*880600*

Applicant Information Workshop Information

Applicant Name: Michael Wolniakowski Location: 2413 West Maple Avenue
Employee ID: 880600 Flint, MI 48507
Email: [email protected] Genesee ISD - Admin Building
Phone: 2489103740 Room 102 A/B
Date & Time: Wednesday, October 26, 2022 02:00 PM EDT
Bring the Following to the Workshop: Workshop Notes:
0
Form(s) of Identification
Driver's License
Social Security Card
Educational Documents (Substitute Teachers ONLY)
Official Transcripts or Teaching Certificate/License

*Be sure to bring ALL application page you were required to print/sign during the online application process.

Fingerprint Status
Completed
Yet to be completed
On File at:

School District & Employee Type Selection

School District(s): Employee Type(s):
Genesee ISD - Flint Community Schools Substitute Teacher

Written Changes to this Packet:

X
Applicant Signature
 Innovative Staffing Solutions for a Better Classroom Experience

APPLICANT ACKNOWLEDGEMENTS:

Equal Opportunity Employer: It is the policy of EDUStaff to prohibit unlawful discrimination in its personnel practices. This includes
all personnel practices, without regard to race, color, religion, sex, age, national origin, veteran status, disability, (or other) protected
status or activity, according to applicable law. If an employee feels that he/she has been subjected to or witnessed any
discrimination, he/she is to report this immediately to EDUStaff or a supervisor. Any complaint will be appropriately investigated.
When a complaint is made, no retaliation shall occur for the good faith complaint. When it is found that an employee has violated
this policy, appropriate action will be taken, up to and including termination. Michigan law requires that a person with a disability or
handicap requiring accommodation for employment must notify EDUStaff, LLC within 182-days after the need is known (the 182-day
limit on accommodation is pursuant to Michigan law but does not apply to federal law).

Offer of Employment: The completion of the application process, actions, and documentation does not constitute automatic
employment with EDUStaff. I recognize that my interactions with EDUStaff during the group orientation meeting are part of the
interview process and that EDUStaff may require additional interviewing and reference checks on top of any district required
interviews and procedures prior to offers of employment. As there are several factors concerning employment offers within a
“pooled dispatching” environment, I understand that there is no guarantee that my application for employment will be accepted.

Employment Relationship: I recognize that if an employment relationship is offered by EDUStaff, the employment relationship will
be with EDUStaff, not the District or ISD. Furthermore, my employment relationship will be considered an “at will” employment
relationship. This means there is no contractual relationship or promise made concerning my employment relationship beyond the
specific relational definitions outlined in the EDUStaff Employee Policy Manual. Ultimately either I or EDUStaff can terminate the
employment relationship with no cause and at any time.

District Approval & Removal: As listed on the first page of this application, I have selected district(s) and position(s) for potential
placement. I recognize that each District has the final authority to grant or deny my access for placement within their district.
Further, if I have been removed from a district, building, or program connected to previous employment or placement, these
removals will remain intact and without question with an employment offer from EDUStaff.

Wages & Local Taxes: You may choose to receive payment of your wages by either direct electronic deposit or payroll debit card. If I
have elected direct deposit, I authorize EDUStaff to initiate automatic deposits of my paycheck to my designated account(s) with my
designated financial institution(s). I understand that funds will be available the morning of my assigned pay day, or the day following
a banking holiday or closure. I further understand that a paycheck will not be mailed to me, but a copy of my check will be available
on my EDUAccess website. I understand that EDUStaff is not responsible for any banking penalties or fees in the event of a direct
deposit error based on either incorrect or incomplete information that I have provided or an error initiated by my financial
institution. In the event of a payroll payment error, I authorize EDUStaff to make additional credits or withdrawals from my
designated account equal to the specific payroll error. My selection of Direct Deposit will remain in effect throughout the duration
of my EDUStaff employment until I initiate a direct deposit change or choose to receive my wages via payroll debit card. If I have
elected to receive my wages via payroll debit card, I acknowledge that I have received and understand the cardholder fees
associated with the payroll debit card. If I have elected tax withholdings for a local taxing municipality, I authorize EDUStaff to
withhold my tax payment at the municipality residency rate. I further allow EDUStaff to pay this withholding upon my behalf as well
as any earnings reporting required by the taxing municipality.

EDUStaff Policies & Procedures: As part of the EDUStaff application process, I acknowledge that the EDUStaff Employee Policy
Manual is available to me electronically at www.edustaffonline.com. I agree to thoroughly read, become familiar with, and abide by
the policies and procedures set forth in this manual. Furthermore, if there are any policies that I do not fully understand, I will
initiate contact with an EDUStaff representative for clarification and assistance.

