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Welcome to the Walt Disney World Resort! - Disney Careers

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NEW EMPLOYEE SELF-IDENTIFICATION FORMIt is <strong>the</strong> policy of <strong>the</strong> Company <strong>to</strong> provide equal opportunity for all employees and applicants for employment withoutregard <strong>to</strong> race, religion, color, sex, sexual orientation, gender identity, national origin, age, marital status, covered veteranstatus, mental or physical disability, pregnancy, or any o<strong>the</strong>r basis prohibited by state or federal law.To help <strong>the</strong> Company comply with federal/state equal employment opportunity record keeping, reporting and o<strong>the</strong>r legalrequirements, please fill out <strong>the</strong> following information:GENDER: Male FemaleETHNICITY (Select only one category that most closely represents your ethnic group):Are you Hispanic or Latino? NO (Not Hispanic or Latino) YESRACE (Select <strong>the</strong> category that most closely represents your ethnic group): NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (Not Hispanic or Latino) ASIAN (Not Hispanic or Latino) BLACK OR AFRICAN AMERICAN (Not Hispanic or Latino) AMERICAN INDIAN OR ALASKAN NATIVE (Not Hispanic or Latino) WHITE (Not Hispanic or Latino) TWO OR MORE RACES (Not Hispanic or Latino) DO NOT WISH TO DISCLOSENAME (Please Print or Type)DATESOCIAL SECURITY NUMBERDATE OF BIRTH


AGREEMENTCAST MEMBER IDEAS AND SUGGESTIONSThe <strong>Disney</strong> tradition and culture is rooted in a legacy of excellence - excellence in exceeding ourguests’ needs and expectations, excellence in fostering a fun and enriching working environmentand excellence in creating value for our shareholders.Each member of <strong>the</strong> WALT DISNEY WORLD® <strong>Resort</strong> cast plays an important role in thiscommitment <strong>to</strong> excellence. Each cast member helps <strong>to</strong> make <strong>the</strong> dreams come true and create <strong>the</strong>magical memories our guests will cherish forever. To continue our success, each of us, as part ofour day-<strong>to</strong>-day responsibilities as cast members, can help WALT DISNEY WORLD <strong>Resort</strong>maintain its position as <strong>the</strong> premier vacation destination in <strong>the</strong> world by paying attention <strong>to</strong> <strong>the</strong>details and searching for new ways <strong>to</strong> improve guest satisfaction and our working environment,not for financial reward, but as part of a team which is committed <strong>to</strong> improvement.I understand that this Agreement allows me <strong>to</strong> have <strong>the</strong> opportunity <strong>to</strong> share my thoughts on ways<strong>to</strong> improve <strong>the</strong> experience of WALT DISNEY WORLD <strong>Resort</strong> guests, increase operationalefficiencies or o<strong>the</strong>rwise enhance <strong>the</strong> WALT DISNEY WORLD <strong>Resort</strong>. I fur<strong>the</strong>r understand thatthis is a limited exception <strong>to</strong> The <strong>Walt</strong> <strong>Disney</strong> Company’s policy regarding <strong>the</strong> submission ofunsolicited ideas and in consideration of this I agree that <strong>the</strong> following terms and conditions shallgovern with respect <strong>to</strong> any ideas or suggestions I submit or o<strong>the</strong>rwise communicate <strong>to</strong> The <strong>Walt</strong><strong>Disney</strong> Company or any of its related, subsidiary or affiliated companies (each, a “<strong>Disney</strong>Company”) at any time during my employment by a <strong>Disney</strong> Company, whe<strong>the</strong>r or not such ideasor suggestions are related <strong>to</strong> matters that are included within my regular job responsibilities:I agree that all ideas or suggestions I submit or o<strong>the</strong>rwise communicate shall immediately become<strong>the</strong> sole property of The <strong>Walt</strong> <strong>Disney</strong> Company, and I hereby assign all rights (including, withoutlimitation, copyright and patent) that I might have or acquire <strong>the</strong>rein <strong>to</strong> The <strong>Walt</strong> <strong>Disney</strong>Company. I understand and agree that no payment or o<strong>the</strong>r compensation shall be payable by any<strong>Disney</strong> Company in connection with any ideas or suggestions I submit or