 - 60,000 60,001 - 80,000

100,001 - 120,000 80,001 - 100,000

120,001 and over 0 0 0 0 0 0 0 0 0 0

Single & Married Filing Separately Married Filing Jointly & Surviving Spouse Head of Household

Income # of Children under age 17

# of Allowances

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 100 1 2 3 4 4 5 6 7 80 1 1 2 3 3 4 4 5 6

0 0 0 0 1 1 1 1 1 20 0 1 1 2 2 2 3 3 4

0 - 30,000 30,001 - 45,000 45,001 - 60,000

75,001 - 90,000 60,001 - 75,000

90,001 and over 0 0 0 0 0 0 0 0 0 0

Income

Social Security Number

Last NameFirst Name M.I.

Address County

City Zip Code Country (If not U.S.)State

Filing Status (Mark one box only) Single or Married Filing Separately Head of Household Married Filing Jointly or Surviving Spouse

YYYY

to determine the number of allowances to enter on Line 1. For married taxpayers, only one spouse may claim the allowance for the N.C. Child Deduction Amount for each child.

Web10-17

North Carolina Employees Only

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

1 Your first name and middle initial Last name

Home address (number and street or rural route)


2 Your Social Security Number

3 Single Married Married, but withhold at higher Single rate.Note: If Married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name is different on your Social Security card, check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . . . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2020. Check the box for the exemption reason and write "exempt" on line 7.

For tax year 2019, I had a right to a refund of all South Carolina Income Tax withheld because I had no tax liability, and for tax year 2020 I expect a refund of all South Carolina Income Tax withheld because I expect to have no tax liability.I elect to use the same residence for tax purposes as my military servicemember spouse. I have provided my employer with a copy of my current military ID card and a copy of my spouse's latest Leave and Earning Statement. State of domicile: 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.Employee’s signature (required) ▶ Date ▶

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

STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE SC W-4

(Rev. 12/13/19) 3527

2020SOUTH CAROLINA EMPLOYEE'S

WITHHOLDING ALLOWANCE CERTIFICATE

1350

dor.sc.gov

SC W-4 Instructions Complete SC W-4 so that your employer can withhold the correct South Carolina Income Tax from your pay. If you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Determine the number of withholding allowances you should claim for withholding for 2020 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Consider completing a new SC W-4 each year and when your personal or financial situation changes to keep your withholding accurate and help you avoid surprises when you file your South Carolina Individual Income Tax return. For the latest information about South Carolina Withholding Tax and the SC W-4, visit dor.sc.gov/withholding. Exemptions. You may claim exemption from South Carolina withholding for 2020 for one of the following reasons: • For tax year 2019, you had a right to a refund of all South Carolina Income Tax withheld because you had no tax

liability, and for tax year 2020 you expect a refund of all South Carolina Income Tax withheld because you expect to have no tax liability.

• Under the Servicemembers Civil Relief Act, you are claiming the same residence for tax purposes as your military servicemember spouse. You are only in South Carolina, or a bordering state, to be with your military spouse who is serving in the state in compliance with military orders. Provide your employer with a copy of your current military ID card and a copy of your spouse's latest Leave and Earnings Statement (LES). The military ID card must have been issued within the last four years. The assignment location on the LES must be in South Carolina or a bordering state. Enter your spouse's state of domicile on the line provided.

If you’re exempt, complete only lines 1, 2, 3, 4, and 7. Check the box for the reason you are claiming an exemption and write "exempt" on line 7. Your exemption for 2020 expires February 17, 2021. If you are a military spouse and you no longer qualify for the exemption, you have 10 days to update your SC W-4 with your employer. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, you may want to add additional withholdings on Line 6 to ensure you are withholding enough. Each employer will require an SC W-4. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using SC 1040ES, Individual Declaration of Estimated Tax, or you can add additional withholding from this job's wages on Line 6. Otherwise, you may owe additional tax.

Employer: Complete boxes 8 and 10 if sending to the SCDOR and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.

