OMB No.

1615-0047; Expires 08/31/12

Form 1-9, Employment
Eligibility Verification

Department of Homeland Security
lJS. Citizenship and Immigration Services

Read instructions carefully before completing this form. The instructions must be available during completion ofthis form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins)
Print Name Last
First
Middle Initial Maiden Name

a~

Apt. #

Date of Birth (month/day/year)

C
City

State

g-f'

Zip Code

I="L

~)'f3
I attest, under penally of perjury, that I ,1m (check one of the following)

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 0 his f m.

~A citizen ofthe United States
D A noncitizen national or the United States (see in~truclions)

D
D

Preparer and/or Translator Certification (Iv be completed and signed if Section I is prepared by a'lJerso other than the employee.) I attest. under
penalty o/perjury. that I huve assisted in the completion o/thisjorm and that to the best a/my knowledge the information is true and correct.
Preparer's/Translator's Signature

Print Name

Address (Street Name and Number. City. State. Zip Code)

Date (month/day/year)

Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document/rom List A OR

examine one document/rom List B and one/rom List C, as listed on the reverse o/this/arm, and record the title, number, and
expiration date, if any, rf the documentM)
List B
OR
List A
ListC

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FL

Document title'
Issuing authority:
Document #'
ExpiratiDn Date (ifany).
Document #:
Expiration Date (if any):

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed doeument(s) appear to be genuine and to relate to the employee named, that the employee began employment on
(month/day/year)
S. t 3
and that to the best of my knowledge the employee is authori:ted to worl. in the United States. (State
employment agencies may omit the date the employee began employment.)
Signature ofEmp oyer or Authorized Representative
Print Name

&.

-(

C Il'employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization

Document Title:

Document #:

Expiration Date (ifany):

Inttest, 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.
Date (month/day/year)
Signature of Employer or ALlthorized Representative
Fonn 1-9 (Rev. 08107/09) Y Page 4

OATH OF LOYALTY
STATE OF FLORIDA
Le~O~2
COUNTY OF

I,

fJ1a,++hi. w D"m?7

, as a citizen of the State of

Florida and of the United States of America, and being
employed by or an officer of the State of Florida and a
recipient of public funds as such employee or officer, do
hereby solemnly swear or affirm that I will support the
constitution of the United States and of the State of Florida.

Sworn to or affirmed and subscribed before me this
tj+ft)
day of t1/lJitlA
' J/)j( '?

,

.=-..:=:......J..<l_---=::Jj~~~____6~-----

by --;."ilAf."

(name of person acknowledged)

o Personally Known
g--pfQduced as Identification:

"FIDV,dt1 D:l",vev Li(!en/)t:.
(type of identification)

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SHERESE GAINOUS

MY COMMISSION. EE 857258
~
.: § EXPIRES: JanU8lY 13, 2017
'~Rf. ..: ' Bonded Thru Nay PublIc UndeIwIItWs

(Seal)

THE FLORIDA LEGISLATURE
OFFICE OF HUMAN RESOURCES
EMPLOYEE HANDBOOK ACKNOWLEDGEMENT

I hereby acknowledge receipt of the Legislative Employee Handbook.

o

Printed copy, or
~ Legislative Intranet under Human Resources

I understand that it is my responsibility to review this document in detail and
request any needed clarification.
I also understand that this signed acknowledgement of receipt will be a
permanent part of my personnel file.

----.M~J
~lVIS/..~
Employ e Name (please pri t)

THE FLORIDA LEGISLATURE
OFFICE OF HUMAN RESOURCES
NEW EMPLOYEE VIDEO
ACKNOWLEDGEMENT

I hereby acknowledge that I have viewed the New Employee Video located on
the Human Resources, New Salaried Employees intranet page:
http://intranet.leg.fla. int/h uman resou rces/new salaried .cfm

q!. .-~_7~B. . : : :&: . -0J. J"o:.'. .!-4- :. . ~

Code from end of video: _ _

_

Em

ure

Revised 12/2012

THE FLORIDA LEGISLATURE
OFFICE OF HUMAN RESOURCES
AUTHORIZATION TO RELEASE INFORMATION
To Whom it May Concern:
By copy of this fonn, I hereby authorize the release of all information requested
by the Human Resources Office of the Florida Legislature regarding my
personal background in any of the following categories.

• Employment History
• Educational Credentials
• Personal References
• Legal History

(fJo.~~~ D{\m5k.
Employee N a m e t

Social Security Number

THE FLORIDA LEGISLATURE
PUBUC RECORDS EXEMPTION
The home addresses, telephone numbers, social security numbers, dates of birth, photographs·, and places of employment of the
spouses and children of the following listed personnel; and the names and locations of schools and day care facilities attended by the
children ofsuch personnel are exempt from the public records disclosure requirements of So 11.0431, F.S.