Coaches’ Code of Conduct: As part of the EDUStaff application process, I acknowledge that the Coaches Code of Conduct is available
to me electronically in the EDUStaff Employee Policy Manual at www.edustaffonline.com. I agree to thoroughly read, become
familiar with, and abide by the policies and procedures set forth in this manual. Furthermore, if there are any policies that I do not
fully understand, I will initiate contact with an EDUStaff representative for clarification and assistance.
Initials _______

4120 Brockton Dr. SE, Suite 200 P: 877.974.6338

Grand Rapids, MI 49512 F: 877.974.6339
www.EDUStaff.org
 Innovative Staffing Solutions for a Better Classroom Experience

Criminal Records Release: I authorize EDUStaff, the ISD, and participating School Districts to secure a criminal history record from
the appropriate law enforcement agency, consistent with current EDUStaff and school board policies and the State of Michigan
regulations. I also authorize EDUStaff and the appropriate school district(s) to release information about my criminal history record
information the school district(s) received concerning me to any employee of a non-public school or other school district to whom I
choose for positional services. I understand this information is required in evaluating my suitability for employment consistent with
Public Act 68 (1993) and Public Act 83 (1995). I fully release EDUStaff and chosen school districts to the maximum extent permitted
by law from any liability whatsoever in connection with either the release or the use of the report obtained from the Michigan
Department of State Police and the F.B.I.

Information Release: I understand that other information concerning my employment must be legally disclosed to a District, ISD,
the State of Michigan, and other governmental entities. According to the social security number (SSN) privacy act (act 2004 PA
454.MCL 445.881et seq.,) no EDUStaff employee shall intentionally obtain, save, dispense or dispose of any individual’s social
security number. In connection with my employment with EDUStaff, I authorize the release of my personal information, criminal
history background information, unprofessional conduct information, teaching certificate information, and any legitimately
requested employment application or verification information requested by an ISD, a participating school district, the Department of
Education, or other government entity.

Acceptable Use Policy: The use of contracted site technology is a privilege and not a right. Depending upon location, a school
district/ISD may require the contracted employee to sign a site specific technology agreement policy. The district/ISD may deny,
restrict, revoke or suspend specific user accounts at any time. The use of technology is intended for educational purposes only and is
limited to job specific functions. Personal use of district/ISD technology is prohibited. Any account user must preserve the privacy
and personal safety of the students. EDUStaff and the contracted site has the right, but not the obligation, to examine the content of
users’ documents or email or track websites visited by users. Any violation of the acceptable use policy will be subject to disciplinary
action up to and including termination.

Certification & Truthfulness: I certify that the information I have provided with this application is accurate, complete, and truthful
to the best of my knowledge. I acknowledge that any information found to be false, misrepresented, or not disclosed in connection
with this application is grounds for denial of my application for employment, offer for employment, and potentially future
termination of my employment. I authorize EDUStaff and its representatives the right to contact my previous employers,
references, public agencies, and educational entities to verify the information I have provided with this application. I hereby waive
any and all rights and claims I may have regarding EDUStaff for contacting, gathering, and using truthful and non-defamatory
information, in a lawful manner, in connection with analyzing my employment credentials and other employment related eligibility.

Michigan Retirement:
If I retired from a Michigan Public School after July 1, 2010, I recognize that it is my responsibility to contact the Michigan Office of
Retirement Services as it pertains to ORS “Core Services” rules that may affect my retirement benefits based on the Public Act 75
(2010).

APPLICANT ACKNOWLEDGEMENT & SIGNATURE:

By signing this applicant statement, I certify that I have read, acknowledge, and agree to all of my supplied application information
and the applicant acknowledgements:

Signature Date

4120 Brockton Dr. SE, Suite 200 P: 877.974.6338

Grand Rapids, MI 49512 F: 877.974.6339
www.EDUStaff.org
 Direct Deposit Agreement Form 
Authorization Agreement 
Authorization Agreement 

I hereby authorize Edustaff (hereafter “Company”) to initiate automatic deposits to my account at the financial institution (hereafter 
“Bank”) named below. I also acknowledge that the company is allowed to reverse and ACH/Direct Deposit credit entry made in error. 

Further, I agree not to hold the company responsible for any delay or loss of funds due to incorrect or incomplete information supplied 
by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. 

This agreement will remain in effect until Edustaff receives a written notice of cancellation from me or my financial institution, or until I 
submit a new direct deposit form to the payroll department.  

Employee – Required Information 

Employee Name / ID:  Michael Wolniakowski 880600

Primary Account Information 

Name of Financial Institution:  Huntington
Routing Number:   044000024
Account Number:  02367866024
Checking   x Savings

Deposit Amount:   100%

Percent (%)  x     Flat Dollar ($) 

 
Secondary Deposit Account Information 

Name of Financial Institution: 

Routing Number:  

Account Number: 
Checking  Savings 

 
TFG Visa@ Debit Card 

  I prefer to receive my wages via the Fintwist/Comdata Mastercard 
 Free Retail Purchase (Point of Sale/PIN & Signature Based, including cashback)
 Free Monthly Maintenance Fee
 ATM Withdrawal (Domestic, $1.90)