South Carolina Employees Only

SC W-4 (2020) Page 3

Personal Allowances WorksheetA Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter “1” if you will file as married filing jointly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BC Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C

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

} D

E Federal child tax credit. • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each eligible child.• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for each eligible child.• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . . . . . . . . . . . . . E

F Federal credit for other dependents. • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent. • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” . . . . . . . . . . . . . . . . . . . F

G Add lines A through F and enter the total here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ G

For accuracy, complete all worksheets that apply. {• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you

have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.

• If the above situation does not apply, stop here and enter the number from line G on line 5 of SC W-4 on page 1.

Deductions, Adjustments, and Additional Income WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage

income not subject to withholding.

1

Enter an estimate of your 2020 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See IRS Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $24,400 if you’re married filing jointly or qualifying widow(er)$18,350 if you’re head of household$12,200 if you’re single or married filing separately

} . . . . . . . . . . . . . . . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2020 adjustments to income and any additional standard deduction for age or

blindness (see IRS Pub. 505 for information about these items) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2020 nonwage income not subject to withholding (such as dividends or interest) . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . . . . . . 7 $8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line G, above . . . . . . . . . . . . . . . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SC W-4 Worksheets KEEP FOR YOUR RECORDS

South Carolina Employees Only

1

Individual Characteristics Form (ICF) Work Opportunity Tax Credit

1. Control No. (For Agency use only)

APPLICANT INFORMATION (See instructions on reverse)

2. Date Received (For Agency Use only)

EMPLOYER INFORMATION

3. Employer Name 4. Employer Address and Telephone 5. Employer Federal ID Number (EIN)

APPLICANT INFORMATION

6. Applicant Name (Last, First, MI) 7. Social Security Number 8. Have you worked for this employerbefore? Yes ____ No ____

If YES, enter last date ofemployment: ____________

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION

9. Employment Start Date 10. Starting Wage 11. Position

12. Are you at least age 16, but under age 40? Yes ___ No ___

If YES, enter your date of birth _____________________

13. Are you a Veteran of the U.S. Armed Forces? Yes ___ No ___

If NO, go to Box 14.

If YES, are you a member of a family that received Supplemental Nutrition Assistance

Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months

before you were hired? Yes ___ No ___

If YES, enter name of primary recipient _______________________ and

city and state where benefits were received _________________.

OR, are you a veteran entitled to compensation for a service-connected disability? Yes ___ No ___

If YES, were you discharged or released from active duty within a year before you were hired? Yes ___ No ___

OR, were you unemployed for a combined period of at least 6 months (whether or not

consecutive) during the year before you were hired? Yes ___ No ___

14. Are you a member of a family that received Supplemental Nutrition Assistance Program

(SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes ___ No___

OR, received SNAP benefits for at least a 3-month period within the last 5 months

But you are no longer receiving them? Yes ___ No___

If YES to either question, enter name of primary recipient _____________________ and city

And state where benefits were received _____________________.

15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by

a State? Yes ___ No___

OR, by an Employment Network under the Ticket to Work Program? Yes ___ No___

OR, by the Department of Veterans Affairs? Yes ___ No___

16. Are you a member of a family that received TANF assistance for at least the last 18 months

U.S. Department Labor

Employment and Training Administration OMB Control No. 1205-0371

Expiration Date: January 31, 2020

Carolinas Staffing Solutions, Inc.4480 Main StShallotte, NC 28470910-754-5393

300220580

2

before you were hired? Yes___ No___

OR, are you a member of a family that received TANF benefits for any 18 months beginning

after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended

within 2 years before you were hired? Yes___ No___

OR, did your family stop being eligible for TANF assistance within 2 years before you were hired

because a Federal or state law limited the maximum time those payments could be made? Yes___No___

If NO, are you a member of a family that received TANF assistance for any 9 months during

the 18-month period before you were hired? Yes___No___

If YES, to any question, enter name of primary recipient ________________________ and

the city and state where benefits were received _________________________.

17. Were you convicted of a felony or released from prison after a felony conviction during

the year before you were hired? Yes___No___

If YES, enter date of conviction ________________ and date of release _________________.

Was this a Federal ____ or a State conviction_____? (Check one)

18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)? Yes__ No __

19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on Yes __ No __

your hiring date?

20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within

60 days before you were hired? Yes__ No__

21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not

consecutive) during the year before you were hired? Yes__ No__

22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not

consecutive) during the year before you were hired? Yes__ No__

23. Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation? Yes__ No__

If YES, what state did you receive unemployment compensation in? _________________________

(Enter state where UI compensation was received)

24. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For

SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the

determination was made.

