Minnesota C lerical, Inc. Payroll Specialist

A step in the right direction!

Welcome to Minnesota Clerical, Inc.

Please find attached the necessary forms that need to be completed, signed, dated, and returned to the office. The Acknowledgement of Responsibility form (service provider) in the packet is to be signed by you, the employee. Also needed with the I-9 form is a

There is a signed Agreement between MN Clerical, Inc. and its clients recognizing that the staff will be employees of MN Clerical, Inc as a (PEO) Professional Employers Organization. The co-employment is established to assist with the HR portion of employee staffing, while the client oversees all aspects of the employment.

As a new employee I would like to explain the pay period procedure. The pay periods run bi-weekly; every other Tuesday is the end of a pay period. On that Tuesday the hours are to be reported to Minnesota Clerical, Inc. along with the employee number you are assigned, please fax:(763)753-7246, email: roxanneolsen@mnclericalinc.com or report via the website: www.mnclericalinc.com. The client will need to be notified of the hoursplease cc: the timecard via email.The payroll is processed and direct deposited to the employee account on that Friday after the last day of the pay period. A paper encrypted check stub will be emailed to you for your records.

MN Clerical, Inc. does offer at no cost to eligible employees the following benefits: $25k life insurance, LTD, and AD&D coverage. If you work 25+ hours per week please complete the life beneficary form in the packet. There is a voluntary employee sponsored benefit package available to you, including Dental, vision, STD, and other plans please check this information on our website at www.mnclericalinc.com or contact the office.

If you have any questions on the employee packet, or payroll reporting please feel free to give me a call. I look forward to working with you and will handle the payroll processing with over thirty years of experience.

Sincerely,

Roxanne L. Olsen President

Minnesota Clerical, Inc 17230 Uplander Street NW

Andover MN 55304 Office: 763-753-7243 Fax: 763-753-7246

MN Clerical, Inc. considers applicants for all positions without regard to race, color, creed, religion, sex, sexual orientation, marital status, age, national origin, veteran/military status, status with regard to public assistance, membership or activity on a local commission, disability, familial status or any other legally protected status.

1. Title of position(s) for which you are applying: 2. Date of Application

Mo. Day Yr. 3. Are you available to work: □ Regular Full-Time □ Regular Part-Time

Days & Hours Available: 4. Home Phone: 5: Cell Phone: 6. Salary Desired?

7. Name: 8: Work Phone

May we contact you at this number? Yes No 9. Address

Street City State Zip

10. Are you over the age of 18? □ Yes □ No

11. Have you ever submitted an application with the company before? □ Yes □ No

Have you ever been employed with the company before? □ Yes □ No If yes, please give dates:

12. Is anyone related to you employed by MN Clerical, Inc.? □ Yes □ No

If yes, please give their name and relationship to you:13. Do you have a valid drivers license? (For driving positions only.) □ Yes □ No

Have you been convicted of any moving violations in the past five years? □ Yes □ NoIf yes, please explain:Do you have restrictions for travel on the job? □ Yes □ No

14. Are you legally eligible to work in the U.S.? □ Yes □ No If hired, you will be required to provide proof of such eligibility.

15. Can you, with or without reasonable accommodation, perform the essential functions of this job?□ Yes □ No

(If you have questions about the function of the job, please ask the interviewer before answering this question.)

16. How did you hear about us?

□ Newspaper Ad □ Employment Agency □ Current Employee:____________ □ Other:_________________

email address

EDUCATION Education Level School Name/Address Years

Completed Did you

Graduate? Degree/Major GPA

High School / GED

□ Yes □ No

Vocational School

□ Yes □ No

College □ Yes □ No

Graduate School □ Yes □ No

OTHER TRAINING, CERTIFICATIONS, LICENSES, SKILLS, AND EXPERIENCE

List any special skills, professional activities, achievements, academic honors, awards or other information related to the position you are applying for (include special training, courses, equipment operated, computer skills, and other relevant skills). Use back page of application if necessary. Do not list any which reflect your race, color, creed, religion, sex, sexual orientation, marital status, age, national origin, veteran/military status, status with regard to public assistance, membership or activity on a local commission, disability, or any other legally protected characteristic. Have you received any job-related training in the United States Military? □ Yes □ No Please give dates and explanation:

EMPLOYMENT Please list your previous employers for the last ten years, starting with the most recent first. Include relevant military or unpaid work

experience, if any. Use Page 3 of application if necessary. Previous salaries or wages will not be used to determine compensation. Please do not use resume in place of requested information.