Signature 

Authorized Signature: Date:  10/13/2022

Rev. 3.8.2022 
 Michael Wolniakowski
Edustaff, LLC

Active Shooter 10/13/2022

A Guide For Substitute Teachers 10/13/2022
Allergy Management 10/13/2022
Bloodborne Pathogens 10/13/2022
COVID-19 Plan, Prepare, and Respond (Educational I 10/13/2022
EDUStaff Pre-Workshop 10/13/2022
FERPA 10/13/2022
Seclusion and Restraint 10/13/2022
Sexual Harassment 10/13/2022
State and Federal Laws: K12 10/13/2022
Title IX 10/13/2022
 Employment Eligibility Verification USCIS
Department of Homeland Security Form I-9
OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 10/31/2022

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Wolniakowski Michael
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
2020 Bagley Streer Flint MI 48504
Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

11/02/1974 331 -7 4 - 0 8 [email protected]

4 248.910.3740
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):

x 1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)
QR Code - Section 1
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 1 of 3

 Employment Eligibility Verification USCIS
Department of Homeland Security Form I-9
OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 10/31/2022

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
Employee Info from Section 1
Wolniakowski Michael Citizen
List A OR List B AND List C
Identity and Employment Authorization Identity Employment Authorization
Document Title Document Title Document Title
Driver's License Social Security Card
Issuing Authority Issuing Authority Issuing Authority
Social Security Administration
Document Number Document Number Document Number
W452603507843 331740854
Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy)
11/02/2023
Document Title

QR Code - Sections 2 & 3

Issuing Authority Additional Information Do Not Write In This Space

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Edustaff Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Edustaff LLC
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
4120 Brockton Dr. SE Grand Rapids MI 49512

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

Form I-9 10/21/2019 Page 2 of 3

 LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.

LIST A LIST B LIST C

Documents that Establish Documents that Establish Documents that Establish
Both Identity and Identity Employment Authorization
Employment Authorization OR AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number
State or outlying possession of the card, unless the card includes one of
2. Permanent Resident Card or Alien
United States provided it contains a the following restrictions:
Registration Receipt Card (Form I-551)
photograph or information such as (1) NOT VALID FOR EMPLOYMENT
name, date of birth, gender, height, eye
3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH
temporary I-551 stamp or temporary INS AUTHORIZATION
I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH
readable immigrant visa government agencies or entities, DHS AUTHORIZATION
provided it contains a photograph or
4. Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued
that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms
I-766) DS-1350, FS-545, FS-240)
3. School ID card with a photograph
5. For a nonimmigrant alien authorized 3. Original or certified copy of birth
to work for a specific employer 4. Voter's registration card certificate issued by a State,
because of his or her status: county, municipal authority, or
5. U.S. Military card or draft record territory of the United States
a. Foreign passport; and
6. Military dependent's ID card bearing an official seal
b. Form I-94 or Form I-94A that has
the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document
(1) The same name as the passport; Card
5. U.S. Citizen ID Card (Form I-197)
and
8. Native American tribal document
(2) An endorsement of the alien's 6. Identification Card for Use of
nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United
that period of endorsement has government authority States (Form I-179)
not yet expired and the
proposed employment is not in For persons under age 18 who are 7. Employment authorization
conflict with any restrictions or unable to present a document document issued by the
limitations identified on the form. Department of Homeland Security
listed above:
6. Passport from the Federated States
10. School record or report card
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with 11. Clinic, doctor, or hospital record
Form I-94 or Form I-94A indicating
nonimmigrant admission under the 12. Day-care or nursery school record
Compact of Free Association Between
the United States and the FSM or RMI

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 10/21/2019 Page 3 of 3

Form W-4 Employee’s Withholding Certificate OMB No. 1545-0074

2022
a Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a Give Form W-4 to your employer.
Department of the Treasury
Internal Revenue Service a Your withholding is subject to review by the IRS.

(a) First name and middle initial Last name (b) Social security number
Step 1:
Enter
Michael Wolniakowski 331-74-0854
Address a Does your name match the
Personal name on your social security
2020 Bagley Streer
Information City or town, state, and ZIP code card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
Flint, MI 48504 www.ssa.gov.
(c) X Single or Married filing separately
Married filing jointly or Qualifying widow(er)
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.

Step 2: Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
Multiple Jobs also works. The correct amount of withholding depends on income earned from all of these jobs.
or Spouse Do only one of the following.
Works (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate
withholding; or
(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This
option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . a
N
TIP: To be accurate, submit a 2022 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Claim Multiply the number of qualifying children under age 17 by $2,000 a $
Dependents a
Multiply the number of other dependents by $500 . . . . $

Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $0

Step 4 (a) Other income (not from jobs). If you want tax withheld for other income you
(optional): expect this year that won’t have withholding, enter the amount of other income here.
This may include interest, dividends, and retirement income . . . . . . . . 4(a) $ 0
Other
Adjustments (b) Deductions. If you expect to claim deductions other than the standard deduction and
want to reduce your withholding, use the Deductions Worksheet on page 3 and enter
the result here . . . . . . . . . . . . . . . . . . . . . . . 4(b) $ 0
(c) Extra withholding. Enter any additional tax you want withheld each pay period . . 4(c) $ $0.00