I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.

25(a). Signature: (See instructions in Box 25.(b) for who signs this

signature block)

25.(b) Indicate with a mark who

signed this form:

Employer, Consultant, SWA,

Participating Agency, Applicant, or

Parent/Guardian (if applicant is a minor)

26. Date:

ETA Form 9061 (Rev. November 2016)

The Essential StaffCARE Fixed Indemnity Medical, Prescription Drug, and Dental Plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois under Policy Series Numbers 25.1204, 26.1801, and 26.212. The Term Life, Accidental Death and Dismemberment and Short-Term Disability Plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois under Policy Series Number 62.200.

For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-798-0803.

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

THE FIXED INDEMNITY MEDICAL PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS OR MINIMUM ESSENTIAL COVERAGE AS DEFINED UNDER THE AFFORDABLE CARE ACT (ACA).

The MEC Wellness/Preventive Plan is an employer-sponsored, self-funded plan that has been deemed to be in compliance with ACA rules and regulations. More information about Preventive Services may be found on the government website at: https://www.healthcare.gov/what-are-my-preventive-care-benefi ts/. For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-798-0803.

Voluntary Electronic Availability of Summary Health Information for MEC/Wellness Preventive PlanCopies of the Summary of Benefi ts and Coverage (“SBC”) and Summary Plan Description (“SPD”) from Essential StaffCARE (“ESC”) are available at the following link: www.essentialstaffcare.com/mec-sbc-spd While you may have other health plans, this is the link for your specifi c MEC plan SPD with ESC. These important documents explain the terms and conditions of your Health Plan, including eligibility, coverage amounts and exclusions along with your rights and responsibilities. At any time, you may request paper copies or revoke your consent to electronic delivery, free of charge, by calling 1-866-798-0803.

For Enrollees of California employer policies: In order to enroll in the Fixed Indemnity Medical Benefi t, you must be enrolled in major medical coverage.

1. You MUST complete the Enrollment Form as part of your New Hire Process.

2. Elect or decline all benefi ts on the Enrollment Form.

3. You MUST Sign and Date the bottom of the form, even if you decline coverage.

4. Return the Enrollment Form to your Branch Manager.

5. Keep the Benefi ts at a Glance page for your records.

Limited Benefi t & Self-Funded Minimum Essential Coverage (MEC) Enrollment Guide

Complete the Enrollment Form to Elect or Decline Coverage

IMPORTANT PLAN INFORMATION: You have two medical plan options. You may enroll in one or both. Additional benefi ts are available to add if you enroll in the Fixed Indemnity Medical Plan.

AFP ESC/MEC 4EUNAVC PVM v20.1

ESC/MEC 4EUNAVC PVM v20.1

A. REQUIRED EMPLOYEE INFORMATION B. MEDICARE INFORMATIONPRINT USING BLACK or BLUE INK (Must Be Filled Out) Do you or any of your dependents receive

Medicare benefi ts? Yes No. If Yes:

Name Home Phone

Social Security # Date of Birth

/ /

Gender M F

Medicare Health Insurance Claim Number (HICN)

Address Apt. # Medicare Effective Date

City Zip State Name of Covered Person(s):1. 2.

C. LIMITED BENEFIT PLAN SELECTION Payroll Deducted Weekly RatesYou MUST select a coverage level before any benefi ts in Section C. Your coverage level for all the benefi ts in Section C will be identical. These plans are underwritten by BCS Insurance Company and 4 Ever Life Insurance Company.

SELECT COVERAGE LEVEL

FIXED INDEMNITYMEDICAL 1 DENTAL TERM LIFE SHORT-TERM

DISABILITY 2

Employee Only $15.98 $5.40 $0.60 $4.20Employee +

Child(ren) $26.54 $14.58 $0.90

Employee + Spouse $30.36 $10.80 $0.90

Employee + Family $40.44 $20.52 $1.80

NO to ALL Benefi ts Yes No Yes No Yes No Yes No

1 This coverage is not available to residents of NH, HI, or PR. 2 STD is not available to persons who work in CA, HI, NJ, NY, or RI.

