Complete the W-4 for employment at Plexivent Plastics starting 9/6/2022. The employer’s address is 1 Plastics Way, Lincoln Valley, ND 58430, and EIN is 56-4658631.
Henry Walker Pierce
2024 Denhoff Highway, Apartment 12
Lincoln Valley, ND 58430
SSN: 687-55-4658
Marital status: Married filing jointly with two dependents under 17
One job and spouse does not work
Does not require any additional amount to be withheld

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PARTIVES MATILAND ALDAS ►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. Address (Street Number and Name) 123 Main Street Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Jonathan Doe Date of Birth (mm/dd/yyyy) 05/17/1991 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) Apt. Number 2. Form 1-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: U.S. Social Security Number Employee's E-mail Address 987-65-4321 jonathandoe@anymail.com 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) City or Town Anytown 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 1-9: An Alien Registration Number/USCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: OR Address (Street Number and Name) Form I-9 10/21/2019 Middle Initial Other Last Names Used (if any) W USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 State KS Signature of Employee Jonathan W. Doe 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.) City or Town First Name (Given Name) ZIP Code 54932 Employee's Telephone Number 620-555-2299 Today's Date (mm/dd/yyyy) 05/02/2022 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) STOP Employer Completes Next Page STOP QR Code - Section 1 Do Not Write In This Space State ZIP Code Page 1 of 3