Step 5: Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Sign
10/13/2022
F

Here
Employee’s signature (This form is not valid unless you sign it.) Date

Employers Employer’s name and address First date of Employer identification

employment number (EIN)
Only

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2022)
Form W-4 (2022) Page 2

General Instructions Specific Instructions

Section references are to the Internal Revenue Code. Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
Future Developments compute your withholding.
For the latest information about developments related to Step 2. Use this step if you (1) have more than one job at the
Form W-4, such as legislation enacted after it was published, same time, or (2) are married filing jointly and you and your
go to www.irs.gov/FormW4. spouse both work.
Purpose of Form Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
Complete Form W-4 so that your employer can withhold the
little less accuracy.
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax If you (and your spouse) have a total of only two jobs, you
return and may owe a penalty. If too much is withheld, you may instead check the box in option (c). The box must also
will generally be due a refund. Complete a new Form W-4 be checked on the Form W-4 for the other job. If the box is
when changes to your personal or financial situation would checked, the standard deduction and tax brackets will be
change the entries on the form. For more information on cut in half for each job to calculate withholding. This option
withholding and when you must furnish a new Form W-4, is roughly accurate for jobs with similar pay; otherwise, more
see Pub. 505, Tax Withholding and Estimated Tax. tax than necessary may be withheld, and this extra amount
will be larger the greater the difference in pay is between the
Exemption from withholding. You may claim exemption
two jobs.
from withholding for 2022 if you meet both of the following
Multiple jobs. Complete Steps 3 through 4(b) on only
conditions: you had no federal income tax liability in 2021
and you expect to have no federal income tax liability in F ! one Form W-4. Withholding will be most accurate if
CAUTION
you do this on the Form W-4 for the highest paying job.
2022. You had no federal income tax liability in 2021 if (1)
your total tax on line 24 on your 2021 Form 1040 or 1040-SR Step 3. This step provides instructions for determining the
is zero (or less than the sum of lines 27a, 28, 29, and 30), or amount of the child tax credit and the credit for other
(2) you were not required to file a return because your dependents that you may be able to claim when you file your
income was below the filing threshold for your correct filing tax return. To qualify for the child tax credit, the child must
status. If you claim exemption, you will have no income tax be under age 17 as of December 31, must be your
withheld from your paycheck and may owe taxes and dependent who generally lives with you for more than half
penalties when you file your 2022 tax return. To claim the year, and must have the required social security number.
exemption from withholding, certify that you meet both of You may be able to claim a credit for other dependents for
the conditions above by writing “Exempt” on Form W-4 in whom a child tax credit can’t be claimed, such as an older
the space below Step 4(c). Then, complete Steps 1(a), 1(b), child or a qualifying relative. For additional eligibility
and 5. Do not complete any other steps. You will need to requirements for these credits, see Pub. 501, Dependents,
submit a new Form W-4 by February 15, 2023. Standard Deduction, and Filing Information. You can also
Your privacy. If you prefer to limit information provided in include other tax credits for which you are eligible in this
Steps 2 through 4, use the online estimator, which will also step, such as the foreign tax credit and the education tax
increase accuracy. credits. To do so, add an estimate of the amount for the year
to your credits for dependents and enter the total amount in
As an alternative to the estimator: if you have concerns
Step 3. Including these credits will increase your paycheck
with Step 2(c), you may choose Step 2(b); if you have
and reduce the amount of any refund you may receive when
concerns with Step 4(a), you may enter an additional amount
you file your tax return.
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box Step 4 (optional).
in Step 2(c), which will increase your withholding and Step 4(a). Enter in this step the total of your other
significantly reduce your paycheck (often by thousands of estimated income for the year, if any. You shouldn’t include
dollars over the year). income from any jobs or self-employment. If you complete
When to use the estimator. Consider using the estimator at Step 4(a), you likely won’t have to make estimated tax
www.irs.gov/W4App if you: payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
1. Expect to work only part of the year;
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
2. Have dividend or capital gain income, or are subject to
Step 4(b). Enter in this step the amount from the
additional taxes, such as Additional Medicare Tax;
Deductions Worksheet, line 5, if you expect to claim
3. Have self-employment income (see below); or deductions other than the basic standard deduction on your
4. Prefer the most accurate withholding for multiple job 2022 tax return and want to reduce your withholding to
situations. account for these deductions. This includes both itemized
deductions and other deductions such as for student loan
Self-employment. Generally, you will owe both income and interest and IRAs.
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an Step 4(c). Enter in this step any additional tax you want
employee. If you want to pay these taxes through withheld from your pay each pay period, including any
withholding from your wages, use the estimator at amounts from the Multiple Jobs Worksheet, line 4. Entering
www.irs.gov/W4App to figure the amount to have withheld. an amount here will reduce your paycheck and will either
increase your refund or reduce any amount of tax that you
Nonresident alien. If you’re a nonresident alien, see Notice owe.
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Form W-4 (2022) Page 3

Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1 Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.

a Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $

b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b $

c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c $

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $

Step 4(b)—Deductions Worksheet (Keep for your records.)