For Term Life / Accidental Death & Dismemberment please write in your benefi ciary information. Accidental Death & Dismemberment is part of the Term Life Benefi t.Name Relationship

D. REQUIRED DEPENDENT INFORMATIONName Social Security # Date of Birth

/ /Gender M F

Relationship Spouse Child Domestic Partner

Name Social Security # Date of Birth / /

Gender M F


Name Social Security # Date of Birth / /

Gender M F


E. OPTIONAL MEC WELLNESS/PREVENTIVE BENEFIT SELECTION Direct Payment Monthly Rates

Enrolling in the Optional MEC Wellness/Preventive Benefi t may DISQUALIFY you from receiving a subsidy from the health insurance exchange. The MEC Wellness/Preventive Benefi t is NOT underwritten by BCS Insurance Company. It is a benefi t offered and provided by your employer. Rates for the MEC Wellness/Preventive Benefi t are billed monthly.

$58.19 Employee Only $65.79 Employee + Child(ren) $71.00 Employee + Spouse $80.87 Employee + Family

NO to MEC Wellness/Preventive

F. REQUIRED SIGNATURE YOU MUST SIGN AND DATE EVEN IF YOU DECLINE COVERAGEI have read the Benefi ts Summary and the Limitations and Exclusions for the Fixed Indemnity Medical Plan. I understand that I have been offered ACA compliant coverage (MEC Wellness/Preventive), and open enrollment is only available for a limited time. I understand that making no benefi t selection is a declination of coverage.

DATE __ __ /__ __ /__ __ __ __ SIGNATURE

ENROLLMENT FORMB1 OFFICE USE ONLY LOCATION __________ New Hire Rehire Date __ __ /__ __ /__ __ __ __2940900-AFP

82940900-M-AFP

Policy Number

WEEKLY LIMITED BENEFITS PREMIUM Medical Dental Term Life STDEmployee Only $15.98 $5.40 $0.60 $4.20

Employee + Child(ren) $26.54 $14.58 $0.90 -

Employee + Spouse $30.36 $10.80 $0.90 -

Employee + Family $40.44 $20.52 $1.80 -

OPTIONAL MEC WELLNESS/PREVENTIVE BENEFIT 1

The optional MEC Wellness/Preventive Benefi t DOES NOT cover medical services. This plan provides coverage for preventive services such as immunization and routine health screening. It does not cover conditions caused by accident or illness.

Benefi t In-Network Non-Network MONTHLY MEC PREMIUM MEC15 Preventive Services for Adults 100% 40% Employee Only $58.19

22 Preventive Services for Women 100% 40% Employee + Child(ren) $65.79

26 Covered Preventive Services for Children 100% 40% Employee + Spouse $71.001 For more information about preventive services, please visit www.healthcare.gov. Employee + Family $80.87

SHORT-TERM DISABILITY BENEFITBenefi t Amount 60% of base pay up to $150 per week

Waiting Period/Maximum Benefi t Period 7 days for injury or sickness / up to 26 weeks

DENTAL BENEFIT Waiting Period/Coinsurance Annual Maximum Benefi t $750 Deductible $50

Coverage A None / 80% Exams, Cleanings, Intraoral Films, and Bitewings

Coverage B 3 Months / 60% Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures

Coverage C 12 Months / 50% Periodontics, Crowns, Bridges, Endodontics and Dentures

Policy Number

FIXED INDEMNITY MEDICAL BENEFITThe Fixed Indemnity Medical Plan pays a flat amount for a covered event caused by an accident or illness. If the covered event costs more, you pay the difference. But if the covered event costs less, you keep the difference.