If you or your spouse; or if you are the child of someone who qualifies; or if you have a child residing with you whose non-custodlal
parent qualifies; you will qualify for this public records exemption.
Please check the box for any ofthe following option(s) that apply:

D
D
D
D
D

o

D
D
D
D

o
o

D

o
D

o

o

Active or former law enforcement personnel, including correctional and correctional probation officers
Current or former public defenders, assistant public defenders, criminal conflict and civil regional counsel. and assistant criminal
conflict and civil regional counsel
Active or former personnel of the Department ofChildren and Family Services whose duties included the investigation of abuse.
neglect, exploitation, fraud, theft or other criminal activities
Active or former personnel ofthe Department of Health whose duties are to support the investigation ofchild abuse or neglect
Active or former personnel ofthe Department of Revenue or local governments whose responsibilities include revenue collection and
enforcement or child support enforcement
Firefighters certified in compliance with s. 633.35
Justices of the Supreme Court, district court ofappeal judges. circuit court judges. and county court judges (* Photographs are not
exempt)
Current or former state attorneys, assistant state attorneys, statewide prosecutors, or assistant statewide prosecutors
Current or former human resource, labor relations, or employee relations directors, assistant directors, managers, or assistant managers
of any local government agency or water management district whose duties include hiring and firing employees. labor contract
negotiation. administration, or other personnel-related duties
Current or former United States attorneys, assistant United States attorneys, United States Court of Appeals judges, United States
district court judges, or United States magistrates if the individual provides a written statement that he or she has made reasonable
efforts to protect such information from being accessible to the public through other means (e.g. unlisted phone number)
Current or former judges of United States Courts of Appeal, United States district judges, and United States magistrate judges
Current or former code enforcement officers
Current or former juvenile probation officers and supervisors, detention superintendents, assistant detention superintendents, juvenile
justice detention officers and supervisors. juvenile justice residential officers and supervisors, juvenilejustice counselors, supervisors.
and administrators, human services coWlselor administrators, rehabilitation therapists and social services counselors ofthe Department
ofJuvenile Justice
Current or former guardians ad litem. ifguardilln ad litem provides a wrltJen stotement that the guardian ad litem has made
reasonable efforts to protect such information from being accessible to the public through other means (e.g. Wllisted phone number)
General magistrates, special magistrates,judges ofcompensation claims, administrative law judges ofthe Division of Administrative
Hearings, and child support enforcement hearing officers ifthe individualprovides a written stotement that he or she has made
reasonable efforts to protect such information from being accessible to the public through other means (e.g. unlisted phone number)
(*Photographs are not exempt)
Investigators or inspectors ofthe Department of Business and Professional Regulation
County Tax Collectors

D Yes, I qualify

o Yes, my spouse qualifies o Yes, my child(ren) qualify

Please provide the position and place ofemployment formerly or currently held and, ifother than yourself, relationship of individual which
qualifies you for this exemption:

~o, neither my spouse, child(ren), nor I qualify

If at some point in the future, you or your spouse, or child(ren) qualifyfor this exemption, please let Human Resources know as soon as

JWSomej!!t

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possible. ir is the responsibility ofthe employee to ensure that prompt notification is provided to Human Resources in order to ensure that the

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Print Name

O<e

~Wi'" yow

Signa

,

Please note: An agency that is the custodkm ofthe personal info
on specified above and is not the employer ofthe officer, employee.
Justice,judge or other person specljied above shall mointain the exempt status ofthe personal infonnatJon !!!llr.ifthe officer, employee,
justice, Judge, other person, or employing agency ofthe designated employee submits a written requestfor maintenance ofthe exemption to
the ctIstodlal agency. §119.071(4)(d)3., FS
Revised: 1010112012

Florida Retirement System (FRS) - Certification Form
1- T~I~

",me

lor~ is not an offer o(emploY"2l:1~to,r_an enrollment lorm. II hired, aRetireml:1nt,~_~_?~e kit may be mailed to your home with an en~?!~~l:1~~loi_~~-]