1 Enter an estimate of your 2022 itemized deductions (from Schedule A (Form 1040)). Such deductions
may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to
$10,000), and medical expenses in excess of 7.5% of your income . . . . . . . . . . . . 1 $

{ }
• $25,900 if you’re married filing jointly or qualifying widow(er)
2 Enter: • $19,400 if you’re head of household . . . . . . . . 2 $
• $12,950 if you’re single or married filing separately

3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater
than line 1, enter “-0-” . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $

4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information . . . . 4 $

5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $

Privacy Act and Paperwork Reduction Act Notice. We ask for the information You are not required to provide the information requested on a form that is
on this form to carry out the Internal Revenue laws of the United States. Internal subject to the Paperwork Reduction Act unless the form displays a valid OMB
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to control number. Books or records relating to a form or its instructions must be
provide this information; your employer uses it to determine your federal income retained as long as their contents may become material in the administration of
tax withholding. Failure to provide a properly completed form will result in your any Internal Revenue law. Generally, tax returns and return information are
being treated as a single person with no other entries on the form; providing confidential, as required by Code section 6103.
fraudulent information may subject you to penalties. Routine uses of this The average time and expenses required to complete and file this form will vary
information include giving it to the Department of Justice for civil and criminal depending on individual circumstances. For estimated averages, see the
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and instructions for your income tax return.
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We If you have suggestions for making this form simpler, we would be happy to hear
may also disclose this information to other countries under a tax treaty, to federal from you. See the instructions for your income tax return.
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
Form W-4 (2022) Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary
Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 -
Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000
$0 - 9,999 $0 $110 $850 $860 $1,020 $1,020 $1,020 $1,020 $1,020 $1,020 $1,770 $1,870
$10,000 - 19,999 110 1,110 1,860 2,060 2,220 2,220 2,220 2,220 2,220 2,970 3,970 4,070
$20,000 - 29,999 850 1,860 2,800 3,000 3,160 3,160 3,160 3,160 3,910 4,910 5,910 6,010
$30,000 - 39,999 860 2,060 3,000 3,200 3,360 3,360 3,360 4,110 5,110 6,110 7,110 7,210
$40,000 - 49,999 1,020 2,220 3,160 3,360 3,520 3,520 4,270 5,270 6,270 7,270 8,270 8,370
$50,000 - 59,999 1,020 2,220 3,160 3,360 3,520 4,270 5,270 6,270 7,270 8,270 9,270 9,370
$60,000 - 69,999 1,020 2,220 3,160 3,360 4,270 5,270 6,270 7,270 8,270 9,270 10,270 10,370
$70,000 - 79,999 1,020 2,220 3,160 4,110 5,270 6,270 7,270 8,270 9,270 10,270 11,270 11,370
$80,000 - 99,999 1,020 2,820 4,760 5,960 7,120 8,120 9,120 10,120 11,120 12,120 13,150 13,450
$100,000 - 149,999 1,870 4,070 6,010 7,210 8,370 9,370 10,510 11,710 12,910 14,110 15,310 15,600
$150,000 - 239,999 2,040 4,440 6,580 7,980 9,340 10,540 11,740 12,940 14,140 15,340 16,540 16,830
$240,000 - 259,999 2,040 4,440 6,580 7,980 9,340 10,540 11,740 12,940 14,140 15,340 16,540 17,590
$260,000 - 279,999 2,040 4,440 6,580 7,980 9,340 10,540 11,740 12,940 14,140 16,100 18,100 19,190
$280,000 - 299,999 2,040 4,440 6,580 7,980 9,340 10,540 11,740 13,700 15,700 17,700 19,700 20,790
$300,000 - 319,999 2,040 4,440 6,580 7,980 9,340 11,300 13,300 15,300 17,300 19,300 21,300 22,390
$320,000 - 364,999 2,100 5,300 8,240 10,440 12,600 14,600 16,600 18,600 20,600 22,600 24,870 26,260
$365,000 - 524,999 2,970 6,470 9,710 12,210 14,670 16,970 19,270 21,570 23,870 26,170 28,470 29,870
$525,000 and over 3,140 6,840 10,280 12,980 15,640 18,140 20,640 23,140 25,640 28,140 30,640 32,240
Single or Married Filing Separately
Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary
Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 -
Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000
$0 - 9,999 $400 $930 $1,020 $1,020 $1,250 $1,870 $1,870 $1,870 $1,870 $1,970 $2,040 $2,040
$10,000 - 19,999 930 1,570 1,660 1,890 2,890 3,510 3,510 3,510 3,610 3,810 3,880 3,880
$20,000 - 29,999 1,020 1,660 1,990 2,990 3,990 4,610 4,610 4,710 4,910 5,110 5,180 5,180
$30,000 - 39,999 1,020 1,890 2,990 3,990 4,990 5,610 5,710 5,910 6,110 6,310 6,380 6,380
$40,000 - 59,999 1,870 3,510 4,610 5,610 6,680 7,500 7,700 7,900 8,100 8,300 8,370 8,370
$60,000 - 79,999 1,870 3,510 4,680 5,880 7,080 7,900 8,100 8,300 8,500 8,700 8,970 9,770
$80,000 - 99,999 1,940 3,780 5,080 6,280 7,480 8,300 8,500 8,700 9,100 10,100 10,970 11,770
$100,000 - 124,999 2,040 3,880 5,180 6,380 7,580 8,400 9,140 10,140 11,140 12,140 13,040 14,140
$125,000 - 149,999 2,040 3,880 5,180 6,520 8,520 10,140 11,140 12,140 13,320 14,620 15,790 16,890
$150,000 - 174,999 2,040 4,420 6,520 8,520 10,520 12,170 13,470 14,770 16,070 17,370 18,540 19,640
$175,000 - 199,999 2,720 5,360 7,460 9,630 11,930 13,860 15,160 16,460 17,760 19,060 20,230 21,330
$200,000 - 249,999 2,970 5,920 8,310 10,610 12,910 14,840 16,140 17,440 18,740 20,040 21,210 22,310
$250,000 - 399,999 2,970 5,920 8,310 10,610 12,910 14,840 16,140 17,440 18,740 20,040 21,210 22,310
$400,000 - 449,999 2,970 5,920 8,310 10,610 12,910 14,840 16,140 17,440 18,740 20,040 21,210 22,470
$450,000 and over 3,140 6,290 8,880 11,380 13,880 16,010 17,510 19,010 20,510 22,010 23,380 24,680
Head of Household
Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary
Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 -
Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000
$0 - 9,999 $0 $760 $910 $1,020 $1,020 $1,020 $1,190 $1,870 $1,870 $1,870 $2,040 $2,040
$10,000 - 19,999 760 1,820 2,110 2,220 2,220 2,390 3,390 4,070 4,070 4,240 4,440 4,440
$20,000 - 29,999 910 2,110 2,400 2,510 2,680 3,680 4,680 5,360 5,530 5,730 5,930 5,930
$30,000 - 39,999 1,020 2,220 2,510 2,790 3,790 4,790 5,790 6,640 6,840 7,040 7,240 7,240
$40,000 - 59,999 1,020 2,240 3,530 4,640 5,640 6,780 7,980 8,860 9,060 9,260 9,460 9,460
$60,000 - 79,999 1,870 4,070 5,360 6,610 7,810 9,010 10,210 11,090 11,290 11,490 11,690 12,170
$80,000 - 99,999 1,870 4,210 5,700 7,010 8,210 9,410 10,610 11,490 11,690 12,380 13,370 14,170
$100,000 - 124,999 2,040 4,440 5,930 7,240 8,440 9,640 10,860 12,540 13,540 14,540 15,540 16,480
$125,000 - 149,999 2,040 4,440 5,930 7,240 8,860 10,860 12,860 14,540 15,540 16,830 18,130 19,230
$150,000 - 174,999 2,040 4,460 6,750 8,860 10,860 12,860 15,000 16,980 18,280 19,580 20,880 21,980
$175,000 - 199,999 2,720 5,920 8,210 10,320 12,600 14,900 17,200 19,180 20,480 21,780 23,080 24,180
$200,000 - 449,999 2,970 6,470 9,060 11,480 13,780 16,080 18,380 20,360 21,660 22,960 24,250 25,360
$450,000 and over 3,140 6,840 9,630 12,250 14,750 17,250 19,750 21,930 23,430 24,930 26,420 27,730
MI-W4
(Rev. 12-20)

EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE

STATE OF MICHIGAN - DEPARTMENT OF TREASURY
This certificate is for Michigan income tax withholding purposes only. Read instructions on page 2 before completing this form.

Issued under P.A. 281 of 1967. 41. Full Social Security Number 42. Date of Birth
331740854 11/02/1974
43. Name (First, Middle Initial, Last) 4. Driver’s License Number or State ID
Michael Wolniakowski 0
Home Address (No., Street, P.O. Box or Rural Route) 45. Are you a new employee? (mm/dd/yyyy)
2020 Bagley Streer Yes If Yes, enter date of hire........
City or Town State ZIP Code
No
Flint MI 48504

6. Enter the number of personal and dependent exemptions (see instructions) ........................................................... 46.

7. Additional amount you want deducted from each pay (if employer agrees) ...................................................................7. $ $0.00 .00

8. I claim exemption from withholding because (see instructions):

a. A Michigan income tax liability is not expected this year.

b. Wages are exempt from withholding. Explain: ___________________________________________________________________________________________________

c. Permanent home (domicile) is located in the following Renaissance Zone: _____________________________________________________________________

EMPLOYEE: If you fail or refuse to file this form, your employer must withhold Michigan income tax from your wages without allowance for any
exemptions. Keep a copy of this form for your records. See additional instructions on page 2.

Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number I am allowed to
claim. If claiming exemption from withholding, I certify that I do not anticipate a Michigan income tax liability this year.

9. Employee’s Signature 4Date

EMPLOYER: Complete the below section.