Outpatient Benefi ts 1 Inpatient Benefi tsPhysician Offi ce Visit $55 per day Standard Care $300 per day

Diagnostic (Lab) $75 per day Intensive Care Unit Maximum 3 $400 per day

Diagnostic (X-Ray) $150 per day Inpatient Surgery $2,000 per day

Ambulance Services $300 per day Anesthesiology $400 per day

Physical, Speech, or Occupational Therapy $50 per day Skilled Nursing 4 $100 per day

Emergency Room Benefi t - Sickness $100 per day Annual Inpatient Maximum 5 No Limit

Emergency Room Benefi t - Accident 2 $300 per day Prescription Drugs (via reimbursement) 6, 7

Outpatient Surgery $500 per day Annual Maximum $600

Anesthesiology $200 per day Per Day $30

Annual Outpatient Maximum $2,000

Wellness CareWellness Care (one per year) $751 all outpatient benefi ts are subject to the outpatient maximum 2 covers treatment for off the job accidents only 3 pays in addition to standard care benefi t 4 for stays in a skilled nursing facility after a hospital stay 5 Subject to internal limits of plan 6 not subject to outpatient maximum 7 To fi le a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc.

TERM LIFE BENEFITEmployee Amount $10,000 (reduces to $7,500 at 65; $5,000 at 70) Child Amount (6 mos to 26 yrs old) $5,000

Spouse Amount $5,000 (terminates at age 70) Infant Amount (15 days to 6 mos) $1,000

ACCIDENTAL DEATH & DISMEMBERMENT (AD&D is part of the Term Life Benefi t.)Employee Amount $20,000 Child Amount (6 mos to 26 yrs old) $5,000

Spouse Amount $20,000 Infant Amount (15 days to 6 mos) $2,500

LIMITED BENEFITS SUMMARYFor more details, please see your Summary Plan Description.

2940900-AFP

82940900-M-AFP

LIMITED BENEFIT EXCLUSIONS AND LIMITATIONSThese are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing.FIXED INDEMNITY MEDICALNo benefi ts will be paid for loss caused by or resulting from:• Intentionally self-infl icted injuries, suicide or any attempt while

sane or insane• Declared or undeclared war• Serving on full-time active duty in the armed forces• The covered person’s commission of a felony• Work-related injury or sickness, whether or not benefi ts are

payable under workers’ compensation or similar lawNo benefi ts will be paid for:• Eye examinations for glasses, any kind of eye glasses, or vision

prescriptions• Hearing examinations or hearing aids• Dental care or treatment other than care of sound, natural

teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident

• Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person’s coverage is in force

• Services provided by a member of the covered person’s immediate family.

The fi xed indemnity medical plan is not available to residents of Hawaii, New Hampshire or Puerto Rico.PRESCRIPTION DRUGSNo benefi ts will be paid for over-the-counter products or medications or for drugs and medications dispensed while you are in a hospital.DENTAL The plan will pay only for procedures specifi ed on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on covered procedures or limitations, please see your summary plan description.

SHORT-TERM DISABILITYNo benefi ts are payable under this coverage in the following instances: • Attempted suicide or intentionally self-infl icted injury• Voluntary taking of poison; voluntary inhalation of gas;

voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse’s child, sibling or parent, or a person who resides in your home

• Declared or undeclared war or act of war• Your commission of or attempt to commit a felony, or any loss

sustained while incarcerated for the felony• Your participation in a riot• If you engage in an illegal occupation • Release of nuclear energy• Operating, riding in, or descending from any aircraft (including

a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; or

• Work-related injury or sickness. Short-Term Disability benefi ts are not available to persons who work in California, Hawaii, New Jersey, New York, or Rhode Island. TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT No Life Insurance benefi ts will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person’s coverage under the policy became effective. For Accidental Death and Dismemberment benefi ts will not be payable for any loss caused in whole or in part by, or resulting in whole or in part from, the following:Attempted suicide or intentionally self infl icted injury; bodily or mental infi rmity; disease of any kind; or medical or surgical treatment for that infi rmity or disease. This does not include bacterial infections resulting from an accidental cut or wound or accidental ingestion of poisonous food substance; voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you, your spouse or domestic partner; you, your spouse’s or domestic partner’s child; sibling or parent; or a person who resides in your home; declared or undeclared war or act of war; your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony; your participation in a riot; if you engage in an illegal occupation; release of nuclear energy; operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; work-related injury or sickness.

Member Services:

For frequently asked questions and network information for the Fixed Indemnity Medical Plan, visit www.esc-enrollment.com/FAQIND. For questions and a full list of preventive services covered by the MEC Wellness/Preventive Plan, as well as the MEC SBC, please visit www.esc-enrollment.com/FAQMEC. A paper copy is also available, free of charge, by calling Essential StaffCARE Customer Service 1-866-798-0803.PLEASE NOTE: Your Company has chosen to take your payroll deductions on a Post-Tax basis.