o<strong>the</strong>rwisecommunicate, whe<strong>the</strong>r or not <strong>the</strong> ideas or suggestions are implemented, and that any idea orsuggestion I submit or o<strong>the</strong>rwise communicate may be used in any manner (or not used at all) andfor any purpose by any <strong>Disney</strong> Company. I shall only submit or o<strong>the</strong>rwise communicate ideas orsuggestions that have been created and developed solely by me and I agree that no o<strong>the</strong>r partyholds any rights with respect <strong>to</strong> <strong>the</strong>se ideas and suggestions. I fur<strong>the</strong>r acknowledge and agree thatI shall continue <strong>to</strong> be bound by <strong>the</strong> terms of my confidentiality agreement with The <strong>Walt</strong> <strong>Disney</strong>Company and that, for purposes of that confidentiality agreement, <strong>the</strong> ideas or suggestions Isubmit or o<strong>the</strong>rwise communicate relate <strong>to</strong> <strong>the</strong> business of a <strong>Disney</strong> Company and/or result fromwork performed by me for a <strong>Disney</strong> Company. I agree that no variation, modification, waiver,change or amendment of this Agreement shall be binding upon any <strong>Disney</strong> Company unless suchvariation, modification, change or amendment is in writing and duly authorized and executed by acorporate officer of The <strong>Walt</strong> <strong>Disney</strong> Company.SignatureDateName (Print)Social Security Number


WALT DISNEY WORLD CO. AND AFFILIATED COMPANIESCAST MEMBER POLICIES, PROCEDURES AND TERMSThe following are examples of expressly forbidden conduct that you cannot do, even one time, and which maylead <strong>to</strong> disciplinary action, not excluding termination:• Our Guests may not always be right, but <strong>the</strong>y will always be our Guests. You may never insult, arguewith, be discourteous <strong>to</strong>, or use profane language in <strong>the</strong> presence of our Guests.• Fighting at <strong>the</strong> WALT DISNEY WORLD® <strong>Resort</strong>, regardless of who started it, may result in terminationof <strong>the</strong> parties involved.• Falsification of any documents or records, such as medical forms, payroll records, or employment applications,may lead <strong>to</strong> dismissal.• Personally using, being in possession of, or being under <strong>the</strong> influence of any controlled substance,in<strong>to</strong>xicants, drugs, or hallucina<strong>to</strong>ry agents on Company property, or reporting <strong>to</strong> work under suchconditions, may result in dismissal.• <strong>Walt</strong> <strong>Disney</strong> <strong>World</strong> Co. and affiliated companies, as responsible vendors of alcoholic beverages, wish<strong>to</strong> advise all Cast Members that Florida law prohibits <strong>the</strong> purchase, possession, and consumption ofalcoholic beverages by persons under <strong>the</strong> age of 21 years, as outlined in <strong>the</strong> form titled “Manda<strong>to</strong>ryRequirements for Sale and Service of Alcoholic Beverages by Employees.” Fur<strong>the</strong>r, it is unlawful fora person of legal drinking age <strong>to</strong> purchase or provide alcoholic beverages <strong>to</strong> a person under <strong>the</strong> age of21 years. Therefore, any Cast Member who violates this law on our property at any time commits aserious breach of Company policy and will be subject <strong>to</strong> termination.• Conviction of, plea of no contest, plea of guilty, or acceptance of any pre-trial diversion in lieu of chargeof, any morals charge, felony, or misdemeanor o<strong>the</strong>r than minor traffic offenses, may result in termination.• Violations of operating rules and procedures that could result in bodily injury <strong>to</strong> Guests or Cast Members,or damage <strong>to</strong> Company property, may result in termination.• Gambling or sleeping while on duty are not allowed.• Only tipped employees may accept tips, but <strong>the</strong>y may not solicit tips or gratuities in any way.• Willful insubordination may result in dismissal.• Dishonesty or misconduct that is detrimental <strong>to</strong> <strong>the</strong> Company, or a Cast Member’s conduct outside ofwork while on Company property that proves <strong>to</strong> be a serious infraction, may result in termination.• Continued violation of <strong>the</strong> WALT DISNEY WORLD Appearance Policy may result in dismissal.