com W-11 Hiring Incentives to Restore Employment (HIRE) Act fons Employee Affidavit >» Do not send this form to the IRS. Keep this form for your records. ‘To be completed by new employes, Affidavit is not valid unless employee signs it. | cory that | ave been unemployed or have net worked for anyone for more than 40 hours during the 60-day period ending on the date | began employment wth this employer. Your name ‘Social security number ® Fest date of employment ase Name of employer ne Under penaties of perjury, | declare that | have examined this stfidavit and, to the best of my knowledge and belie, Is true, corract, and complete, roles sana ole rt Instructions to the Arausites aloe" an areloyen your sng stepsblng you erento Employer + begins employment with you after stepparent your nae nape, your Secon references aot the itera ier aetetr ie. aja aan ear ornate et Cat saiataranacants, Rakes ane er onpojesisaquatesemooyeeunder PT NaN Sheu gunginesocay Spondon Sta dopanet ef anyone ‘who owe more than 50% of your emoioye the HIRE Act. You can use ancther period ending on the Gate te employee gutstanding stock or capital and profs Similar statement ft contalne ihe Eagins employment with you: ‘Moret. information above and the employee spre tuner panales of perry” +s not employed by you to replace Ir you ere an estte ots, see fe saa de another ermployee unless the other section 51) ad section 182(812 for roquremorts oa quale employee aoreiporiream wage | comnnearn ‘may complete this afidavit or simtar Sly eee eee ‘Do not send this form to the IRS. ‘Statement. You cannot Gaim the HIRE : PA cco win your other payrot ‘Act Danes, ineuding the payrol tax + ts notrolatod to you. An employes is EEREN and income fax records exomplion or tho now Ae tention Felated to you ha or ahe is your chic or Credit unless the employee completes descendent of your eh fand signs this affidavit or salar Statomont under penalties of perry and 's otherwise a qualified employes. Gane ar Fon WTt ao