Essential StaffCARE Customer Service: 1-866-798-0803• Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets.• Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time.

Bilingual representatives are available.• Members can also visit www.paisc.com and click on “Members” and enter your group number.

Carolinas Staffing Solutions, Inc. Work Place Guidelines

________ADA Accommodation Under Title I of the Americans with Disabilities Act (ADA), a reasonable accommodation is a modification or adjustment to a job, the work environment, or the way th ings are usually done during the hiring process. These modifications enable an individual with a disability to have an equal opportunity not only to get a job, but successfully perform their job tasks to the same extent as people without disabilities. The ADA requires reasonable accommodations as they relate to three aspects of employment: 1) ensuring equal opportunity in the application process; 2) enabling a qualified individual with a disability to perform the essential

functions of a job; and 3) making it possible for an employee with a disability to enjoy equal benefits and privileges of employment. ________Employment at Will. Nothing contained in our companies policies and procedures is intended to nor does it create a contract of employment for any specific duration. I understand and agree that my employment can be terminated with or without cause and with or without notice at any time. I understand that no employee of the

company has the authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing. ________Equal Opportunity Employer. It is the policy of Carolinas Staffing Solutions Inc. that no employee, applicant for employment, customer, vendor, independent contractor or other individual will be discriminated against based upon age, race, color, creed, religion, sex, sexual orientation, national origin, disability, veteran status

or other protected class of characteristics established under applicable federal, state or local statue or ordinance. Carolinas Staffing Solutions Inc. will not condone, permit or tolerate discrimination as described above. Persons who engage in such discrimination will be subject to appropriate discipline up to and including termination of his/her employment. ________Sexual Harassment in the Work Place. It is our policy to provide a work environment free from

harassment. Carolinas Staffing Solutions Inc. will not tolerate any conduct that violates this policy and will promptly investigate and resolve all alleged complaints and take appropriate disciplinary action against employees who violate this policy. Carolinas Staffing Solutions Inc. will not tolerate harassment of any employee by any other employee, supervisor, vendor or customer. Harassment for any discriminatory reason, such as sex, race, color, national origin, disability, age, religion, marital status, sexual orientation, or any other p rotected category, violates this policy. Sexual harassment includes unwelcome sexual advances, requests for sexual favors or any other conduct

of a sexual nature when: (1) submission to the conduct is made, either implicitly or explicitly, a condition of employment; (2) submission to or rejection of the conduct is used as the basis for an employment decision affecting the harassed employee; or (3) the harassment has the purpose or effect of unreasonably interfering with the employee’s work performance or creating an environment that is intimidating, hostile or offensive to the employee. You must exercise your own good judgment to avoid any conduct that may be perceived by others as harassment or that may violate this policy. The following conduct is a partial list of these behaviors:

Unwanted sexual advances Offering employment benefits in exchange for sexual favors Making or threatening reprisals after a negative response to sexual advances Visual conduct: leering, making sexual gestures, displaying of sexually suggestive objects or pictures, cartoons or posters

Verbal conduct: making or using derogatory comments, epithets, slurs and jokes Verbal sexual advances or propositions Verbal abuse of a sexual nature, graphic verbal commentaries about an individual’s body, sexually degrading words used to describe an individual, suggestive or obscene letters, notes or invitations Physical conduct: touching, assaulting, impeding or blocking movements

________Prohibition of Discrimination Carolinas Staffing Solutions Inc. does not discriminate on the basis of race, color, ethnicity, religion, national origin, sex (including sexual orientation, transgender status, or gender identity), disability (including HIV, AIDS, or sickle cell trait), pregnancy, marital status, age (except as authorized

https://www.eeoc.gov/laws/guidance/fact-sheet-disability-discrimination

by law), ancestry, genetic information, which are classes protected by State and/or Federal law (collectively, "protected classes") in its programs and activities, including employment opportunities, It is the legal obliga tion and the policy of Carolinas Staffing Solutions Inc. to employ only those persons who are best qualified, with or without reasonable accommodations.