1 Name of Current/Most Recent Employer Main Telephone Number (include area code)

Type of Business May we contact this employer? □ Yes □ No

Street Address Employment dates (include month and year) From: To:

City, State, Zip

Your Job Title: Wages (Circle: Annual or Hourly) Start: End: Bonus/Commissions

Brief Description of Responsibilities:

Name/Title of Supervisor: Supervisors direct phone number:

2 Previous Employer Main Telephone Number (include area code)

Type of Business May we contact this employer? □ Yes □ No

Street Address Employment dates (include month and year) From: To:

City, State, Zip

Your Job Title: Wages (Circle: Annual or Hourly) Start: End: Bonus/Commissions

Brief Description of Responsibilities:

Name/Title of Supervisor: Supervisors direct phone number:

3 Previous Employer Main Telephone Number (include area code)

Type of Business May we contact this employer? □ Yes □ No

Street Address Employment dates (include month and year) From: To:

City, State, Zip

Your Job Title: Wages (Circle: Annual or Hourly) Start: End: Bonus/Commissions

Brief Description of Responsibilities:

Name/Title of Supervisor: Supervisors direct phone number:

REFERENCES Give name, address, and telephone number of three business references who are not related to you.

NAME ADDRESS TELEPHONE

Are you subject to a non-compete, non-disclosure or confidentiality agreement with any current or former employer that would affect your employment with MN Clerical, Inc.? □ Yes □ No Are you subject to a restrictive covenant (e.g., non-compete and/or non-solicitation agreement) with any current former employer that would affect your employment with MN Clerical, Inc.? □ Yes □ No

ADDITIONAL EMPLOYMENT INFORMATION

OTHER JOB RELATED INFORMATION

CANDIDATE STATEMENT ◘ PLEASE READ CAREFULLY BEFORE SIGNING ◘

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be the cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that the submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by MN Clerical, Inc. that such employment with the Company is AT WILL, for no specified duration and may be terminated by either the Company or myself at anytime, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of the Company or its representatives used during the employment process is deemed a contract of employment, real or implied. I understand that no representative of the Company, except the president, has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the president of MN Clerical, Inc.. In consideration for employment with MN Clerical, Inc., if employed, I agree to conform to the rules, regulations, policies and procedures of the Company at all times and understand that such obedience is a condition of employment. I understand that due to the nature of the Company’s business, attendance and punctuality are considered essential requirements of every job at the Company and that poor attendance or tardiness will result in disciplinary action. I authorize you to communicate with persons listed as references, former employers, and any others with whom you desire to check. I agree to hold such persons harmless with respect to any information they may give about me. If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could reflect adversely on the Company. I understand this decision is to rest with the Company. If employed, I agree to hold in strictest confidence any information concerning the Company which may come to my knowledge. I understand that if employed by the Company, I may be required to sign a confidentiality disclosure and/or, a non-compete agreement. I understand that if offered a position with the Company I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand those unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to MN Clerical, Inc. and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application. I understand that in the event that employment disputes arise between the Company and me, the Company and I will resolve these disputes through an Alternative Dispute Resolution Agreement. The ADR Agreement provides for final and binding arbitration. This ADR Policy applies to all disputes. THE ADR AGREEMENT DOES, HOWEVER, PRECLUDE ME FROM PERSUING COURT ACTION REGARDING ANY SUCH DISPUTES. I understand that an offer of employment is conditional on my providing documentation necessary to establish my identity and eligibility to work in the United States in accordance with the requirements of the Immigration and Naturalization Services I-9 form, and completion of the company’s standard employee agreement concerning patents and confidential information. In consideration of my employment, I agree to abide by all policies and regulations of the Company. My signature is evidence that I have read, understood, and agree with the above statements.

Signature of Applicant: _________________________________________________ Date:

Form W-4 (2016)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, 2017. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2016. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other 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 $2,000 of child or dependent care expenses for which you plan to 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 total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20161 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 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 the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to 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 to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the 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 to the 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 (2016)

ACKNOWLEDGEMENT OF RESPONSBILITIES (SERVICE PROVIDER-STAFF)

On this__________day of ______________________20______, Minnesota Clerical, Inc.

a Minnesota Corporation, hereinafter referred to as Minnesota Clerical, and acknowledge

the following as a summary of the responsibilities of the parties herein:

1. Minnesota Clerical is responsible for making final determination in the hiring

of all Service Providers for clerical and secretarial services requested by its clients.

2. In the event it should become necessary to discipline any Service Provider

providing clerical and secretarial services for its clients, Minnesota Clerical shall make

the final decision regarding the continued employment status of such Service Providers,

upon the advice and information of its client.

3. Issues regarding compensation, benefits, vacation, and any other terms,

conditions or benefits of employment, except as stated in paragraph 2 above, are to be

determined solely between the Service Provider and the client of Minnesota Clerical to

whom the clerical and secretarial services are being provided.

4. Nothing herein is intended to prevent either party to this Acknowledgement

from terminating their relationship with other at any time and both parties agree that

their relationship is voluntary and “at will”.

Minnesota Clerical, Inc.

By: ___________________________ _____________________________ Roxanne L. Olsen (Service Provider/Employee signature) 17230 Uplander Street NW Andover, MN 55304

Employer Name Employee Name Employee Social Security # Current Address City State ZIP Home Phone Work Phone please enter all dates in mm/dd/yyyy format

Primary and Contingent Beneficiaries – Unless you designate a percentage, proceeds are paid to primary surviving beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or contingent).