• Excessive tardiness or absenteeism, three days of unreported absence, or failure <strong>to</strong> return <strong>to</strong> work froma leave or vacation may result in termination.• Violation of <strong>the</strong> Company’s Substance Abuse Policy may result in dismissal.• Theft of any food, beverage, merchandise (including items earmarked for disposal), services, orproperty belonging <strong>to</strong> <strong>Walt</strong> <strong>Disney</strong> <strong>World</strong> Co., its affiliated and related companies, a guest, or fellow employee,may result in termination.Please remember that whe<strong>the</strong>r you are at work, on your way <strong>to</strong> or from work, or at <strong>the</strong> WALT DISNEY WORLD<strong>Resort</strong> as a Guest, you are still a Cast Member and should conduct yourself accordingly. Any violation ofCompany policy on or off property at any time may result in disciplinary action, not excluding termination.I have read and understand <strong>the</strong> above policies and have received a copy of this document.Signature:Name (Print):Date:Social Security Number:


ACKNOWLEDGMENT OF POLICYCOMPUTER USAGE AND SECURITYIt is <strong>the</strong> policy of <strong>the</strong> Company that its computer systems be used appropriately and in a secure environment.CONFIDENTIAL INFORMATION AND SECURITY(Employee Policy Manual P. 13-14)A. Any access <strong>to</strong> any proprietary or confidential Company information by anyone without a need <strong>to</strong> know isprohibited.B. Any disclosure of any proprietary or confidential information, including employee, cus<strong>to</strong>mer, or vendorinformation, <strong>to</strong> anyone without a need <strong>to</strong> know is prohibited.C. All employees are required <strong>to</strong> ensure that <strong>the</strong> Company’s assets are protected against improper use,disclosure, <strong>the</strong>ft, compromise or destruction. Employees must:• Follow all Security Policies and Standards issued by <strong>the</strong> Information Technology Department.• Not subvert or disable password, virus detection, or o<strong>the</strong>r security protections.• Not disclose or share passwords or o<strong>the</strong>r security features.• Not attempt unauthorized access <strong>to</strong> any Company computer system, device, site or asset.• Not attempt <strong>to</strong> access any Company computer system, device, network, site or o<strong>the</strong>r asset from anyunauthorized device, location, or software.• Report incidents of any attempted information security breach or security lapse <strong>to</strong> management.• Participate in periodic security awareness training.D. The use of computer passwords does not constitute any promise of confidentiality <strong>to</strong> any employeeregarding any communications or material created, accessed or s<strong>to</strong>red through <strong>the</strong> use of such passwords.E. Management, in its sole discretion and without fur<strong>the</strong>r notice, may periodically access, moni<strong>to</strong>r, review,disclose, and control any aspect of access <strong>to</strong> or use of Company computer resources (e.g., equipment,software, systems, networks, data, documentation, or files, including individual employee computer files,electronic mail, or Internet usage).F. Employees whose employment with <strong>the</strong> Company has terminated or whose duties no longer require use ofCompany computer systems or access <strong>to</strong> Company data must return <strong>to</strong> <strong>the</strong>ir supervisor all Companyproperty and equipment used in connection with Company computer systems. Such items include, withoutlimitation, keys, access badges and computer equipment.I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE POLICY.SignatureDateName (Print)Social Security Number