________Complaint Procedure Any employee who believes they have been harassed, discriminated against or subject to retaliation by a co-worker, supervisor, agent, client, vendor or customer of Carolinas Staffing Solutions Inc. in violation of this policy or who is aware of such harassment, discrimination of or retaliation against others, should immediately provide a written or verbal report to the Corporate Office in Shallotte NC. After a report is

received, a thorough and objective investigation by management will be undertaken. The investigation will be completed and a determination made and communicated to the employee as soon as practical. The Company expects all employees to fully cooperate with any investigation conducted by the Company into a complaint of proscribed harassment, discrimination or retaliation, or regarding the alleged violation of any other Company policies and during the investigation to keep matters related to the investigation confidential. If we determine that this policy has been violated, remedial action will be taken, commensurate with the severity of the offense. Appropriate action will

also be taken to deter any future harassment or discrimination prohibited by this policy. If a complaint of prohibited harassment, discrimination or retaliation is substantiated, appropriate disciplinary action, up to and including termination of employment, will be taken. The Equal Employment Opportunity Commission (EEOC) and equivalent state agencies will accept and investigate charges of unlawful discrimination or harassment at no charge to the complaining party.

________Protection Against Retaliation Retaliation is prohibited against any person by another employee or by Carolinas Staffing Solutions Inc. for using this complaint procedure, reporting proscribed harassment, or for filing, testifying, assisting or participating in any manner in any investigation, proceeding or hearing conducted by a governmental enforcement agency. Prohibited retaliation includes, but is not limited to, termination, demotion, suspension, failure to hire or consider for hire, failure to give equal consideration in making employment decisions, failure to make employment recommendations impartially, adversely affecting working conditions or otherwise

denying any employment benefit. Employees should report any retaliation prohibited by this policy to the Corporate Office in Shallotte NC. Any report of retaliatory conduct will be investigated in a thorough and objective manner. If a report of retaliation is substantiated, appropriate disciplinary action, up to and including termination of employment will be taken.

If at any time you feel in violation of any of the above listed Work Place Policies please contact the Corporate

Office in Shallotte NC. You will need to speak with Estalene Marlowe or Dana Marlowe.

Carolinas Staffing Solutions Inc.

4480 Main St

Shallotte NC 28470

Phone – 910-754-5393

Fax – 910-754-5433

Or Email the following:

[email protected]

[email protected]

____________________________________________________________________

Employees Signature

mailto:[email protected]

mailto:[email protected]

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

1 Your first name and middle initial Last name

Home address (number and street or rural route)


2 Your Social Security Number

3 Single Married Married, but withhold at higher Single rate.Note: If Married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name is different on your Social Security card, check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . . . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2020. Check the box for the exemption reason and write "exempt" on line 7.

For tax year 2019, I had a right to a refund of all South Carolina Income Tax withheld because I had no tax liability, and for tax year 2020 I expect a refund of all South Carolina Income Tax withheld because I expect to have no tax liability.I elect to use the same residence for tax purposes as my military servicemember spouse. I have provided my employer with a copy of my current military ID card and a copy of my spouse's latest Leave and Earning Statement. State of domicile: 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.Employee’s signature (required) ▶ Date ▶

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

STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE SC W-4

(Rev. 12/13/19) 3527

2020SOUTH CAROLINA EMPLOYEE'S

WITHHOLDING ALLOWANCE CERTIFICATE

1350

dor.sc.gov

SC W-4 Instructions Complete SC W-4 so that your employer can withhold the correct South Carolina Income Tax from your pay. If you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Determine the number of withholding allowances you should claim for withholding for 2020 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Consider completing a new SC W-4 each year and when your personal or financial situation changes to keep your withholding accurate and help you avoid surprises when you file your South Carolina Individual Income Tax return. For the latest information about South Carolina Withholding Tax and the SC W-4, visit dor.sc.gov/withholding. Exemptions. You may claim exemption from South Carolina withholding for 2020 for one of the following reasons: • For tax year 2019, you had a right to a refund of all South Carolina Income Tax withheld because you had no tax

liability, and for tax year 2020 you expect a refund of all South Carolina Income Tax withheld because you expect to have no tax liability.

