Temporary Employment Agreement

NAME: / SOCIAL SECURITY NUMBER OR PID:
HOME PHONE: / CELL PHONE:
ADDRESS(STREET, CITY, STATE AND ZIP): / BIRTH DATE:
START DATE: / TERMINATION DATE:
DEPARTMENT NAME AND NUMBER: / SUPERVISOR NAME:
HOURLY PAY RATE: / TOTAL ESTIMATED EARNINGS:
ACCOUNT #: / TITLE:
DESCRIPTION OF WORK PERFORMED:
CHECK ONE BOX FORETHINICITY: / Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican,
South or Central American, or other Spanish culture or origin,
regardless of race. / Not Hispanic or Latino
CHECK ONE OR MORE OF THE FOLLOWING TO DESCRIBE YOURRACE:
Asian
/ American Indian / Alaskan Native / Black or African American
/ Native Hawaiian or Other Pacific Islander
/ White

Signed:
Initiating Officer: X DATE: / Signed:
Dean: X Date:

TO BE COMPLETED BY TEMPORARY EMPLOYEE: AFTER INITIAL APPOINTMENT, COMPLETE TAX INFO ONLY TO MAKE CHANGES.

FEDERAL INCOME TAX WITHOLDING (W-4) COMPLETED ONLY IF MAKING A CHANGE AFTER INITIAL APPOINTMENT
  1. Marital Status: Single Married Married, but withhold at higher Single Rate
  2. Total number of allowances (EXEMPTIONS) I am claiming:
  3. Additional amount, if any, you want deducted from each check:
  4. I claim exemption because:
  1. Last year I did not owe any Federal income tax and had a right to a full refund of all income tax.
  2. This year I do not expect to owe any Federal income tax and expect to have a right to a full refund of all income tax withheld.
-If A and B are both applicable, you must CHECK both and enter EXEMPT here:
STATE INCOME TAX WITHOLDING (L-4)
1. EXEMPTIONS:
(a) If you claim neither yourself nor your spouse enter “0;” or (b) if you claim yourself enter “1;” or
(c) If you claim yourself and your spouse enter “2” here:
2. CREDITS:
If during the past year you will provide more than one-half support of persons closely related to you (other than your spouse)
enter the number of dependents here:
RETIREMENT STYSTEM
I AM AN ACTIVE CONTRIBUTING MEMBER OF:
  1. Teachers’ Retirement System of Louisiana:
  2. State Employees’ Retirement System of Louisiana:
  3. Other:

I understand that:
  1. My completed I-9 form (with a copy of my Drivers License and Social Security Card) will accompany my initial appointment form.
  2. Form I-9 must be completed on the FIRST DAY OF EMPLOYMENT.
  3. Social Security and Medicare taxes will be deducted from my check.
  4. I will notify the Office of Human Resources Management of address changes and/or direct deposit changes.
  5. I understand that all direct deposits will go to the last designated bank account on file in Human Resources Office. Any changes must be designated on a new direct deposit form.

Employee Signature: X______Date ______

Revised 06/2012