COSTUMINGCostuming Issue and Return PolicyCast Member Understanding and Authorization for Payroll DeductionThe costumes issued <strong>to</strong> you by <strong>the</strong> Company will remain <strong>the</strong> property of <strong>Walt</strong> <strong>Disney</strong> <strong>World</strong> Co. It is yourobligation <strong>to</strong> return <strong>the</strong> costumes issued <strong>to</strong> you by <strong>the</strong> specified due date if it is on a short term basis (specialissue), or upon termination of your employment. You will be financially responsible through payrolldeduction for any costumes that are not returned <strong>to</strong> <strong>Walt</strong> <strong>Disney</strong> <strong>World</strong> Co. as requested or are damaged inexcess of normal wear and tear. Costumes may be returned <strong>to</strong> any WDW Costuming location.Specifically, if at any time you exceed <strong>the</strong> number of costumes you are allotted or you are issued a costumeon a short term basis (i.e., a special issue costume and/or accessory causing you <strong>to</strong> exceed your authorizedcostume allotment,) it is your responsibility <strong>to</strong> return it by <strong>the</strong> specified due date, which is one (1) week from<strong>the</strong> issue date. IMPORTANT: If a costume or accessory is not returned by <strong>the</strong> required due date, youwill be subject <strong>to</strong> payroll deduction(s) for <strong>the</strong> amount of <strong>the</strong> costume and/or accessory. Your pay willbe au<strong>to</strong>matically deducted up <strong>to</strong> twenty-five dollars ($25.00) per week until <strong>the</strong> cost of <strong>the</strong> item isrecovered.Cast Members replacing lost name tags will also be subject <strong>to</strong> an au<strong>to</strong>matic payroll deduction for <strong>the</strong>replacement cost of <strong>the</strong> name tag.Upon termination from <strong>the</strong> Company, it is your responsibility <strong>to</strong> return all costume items issued <strong>to</strong> you. If youfail <strong>to</strong> do so you will be subject <strong>to</strong> payroll deduction from your final paycheck. Your pay will be deducted for<strong>the</strong> <strong>to</strong>tal dollar value of all costume items issued <strong>to</strong> you.In addition, <strong>the</strong> costumes issued <strong>to</strong> you are not <strong>to</strong> be given, sold, loaned, leased, rented or transferred <strong>to</strong> anyo<strong>the</strong>r person. Fur<strong>the</strong>rmore, failure <strong>to</strong> return <strong>the</strong> costumes issued <strong>to</strong> you may be considered <strong>the</strong>ft of Companyproperty and may result in disciplinary action, up <strong>to</strong> and including termination. Additionally, your use of <strong>the</strong>costumes issued <strong>to</strong> you is governed by <strong>the</strong> policies set forth by <strong>the</strong> <strong>Walt</strong> <strong>Disney</strong> <strong>World</strong> Co. relating <strong>to</strong> <strong>the</strong> useof your costumes off property.I certify that I have read, understand and acknowledge this document.I understand and authorize that when I do not return any costumes or accessoriesby <strong>the</strong> designated Company due date, I will be subject <strong>to</strong> an au<strong>to</strong>matic payrolldeduction up <strong>to</strong> twenty-five ($25.00) dollars per week until <strong>the</strong> <strong>to</strong>tal cost of <strong>the</strong>item(s) is recovered. I also understand that if I terminate from <strong>the</strong> Company anddo not return any costume items issued <strong>to</strong> me, a deduction will be made from myfinal paycheck for <strong>the</strong> <strong>to</strong>tal dollar value of <strong>the</strong>se costume items.Employee SignatureDateName (Print)Social Security NumberRev. 4-17-09


Form W-4 (2012)Purpose. Complete Form W-4 so that youremployer can withhold <strong>the</strong> correct federal incometax from your pay. Consider completing a new FormW-4 each year and when your personal or financialsituation changes.Exemption from withholding. If you are exempt,complete only lines 1, 2, 3, 4, and 7 and sign <strong>the</strong>form <strong>to</strong> validate it. Your exemption for 2012 expiresFebruary 18, 2013. See Pub. 505, Tax Withholdingand Estimated Tax.Note. If ano<strong>the</strong>r person can claim you as adependent on his or her tax return, you cannot claimexemption from withholding if your income exceeds$950 and includes more than $300 of unearnedincome (for example, interest and dividends).Basic instructions. If you are not exempt, complete<strong>the</strong> Personal Allowances Worksheet below. Theworksheets on page 2 fur<strong>the</strong>r adjust yourwithholding allowances based on itemizeddeductions, certain credits, adjustments <strong>to</strong> income,or two-earners/multiple jobs situations.Complete all worksheets that apply. However, youmay claim fewer (or zero) allowances. For regularwages, withholding must be based on allowancesyou claimed and may not be a flat amount orpercentage of wages.Head of household. Generally, you can claim headof household filing status on your tax return only ifyou are unmarried and pay more than 50% of <strong>the</strong>costs of keeping up a home for yourself and yourdependent(s) or o<strong>the</strong>r qualifying individuals. SeePub. 