• Under the Servicemembers Civil Relief Act, you are claiming the same residence for tax purposes as your military servicemember spouse. You are only in South Carolina, or a bordering state, to be with your military spouse who is serving in the state in compliance with military orders. Provide your employer with a copy of your current military ID card and a copy of your spouse's latest Leave and Earnings Statement (LES). The military ID card must have been issued within the last four years. The assignment location on the LES must be in South Carolina or a bordering state. Enter your spouse's state of domicile on the line provided.

If you’re exempt, complete only lines 1, 2, 3, 4, and 7. Check the box for the reason you are claiming an exemption and write "exempt" on line 7. Your exemption for 2020 expires February 17, 2021. If you are a military spouse and you no longer qualify for the exemption, you have 10 days to update your SC W-4 with your employer. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, you may want to add additional withholdings on Line 6 to ensure you are withholding enough. Each employer will require an SC W-4. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using SC 1040ES, Individual Declaration of Estimated Tax, or you can add additional withholding from this job's wages on Line 6. Otherwise, you may owe additional tax.

Employer: Complete boxes 8 and 10 if sending to the SCDOR and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.

SC W-4 (2020) Page 2

Instructions for employers. Employees should not complete box 8, 9, or 10. Employers will complete these boxes if necessary. • New hire reporting. In accordance with Section 43-5-598 of the South Carolina Code of Laws and 42 USC Sec.

653a, employers must report newly hired employees within 20 days after the employee's first day of work. For more information go to newhire.sc.gov.

• Box 8. Employers should enter their name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders.

• Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from your service for at least 60 days, enter the rehire date.

• Box 10. Employers should enter their Employer Identification Number (EIN). All employers reporting South Carolina wages or withholdings must submit the W-2s directly to the SCDOR. Submitting the W-2s to the Social Security Administration does not meet this requirement. You may submit W-2s using our free tax portal at MyDORWAY.dor.sc.gov. Withholding tax tables are available at dor.sc.gov/withholding. Worksheet Instructions Personal Allowances Worksheet. Complete the worksheet on page 3 first to determine the number of withholding allowances to claim. • Line C. Head of household. Generally, you may claim head of household filing status on your tax return only if

you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See IRS Pub. 501 for more information about filing status.

• Line E. Federal child tax credit. When you file your tax return, you may be eligible to claim a federal child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid Social Security Number. To learn more about this credit, see IRS Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

• Line F. Federal credit for other dependents. When you file your tax return, you may be eligible to claim a federal credit for other dependents for whom a federal child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or Social Security Number requirement for the federal child tax credit, or a qualifying relative. To learn more about this credit, see IRS Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

Enter the total from Line G of this worksheet on Line 5 of the SC W-4. Deductions, Adjustments, and Additional Income Worksheet. Complete this optional worksheet if you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding. • Reduce withholding. Complete this worksheet to determine if you're able to reduce the tax withheld from your

paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you reduce your withholding, your refund at the end of the year will be smaller, but your paycheck will be larger.

• Increase withholding. You can also use this worksheet to determine how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.

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

SC W-4 (2020) Page 3

Personal Allowances WorksheetA Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AB Enter “1” if you will file as married filing jointly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BC Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C

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

} D

E Federal child tax credit. • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each eligible child.• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for each eligible child.• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . . . . . . . . . . . . . E

F Federal credit for other dependents. • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent. • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” . . . . . . . . . . . . . . . . . . . F

G Add lines A through F and enter the total here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ G

For accuracy, complete all worksheets that apply. {• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you

have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.

• If the above situation does not apply, stop here and enter the number from line G on line 5 of SC W-4 on page 1.

Deductions, Adjustments, and Additional Income WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage

income not subject to withholding.

1

Enter an estimate of your 2020 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See IRS Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $24,400 if you’re married filing jointly or qualifying widow(er)$18,350 if you’re head of household$12,200 if you’re single or married filing separately

} . . . . . . . . . . . . . . . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2020 adjustments to income and any additional standard deduction for age or

blindness (see IRS Pub. 505 for information about these items) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2020 nonwage income not subject to withholding (such as dividends or interest) . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . . . . . . 7 $8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line G, above . . . . . . . . . . . . . . . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SC W-4 Worksheets KEEP FOR YOUR RECORDS

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