Basic Term Life Insurance, Life Insurance Company of North America - Policy No.

Employee’s Primary Beneficiary(ies): Relationship Social Security Number Date

of Birth % (total must equal 100%)

Employee’s Contingent Beneficiary(ies): Relationship Social Security Number Date

of Birth % (total must equal 100%)

Basic Accident Insurance, Life Insurance Company of North America - Policy No.

Employee’s Primary Beneficiary(ies): Relationship Social Security Number Date

of Birth % (total must equal 100%)

Employee’s Contingent Beneficiary(ies): Relationship Social Security Number Date

of Birth % (total must equal 100%)

If you need additional space using the above format, attach a separate piece of paper with the appropriate policy number, the date, and your signature.

Note: This form is not complete without your signature. Please sign the form where indicated.

Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as beneficiary, it is possible that payment of benefits may be delayed or disputed unless your spouse also signs the beneficiary designation.

Spouse Signature Date / /

Owner Signature Date / /

BENEFICIARY DESIGNATION FORM Life Insurance Company of North America

GUIDELINES FOR DESIGNATION OF BENEFICIARIES

General - Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries.

Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child’s estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation.

Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: “To [name of trustee], trustee of the [name of trust], under a trust agreement dated [date of trust].”

If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should recognize the possibility that your will which was intended to create this trust may not be admitted to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation.

Life Status Changes - We recommend that you review your beneficiary designation when significant life status events occur, such as marriage, divorce, or birth of a child.

See an Attorney! The above guidelines are general and are not intended to be relied on as legal advice. Unless your designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation. A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear and unambiguous, and meets legal requirements.

MNsure Coverage Options and Your Health Coverage: For Employees whose Employers do not offer health coverage

General Information When key parts of the health care law known as the Affordable Care Act take effect, there will be a new place to buy health insurance in Minnesota: MNsure. To assist you as you evaluate options for you and your family, this notice provides some basic information about MNsure and employment-based health coverage offered by your employer.

What is MNsure? MNsure is designed to help you find health insurance that meets your needs and fits your budget. MNsure offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium for health insurance plans sold through MNsure or free or low-cost insurance from Medical Assistance or MinnesotaCare. Open enrollment for health insurance coverage through MNsure begins in October 2013 for coverage starting January 1, 2014.

Can I Save Money on my Health Insurance Premiums through MNsure? Yes. You may qualify to save money and lower or eliminate your monthly premium. You may qualify for a tax credit or MinnesotaCare only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through MNsure? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit or MinnesotaCare through MNsure and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, a reduction in certain cost-sharing, or MinnesotaCare if your employer does not offer coverage at all or offers coverage that does not meet certain standards. If the cost of a plan from your employer for you, the employee only, is more than 9.5% of your household income for the year, or if the coverage does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1If you are seeking help paying costs for health coverage through MNsure, you will need information about the cost and value of your employer coverage to complete an online or paper application. If your employer offers health coverage to you, ask your employer to complete and give you the Health Coverage from Jobs (Appendix A) form. If your employer does not offer coverage to you, you do not need your employer to complete the Health Coverage from Jobs (Appendix A) form.

Note: If you purchase a health plan through MNsure instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution, as well as your employee contribution to employer-offered coverage, is often excluded from income for Federal and State income tax purposes. Your payments for coverage through MNsure are made on an after-tax basis.

How Can I Get More Information? There is help available to you to evaluate your coverage options through MNsure, including your eligibility for coverage through MNsure and its cost. Please visit www.mnsure.org for more information, including an online application for health insurance coverage, or call 1-855-3MNsure (1-855-366-7873).

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by theplan is no less than 60 percent of such costs.

Minnesota C lerical, Inc. Payroll Specialist

A step in the right direction!

PA Y R O L L DIR E C T D EPOSI T A U T H O RI Z A T I O N F O R M

Please check one: ______ New Participant ______ Change in Account

Employee Name: ______________________________________________

Employee Number: _____________ SS #: _________________________

Until revoked by me in writing Minnesota Clerical, Inc. is hereby authorized to deposit my net pay each pay period directly to my bank or financial institution as shown below. I authorize the financial institution(s) listed below to accept and credit entries by Minnesota Clerical, Inc. to debit my account(s).

Bank or Financial Institution: _____________________________________

City/State/Zip: ________________________________________________

Account Number: ______________________________________________

Routing Number: ______________________________________________

Please check one: _________ Checking Account

_________ Savings Account

If requesting a specific amount be deposited each pay period to an account please indicate the amount: $____________________

For accuracy, please attach a voided check or for savings a deposit slip

Employee Signature: __________________________________ Date: _____________

Minnesota Clerical, Inc. 17230 Uplander Street NW* Andover MN 55304* 763-753-7243 Fax: 763-753-7246

The Company Employment Dispute Resolution Procedure