501, Exemptions, Standard Deduction, andFiling Information, for information.Tax credits. You can take projected tax credits in<strong>to</strong>account in figuring your allowable number ofwithholding allowances. Credits for child ordependent care expenses and <strong>the</strong> child tax creditmay be claimed using <strong>the</strong> Personal AllowancesWorksheet below. See Pub. 505 for information onconverting your o<strong>the</strong>r credits in<strong>to</strong> withholdingallowances.Nonwage income. If you have a large amount ofnonwage income, such as interest or dividends,consider making estimated tax payments using Form1040-ES, Estimated Tax for Individuals. O<strong>the</strong>rwise, youmay owe additional tax. If you have pension or annuityincome, see Pub. 505 <strong>to</strong> find out if you should adjustyour withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have aworking spouse or more than one job, figure <strong>the</strong><strong>to</strong>tal number of allowances you are entitled <strong>to</strong> claimon all jobs using worksheets from only one FormW-4. Your withholding usually will be most accuratewhen all allowances are claimed on <strong>the</strong> Form W-4for <strong>the</strong> highest paying job and zero allowances areclaimed on <strong>the</strong> o<strong>the</strong>rs. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien,see Notice 1392, Supplemental Form W-4Instructions for Nonresident Aliens, beforecompleting this form.Check your withholding. After your Form W-4 takeseffect, use Pub. 505 <strong>to</strong> see how <strong>the</strong> amount you arehaving withheld compares <strong>to</strong> your projected <strong>to</strong>tal taxfor 2012. See Pub. 505, especially if your earningsexceed $130,000 (Single) or $180,000 (Married).Future developments. The IRS has created a pageon IRS.gov for information about Form W-4, atwww.irs.gov/w4. Information about any futuredevelopments affecting Form W-4 (such aslegislation enacted after we release it) will be postedon that page.Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A• You are single and have only one job; orB Enter “1” if:{ • You are married, have only one job, and your spouse does not work; or . . . B• Your wages from a second job or your spouse’s wages (or <strong>the</strong> <strong>to</strong>tal of both) are $1,500 or less.C Enter “1” for your spouse. But, you may choose <strong>to</strong> enter “-0-” if you are married and have ei<strong>the</strong>r a working spouse or morethan one job. (Entering “-0-” may help you avoid having <strong>to</strong>o little tax withheld.) . . . . . . . . . . . . . . CD Enter number of dependents (o<strong>the</strong>r than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan <strong>to</strong> claim a credit . . . F(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.• If your <strong>to</strong>tal income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; <strong>the</strong>n less “1” if you have three <strong>to</strong>seven eligible children or less “2” if you have eight or more eligible children.• If your <strong>to</strong>tal income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child . . . GH Add lines A through G and enter <strong>to</strong>tal here. (Note. This may be different from <strong>the</strong> number of exemptions you claim on your tax return.) ▶ H{• If you plan <strong>to</strong> itemize or claim adjustments <strong>to</strong> income and want <strong>to</strong> reduce your withholding, see <strong>the</strong> DeductionsFor accuracy, and Adjustments Worksheet on page 2.complete all • If you are single and have more than one job or are married and you and your spouse both work and <strong>the</strong> combinedworksheets earnings from all jobs exceed $40,000 ($10,000 if married), see <strong>the</strong> Two-Earners/Multiple Jobs Worksheet on page 2 <strong>to</strong>that apply. avoid having <strong>to</strong>o little tax withheld.