I-9 Form HR HUB Step 1 of 3 33% Employment Eligibility Verification - USCIS Form I-9Department of Homeland Security U.S. Citizenship and Immigration ServicesSection 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 (if any) Other Last Names Used (if any) Address (Street Number and Name) Apt. Number (if any) City or Town State ZIP Code Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY U.S. Social Security Number Employee's Email Address Employee's Telephone NumberI am awareI 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 at testing to my citizenship or immigration status, is true and correct.Check one of the following boxes to attest to your citizenship or immigration status 1. A citizen of the United States 2. A noncitizen national of the United States 3. A lawful permanent resident 4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until Authorized to work until (exp. date, if any) MM slash DD slash YYYY If you check Item Number 4., enter one of these:USCIS A-Number (OR) Form I-94 Admission Number (OR) Foreign Passport Number and Country of Issuance Signature of EmployeeToday's Date MM slash DD slash YYYY Preparer and/or Translator Certification on Page 3If 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 Instructions.List A - Document Title 1 List A - Doc 1 - Issuing Authority List A - Doc 1 - Document Number (if any) List A - Doc 1 - Expiration Date (if any) MM slash DD slash YYYY List A - Document Title 2 (if any) List A - Doc 2 - Issuing Authority List A - Doc 2 - Document Number (if any) List A - Doc 2 - Expiration Date (if any) MM slash DD slash YYYY List A - Document Title 3 (if any) List A - Doc 3 - Issuing Authority List A - Doc 3 - Document Number (if any) List A - Doc 3 - Expiration Date (if any) MM slash DD slash YYYY List B - Document Title 1 (if any) List B - Doc 1 - Issuing Authority List B - Doc 1 - Document Number (if any) List B - Doc 1 - Expiration Date (if any) MM slash DD slash YYYY List C - Document Title 1 (if any) List C - Doc 1 - Issuing Authority List C - Doc 1 - Document Number (if any) List C - Doc 1 - Expiration Date (if any) MM slash DD slash YYYY Additional InformationAuthorized by DHS Check here if you used an alternative procedure authorized by DHS to examine documents. 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 slash DD slash YYYY Last Name, First Name and Title of Employer or Authorized RepresentativeSignature of Employeror Authorized RepresentativeToday's Date MM slash DD slash YYYY Employer's Business or Organization Name Employer's Business or Organization Address, City or Town, State, ZIP Code Supplement B, Reverification and Rehire on Page 4For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4. Supplement A, Preparer and/or Translator Certification for Section 1Form I-9 Supplement AA. Last Name (Family Name) from Section 1.A. First Name (Given Name) from Section 1.A. Middle initial (if any) from Section 1.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.AttestI 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.A1. Signature of Preparer or TranslatorA1. Date MM slash DD slash YYYY A1. Last Name (Family Name) A1. First Name (Given Name) A1. Middle Initial (if any) A1. Address (Street Number and Name) A1. City or Town A1. State A1. ZIP Code AttestI 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.A2. Signature of Preparer or TranslatorA2. Date MM slash DD slash YYYY A2. Last Name (Family Name) A2. First Name (Given Name) A2. Middle Initial (if any) A2. Address (Street Number and Name) A2. City or Town A2. State A2. ZIP Code AttestI 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.A3. Signature of Preparer or TranslatorA3. Date MM slash DD slash YYYY A3. Last Name (Family Name) A3. First Name (Given Name) A3. Middle Initial (if any) A3. Address (Street Number and Name) A3. City or Town A3. State A3. ZIP Code AttestI 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.A4. Signature of Preparer or TranslatorA4. Date MM slash DD slash YYYY A4. Last Name (Family Name) A4. First Name (Given Name) A4. Middle Initial (if any) A4. Address (Street Number and Name) A4. City or Town A4. State A4. ZIP Code Supplement B, Reverification and Rehire (formerly Section 3)Form I-9 Supplement BB. Last Name (Family Name) from Section 1.B. First Name (Given Name) from Section 1.B. Middle initial (if any) from Section 1.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)B1. Date of Rehire (if applicable) MM slash DD slash YYYY B1. Last Name (Family Name) B1. First Name (Given Name) B1. Middle Initial 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.B1. Document Title B1. Document Number (if any) B1. Expiration Date (if any) MM slash DD slash YYYY AttestI 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.B1. Name of Employer or Authorized RepresentativeB1. Signature of Employeror Authorized RepresentativeB1. Today's Date MM slash DD slash YYYY B1. Additional Information (Initial and date each notation.) B1. Alternative procedure authorized by DHS Check here if you used an alternative procedure authorized by DHS to examine documents. B2. Date of Rehire (if applicable) MM slash DD slash YYYY B2. Last Name (Family Name) B2. First Name (Given Name) B2. Middle Initial 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.B2. Document Title B2. Document Number (if any) B2. Expiration Date (if any) MM slash DD slash YYYY AttestI 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.B2. Name of Employer or Authorized RepresentativeB2. Signature of Employeror Authorized RepresentativeB2. Today's Date MM slash DD slash YYYY B2. Additional Information (Initial and date each notation.) B2. Alternative procedure authorized by DHS Check here if you used an alternative procedure authorized by DHS to examine documents. B3. Date of Rehire (if applicable) MM slash DD slash YYYY B3. Last Name (Family Name) B3. First Name (Given Name) B3. Middle Initial 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.B3. Document Title B3. Document Number (if any) B3. Expiration Date (if any) MM slash DD slash YYYY AttestI 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.B3. Name of Employer or Authorized RepresentativeB3. Signature of Employeror Authorized RepresentativeB3. Today's Date MM slash DD slash YYYY B3. Additional Information (Initial and date each notation.) B3. Alternative procedure authorized by DHS Check here if you used an alternative procedure authorized by DHS to examine documents. EmailThis field is for validation purposes and should be left unchanged. Subscribe To Our NewsletterReceive Senior Care news and articles. Success! Name Email About You About You I'm a Senior / Family Member of a senior. 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