-l1'1l1Mhtw

Agency Name

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Sc:.nl.rk-~

Previous FRS Employer ~

_
~_~~~~~~ __

~~~~

PLEASE COMPLETE SECTION I, II, III, OR IV
I.

I have never been a

t -Ii "3

of a State of Florida administered retirement Pla~

DATErS'j

SIGNATURE
II.

STOP HERE

I was a member of 'e following State of Florida administered retirement plan (also complete Section III or IV) 1

o FRS Pension Plan (inc!. DROP) 0 FRS Investment Plan 0
o State Community College Optional Retirement Program (SCCORP)
o Other

State University System Optional Retirement Program (SUSORP)
0 Senior Management Service Optional Annuity Program (SMSOAP)

III. I am not retired from any State of Florida administered retirement plan, I understand that if it is later
determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or
h
after my DROP termination date, or at any time during the i through 12 months after I retired or after
my DROP termination date, I must repay all unauthorized benefits received (see Section IV for details),
or, if in the Investment Plan, terminate my employment. My employer may also be liable for repaying
any unauthorized benefits I received.
DATE

SIGNATURE

IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement effective date, DROP termination date, or date I received my first distribution from the FRS Investment
Plan, SUSORP, SCCORP, SMSOAP, or other plan was
_

initiallyreenipl()y~d,~¥~nFR~"e6*~I'?~ielllPI?yeroh9Fafter;J~lyi'201g!I\'{rnn()t~ep~I'~: [~'j'iiil~f~1~

1(1, am
mitted, tO",pa rtit:i pate'.in'a,§tl!leof,EI6"ida',!qmlrllstllreail'etlrern~rltjl.?15!I1.to,.ea rlianadditio~ali.··""
reti rem elifbenef,it;" "", ,,","""""",'"""'"""""",,, "'""""',"""","""""""""'" "" """'"'' "" '", """, """",'""'" ",', "", ,"" ""
,
I understand that as a Pension Plan retiree:
2
a. If I am employed by an FRS-covered employer in any type of, position during the first 6 calendar
months after I retired or after my DROP termination date, my retirement and DROP status are
voided, all retirement and DROP benefits I received must be repaid,3 and I must reapply for
retirement in order to receive future benefits,
h
b. If I am reemployed by an FRS-covered employer at any time during the yth through the 1i months
after I retired or after my DROP termination date, my monthly retirement benefit must be
a
4
suspended and any unauthorized benefits received must be repaid My employer may also be
liable for repaying any unauthorized benefits I received.
I understand that as an Investment Plan retiree:
2
If I am employed by an FRS-covered employer in any type of position during the first 6 calendar
months after I retired, I must repal any benefits received or terminate employment for an
additional period to satisfy the 6 calendar month termination requirement.
h
h
b. If I am reemployed by an FRS-covered employer at any time during the i through the 1i months
after my retirement, I will not be eligible for additional distributions until I terminate employment or
complete 12 calendar months of retirement. 4

a.

DATE

SIGNATURE

11f you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you
terminated FRS-covered employment, You may have a one-time 2 Election to switch FRS retirement plans, Also, alternative retirement programs are available to certain em~IOyeeS_ Contact your employer for deadline and other information,
Positions Include OPS, temporary, seasonal, SUbstitute teachers, part-time, full-time, regularly established, etc,
3Florida law requires areturn of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination Or
reemployment provlslons_ Similar provisions apply to unauthorized SUSORP, SCCORP, or other state-administered plan distributions - contact that plan's administrator for details,
•{
4There are no reemployment exemptions/exceptions for Pension Plan members whose effective date of retirement or DROP termination date is on or after July 1,2010 or Invest· .• A.1
ment Plan members who retire on or after July 1, 2010.
0

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CERT

Revised 06-2011

EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE'S PERSONNEL FILE. DO NOT SEND THIS FORM TO THE FRS, UNLESS REQUESTED.

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. - - - - - - - - - - - - - - - - - - _ . _ - - _ .. _------ ...

HUMAN RESOURCES OFFICE
SENATE IN-PROCESSING CHECK LIST
EMPLOYEE NAME:

rql'A .\l"'t..~) '"b(A~$b-1
3

OFFICEIDISTRICT:

i

EMPLOYMENT DATE:

3 .

s,

{?;.

____

Check the "Yes" column to reflect enclosures received from employee. Check the "DELAY" column
to reflect forms that are missing or pending.

YES DELAY
j

1.

AUTHORIZATION LETTER

- Ii

2.

FDLE CRIMINAL HISTORY BACKGROUND

3.

EMPLOYMENT VERIFICATION CHECK

- ./

4.

FORM 1-9

/

5.

APPLICATION

6.

OFFICIAL COLLEGE TRANSCRIPTS - LtJ~ \.\ '("""Lv &..~

.I

7.

SOCIAL SECURITY CARD

j

8.

W-4

I

9.

OATH OF LOYALTY

I

10.

DIRECT DEPOSIT AUTHORIZATION FORM

11.

AUTHORIZATION TO RELEASE INFORMATION

/

12.

PUBLIC RECORDS EXEMPTION

j

13.

RETIREMENT STATEMENT (FRS)

j

I

-

/

-

7 3 .1 '12>

14.

EMPLOYEE HANDBOOK ACKNOWLEDGEMENT

15.

EMPLOYEE VIDEO ACKNOWLEDGEMENT

/

16.

FINANCIAL DISCLOSURE

.,/

REQUEST TRANSFER REPORT
PREVIOUS EMPLOYMENT*
AUDIT

MAILED

_ _.RECEIVED

3- ~,,'3MAILED

_ _RECEIVED

-

#Oo1tial)

Revised 1/25/13