• If nei<strong>the</strong>r of <strong>the</strong> above situations applies, s<strong>to</strong>p here and enter <strong>the</strong> number from line H on line 5 of Form W-4 below.Form W-4Department of <strong>the</strong> TreasuryInternal Revenue ServiceSeparate here and give Form W-4 <strong>to</strong> your employer. Keep <strong>the</strong> <strong>to</strong>p part for your records.Employee's Withholding Allowance Certificate▶ Whe<strong>the</strong>r you are entitled <strong>to</strong> claim a certain number of allowances or exemption from withholding issubject <strong>to</strong> review by <strong>the</strong> IRS. Your employer may be required <strong>to</strong> send a copy of this form <strong>to</strong> <strong>the</strong> IRS.1 Your first name and middle initial Last nameOMB No. 1545-007420122 Your social security numberHome address (number and street or rural route)3 Single Married Married, but withhold at higher Single rate.Note. If married, but legally separated, or spouse is a nonresident alien, check <strong>the</strong> “Single” box.City or <strong>to</strong>wn, state, and ZIP code4 If your last name differs from that shown on your social security card,check here. You must call 1-800-772-1213 for a replacement card. ▶5 Total number of allowances you are claiming (from line H above or from <strong>the</strong> applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2012, and I certify that I meet both of <strong>the</strong> following conditions for exemption.• Last year I had a right <strong>to</strong> a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect <strong>to</strong> have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7Under penalties of perjury, I declare that I have examined this certificate and, <strong>to</strong> <strong>the</strong> best of my knowledge and belief, it is true, correct, and complete.Employee’s signature(This form is not valid unless you sign it.) ▶Date ▶8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending <strong>to</strong> <strong>the</strong> IRS.) 9 Office code (optional) 10 Employer identification number (EIN)For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2012)


Form W-4 (2012) Page 2Deductions and Adjustments WorksheetNote. Use this worksheet only if you plan <strong>to</strong> itemize deductions or claim certain credits or adjustments <strong>to</strong> income.1 Enter an estimate of your 2012 itemized deductions. These include qualifying home mortgage interest,charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, andmiscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . . 1 $$11,900 if married filing jointly or qualifying widow(er)2 Enter:{$8,700 if head of household}. . . . . . . . . . . 2 $$5,950 if single or married filing separately3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2012 adjustments <strong>to</strong> income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter <strong>the</strong> <strong>to</strong>tal. (Include any amount for credits from <strong>the</strong> Converting Credits <strong>to</strong>Withholding Allowances for 2012 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2012 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide <strong>the</strong> amount on line 7 by $3,800 and enter <strong>the</strong> result here. Drop any fraction . . . . . . . 89 Enter <strong>the</strong> number from <strong>the</strong> Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 910 Add lines 8 and 9 and enter <strong>the</strong> <strong>to</strong>tal here. If you plan <strong>to</strong> use <strong>the</strong> Two-Earners/Multiple Jobs Worksheet,also enter this <strong>to</strong>tal on line 1 below. O<strong>the</strong>rwise, s<strong>to</strong>p here and enter this <strong>to</strong>tal on Form W-4, line 5, page 1 10Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if <strong>the</strong> instructions under line H on page 1 direct you here.1 Enter <strong>the</strong> number from line H, page 1 (or from line 10 above if you used <strong>the</strong> Deductions and Adjustments Worksheet) 12 Find <strong>the</strong> number in Table 1 below that applies <strong>to</strong> <strong>the</strong> LOWEST paying job and enter it here. However, ifyou are married filing jointly and wages from <strong>the</strong> highest paying job are $65,000 or less, do not enter morethan “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 If line 1 is more than or equal <strong>to</strong> line 2, subtract line 2 from line 1. Enter <strong>the</strong> result here (if zero, enter“-0-”) and on Form W-4, line 5, page 1. Do not use <strong>the</strong> rest of this worksheet . . . . . . . . . 3Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below <strong>to</strong> figure <strong>the</strong> additionalwithholding amount necessary <strong>to</strong> avoid a year-end tax bill.4 Enter <strong>the</strong> number from line 2 of this worksheet . . . . . . . . . . 45 Enter <strong>the</strong> number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find <strong>the</strong> amount in Table 2 below that applies <strong>to</strong> <strong>the</strong> HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter <strong>the</strong> result here. This is <strong>the</strong> additional annual withholding needed . . 8 $9 Divide line 8 by <strong>the</strong> number of pay periods remaining in 2012. For example, divide by 26 if you are paidevery two weeks and you complete this form in December 2011. Enter <strong>the</strong> result here and on Form W-4,line 6, page 1. This is <strong>the</strong> additional amount <strong>to</strong> be withheld from each paycheck . . . . . . . . 9 $Table 1Table 2Married Filing JointlyAll O<strong>the</strong>rsMarried Filing JointlyAll O<strong>the</strong>rsIf wages from LOWESTpaying job are—Enter online 2 above$0 - $5,000 05,001 - 12,000 112,001 - 22,000 222,001 - 25,000 325,001 - 30,000 430,001 - 40,000 540,001 - 48,000 648,001 - 55,000 755,001 - 65,000 865,001 - 72,000 972,001 - 85,000 1085,001 - 97,000 1197,001 - 110,000 12110,001 - 120,000 13120,001 - 135,000 14135,001 and over 15If wages from LOWESTpaying job are—Enter online 2 above$0 - $8,000 08,001 - 15,000 115,001 - 25,000 225,001 - 30,000 330,001 - 40,000 440,001 - 50,000 550,001 - 65,000 665,001 - 80,000 780,001 - 95,000 895,001 - 120,000 9120,001 and over 10Privacy Act and Paperwork Reduction Act Notice. We ask for <strong>the</strong> information on thisform <strong>to</strong> carry out <strong>the</strong> Internal Revenue laws of <strong>the</strong> United States. Internal Revenue Codesections 3402(f)(2) and 6109 and <strong>the</strong>ir regulations require you <strong>to</strong> provide this information; youremployer uses it <strong>to</strong> determine your federal income tax withholding. Failure <strong>to</strong> provide aproperly completed form will result in your being treated as a single person who claims nowithholding allowances; providing fraudulent information may subject you <strong>to</strong> penalties. Routineuses of this information include giving it <strong>to</strong> <strong>the</strong> Department of Justice for civil and criminallitigation; <strong>to</strong> cities, states, <strong>the</strong> District of Columbia, and U.S. commonwealths and possessionsfor use in administering <strong>the</strong>ir tax laws; and <strong>to</strong> <strong>the</strong> Department of Health and Human Servicesfor use in <strong>the</strong> National Direc<strong>to</strong>ry of New Hires. We may also disclose this information <strong>to</strong> o<strong>the</strong>rcountries under a tax treaty, <strong>to</strong> federal and state agencies <strong>to</strong> enforce federal nontax criminallaws, or <strong>to</strong> federal law enforcement and intelligence agencies <strong>to</strong> combat terrorism.If wages from HIGHESTpaying job are—Enter online 7 above$0 - $70,000 $57070,001 - 125,000 950125,001 - 190,000 1,060190,001 - 340,000 1,250340,001 and over 1,330If wages from HIGHESTpaying job are—Enter online 7 above$0 - $35,000 $57035,001 - 90,000 95090,001 - 170,000 1,060170,001 - 375,000 1,250375,001 and over 1,330You are not required <strong>to</strong> provide <strong>the</strong> information requested on a form that is subject <strong>to</strong> <strong>the</strong>Paperwork Reduction Act unless <strong>the</strong> form displays a valid OMB control number. Books orrecords relating <strong>to</strong> a form or its instructions must be retained as long as <strong>the</strong>ir contents maybecome material in <strong>the</strong> administration of any Internal Revenue law. Generally, tax returns andreturn information are confidential, as required by Code section 6103.The average time and expenses required <strong>to</strong> complete and file this form will vary dependingon individual circumstances. For estimated averages, see <strong>the</strong> instructions for your income taxreturn.If you have suggestions for making this form simpler, we would be happy <strong>to</strong> hear from you.See <strong>the</strong> instructions for your income tax return.

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