10. Employer’s Name 411. Federal Employer Identification Number
EDUStaff LLC 27-3229048
Address (No., Street, P.O. Box or Rural Route) City or Town State ZIP Code
4120 Brockton Dr SE MI 49512
Grand Rapids
Name of Contact Person Contact Phone Number
Jodi Center 877-974-6338
INSTRUCTIONS TO EMPLOYER: Keep a copy of this certificate with your records. All new hires must be reported to the State of Michigan. See
www.mi-newhire.com for information.

In addition, a copy of this form must be sent to the Michigan Department of Treasury if the employee claims 10 or more exemptions or claims they are
exempt from withholding. Send a copy to:
Michigan Department of Treasury
Tax Technical Section
P.O. Box 30477
Lansing, MI 48909
 INSTRUCTIONS TO EMPLOYEE’S
MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE (Form MI-W4)
You must submit a Michigan withholding exemption Line 7: You may designate additional withholding if you
certificate (form MI-W4) to your employer on or before expect to owe more than the amount withheld.
the date that employment begins. If you fail or refuse
Line 8a: You may claim exemption from Michigan income
to submit this certificate, your employer must withhold
tax withholding if all of the following conditions are met:
tax from your compensation without allowance for any
exemptions. Your employer is required to notify the i) Your employment is intermittent, temporary, or less
Michigan Department of Treasury if you have claimed 10 than full time;
or more personal or dependency exemptions or claimed
ii) Your personal and dependency exemptions exceed
that you are exempt from withholding.
your annual taxable compensation;
You MUST provide a new MI-W4 to your employer
iii) You claimed exemption from federal withholding;
within 10 days if your residency status changes or if
and
your exemptions decrease because: a) your spouse, for
whom you have been claiming an exemption, is divorced iv) You did not incur a Michigan income tax liability for
or legally separated from you or claims his/her own the previous year.
exemption(s) on a separate certificate, or b) a dependent
Line 8b: Reasons wages might be exempt from
no longer qualifies under the Internal Revenue Code.
withholding include:
Line 5: If you check “Yes,” enter your date of hire.
• You are a nonresident spouse of military personnel
Line 6: Personal and dependency exemptions. The stationed in Michigan.
number of exemptions claimed here may not exceed
• You are a resident of one of the following reciprocal
the number of exemptions you are entitled to claim on a
states while working in Michigan: Illinois, Indiana,
Michigan Individual Income Tax Return (Form MI-1040).
Kentucky, Minnesota, Ohio, or Wisconsin.
Dependents include qualifying children and qualifying
relatives under the Internal Revenue Code, even if your • You are an enrolled member of a federally-
AGI exceeds the limits to claim federal tax credits for recognized tribe that does not have a tax
them. agreement with the state of Michigan, you reside
within that tribe’s Indian Country (as defined in 18
Do not claim the same exemptions more than once or tax
USC 1151), and compensation from this job will be
will be under-withheld. Specifically, do not claim:
earned within that Indian Country.
• Your personal exemption if someone else will claim
Line 8c: For questions about Renaissance Zones,
you as their dependent.
contact your local assessor’s office.
• Your personal exemption with more than one
employer at a time.
• Your spouse’s personal exemption if they claim it
with their employer.
• Your dependency exemptions if someone else (for
example, your spouse) is claiming them with their
employer.
 880600

Conviction Disclosure Form

Michael Wolniakowski White
Name Race

11/02/1974 Male 0854

Maiden name DOB Gender SSN

Driver’s License # Position

Yes No
✔ Answer "Yes" if : you have been convicted of a misdemeanor or felony, pled guilty or nolo contendere
(no contest) to a misdemeanor or felony charge, pled guilty or no contest to a crime, you are awaiting
disposition of a pending criminal case?

✔ Have you had a teaching, school counselor, school psychologist, or school administrator certificate
suspended or revoked?

✔ Is there currently action pending against your teaching, school counselor, school psychologist, or school
administrator certificate?

✔ Have you ever surrendered or nullified a teaching, school counselor, school psychologist, or school
administrator certificate?

✔ Has this conviction/action previously been disclosed to State Department of Education?

In signing this form, I understand and agree that:

• If I have been convicted of a Listed Offense, my employment shall be terminated. I also understand that if I
have been convicted of a felony other than a listed offense, the superintendent or chief administrator
and the board or governing body of the district(s) where I work must each approve my work assignment
in writing.
• Until the criminal history report is received and reviewed by the employing school district, I am regarded
as a conditional employee and if the criminal history report is not the same as my representation(s)
above, my employment is voidable at the option of the employer.
• By signing this document (electronically or otherwise), I acknowledge that any district where I work or
intend to work has the authority to run a criminal conviction history check at any time while I am
employed by EDUStaff.

Signature Date

4120 Brockton Dr SE P: (877) 974-6338

Suite 200 F: (877) 974-6339
Grand Rapids, MI 49512 www.edustaff.org
 880600

Conviction Disclosure Form

(may be discarded if left blank)

List any convictions and/or actions on your criminal history record below.

