i9-verification – BEACON LIGHT HOME

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START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

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ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Employee Information and Attestation — complete no later than first day of employment

Personal Identity

Last Name (Family Name)

First Name (Given Name)

M.I.

Other Last Names Used

Residential Address

Street Address

Apt. / Unit (if any)

City or Town

State

ZIP Code

Personal Details

Date of Birth

U.S. Social Security No.

Employee's Email Address

Telephone Number

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I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1 A citizen of the United States 2 A noncitizen national of the United States (See Instructions.) 3 A lawful permanent resident (Enter USCIS or A-Number.) 4 A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

Form I-94 Admission Number

Foreign Passport No. & Country

Signature of Employee

✍️ Draw your signature here

Today's Date (mm/dd/yyyy)

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If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Verification Submitted Successfully

Thank you. Your Form I-9 Section 1: Employee Information and Attestation has been successfully validated and recorded.

Employee Name: -

Submission Date: -

Attestation Code: -

Submission Failed

An error occurred while processing your verification form. Please try again.