LIST YEAR, TYPE (M=MISDEMEANOR, F=FELONY, P = PENDING), CONVICTION OR ARRANGEMENT &

EXPLANATION

Signature Date

4120 Brockton Dr SE P: (877) 974-6338

Suite 200 F: (877) 974-6339
Grand Rapids, MI 49512 www.edustaff.org
 2021-2022 EDUSTAFF EMPLOYEE INSTRUCTION GUIDE

I. All Employees:
a. Call and schedule an appointment for fingerprinting at the above phone number and
address.
b. Appointment times:
i. Tuesday: 1:00 pm-4:00 pm
ii. Wednesday: 7:30 am-11:30 am
iii. Thursday: 1:00 pm-5:30 pm
c. The process takes approximately 10-15 minutes.
d. We ONLY accept checks, money orders, and credit/debit cards. (Visa, MasterCard,
Discover)
i. Make the checks/money orders payable to “GISD” in the amount of $62.00.
e. You must bring a valid driver’s license/ID/passport.
f. ***New Instructions Regarding Covid Screening:
i. Wait in your vehicle until we call or text you when we are ready for your entry.
ii. Please come alone if possible.
iii. You will need to complete a short 4 question health screen survey and have your
temperature taken prior to entry.
iv. A face covering which covers your nose and mouth is required for entry into our
building and for your entire appointment.
II. Substitute Teachers:
a. You MUST bring your official transcripts or Valid/Expired teaching certificate.
i. At least 60 semester hours with a combined GPA of over 2.0.
b. You will fill out a Substitute Teacher packet with our fingerprint technician that will contain
your Livescan form. GISD will then be the source of your fingerprint results.
c. Upon check out, you will receive a release form to fill out. This will allow you to share your
results with multiple districts of your choosing.
III. Substitute Paraprofessionals:
a. You will fill out a Green packet with our fingerprint technician that will contain your Livescan
form. GISD will then be the source of your fingerprint results.
b. Upon check out, you will receive a release form to fill out. This will allow you to share your
results with multiple districts of your choosing.
 Flint Community Schools
Human Resources / Legal Affairs 880600
923 E. Kearsley Street • Flint, MI 48503 • (810) 760-1218
HR Staff: Use this form to request that another district send fingerprints to Flint Community Schools.

PUBLIC ACT 68 of 1993 and PUBLIC AT 83 of 1995

AUTHORIZATION FOR CRIMINAL RECORDS CHECK

RELEASE OF INFORMATION FROM A LOCAL DISTRICT

The undersigned is a candidate for employment with the Flint Community School District
and has indicated that a criminal records check was completed through the employment
process at your school district. The candidate is requesting that this information be
released to the Flint Community School District.

READ CAREFULLY – THIS DOCUMENT CONTAINS A RELEASE

Michael Wolniakowski x
Print Name ________________________ Male_____Female_____
First/Middle/Last

0854
Social Security # __xxx-xx-_______ 11/02/1974
Date of Birth __________

Genesee ISD
I hereby authorize ___________________________________ and its employees and
agents to forward a copy of my criminal records check for the purpose of evaluating my
qualifications as a candidate for employment with the Flint Community School District. I do
hereby release the school district, its individual board members employees, and agents, past
and present, from any and all claims and/or liability whatsoever for any damages or
consequences which may result from the pre-employment investigation, including the criminal
records check.

TCN# _______________________________

Human Resources/Labor Relations

Flint Community Schools
923 E. Kearsley Street
Flint, MI 48503

Fax: (810) 760-6834

[email protected]

Michael Wolniakowski
______________________________ __________
Print Full Name – Candidate Date

______________________________
Signature – Candidate

Dara Benton __________

Signature – District Representative Date
R:\Human_Resources\Forms-Letterhead\RELEASE CRIM REC CHECK 4-8-2021- Blank.doc
Revised: 4/8/2021
 880600

Edustaff, LLC Innovative Staffing Solutions for a Better Classroom Experience

EMPLOYEE REFERENCE CHECK FORM

The following individual has applied for a position with Edustaff, LLC and has authorized completion of the "Previous
Employer Statement" section of this form, and copies of any existing relevant unprofessional conduct documentation.

Applicant Name Wolniakowski,

Attn Human Resources Michael
Address LYONS TWO HS
100 S BRAINARD Date of Birth 11/02/1974
LAGRANGE IL 60525 SSN xxx-xx-0854

Please complete, sign, and return the attached form (and any appropriate supporting documentation) by any of the
following means:
MAIL: Attn: Reference Processing EMAIL: [email protected]
Edustaff, LLC FAX: 8779746339
4120 BROCKTON DR SE SUITE 200
GRAND RAPIDS MI 49512
If preferred, this can also be done online if you are kind enough to either send us an email address or call 8779746338
so you can be provided a link to do so.

Legal References and Applicant's Release

As a condition for employment with EDUStaff, LLC, to be contracted within an educational entity,
I authorize my current and former employer(s) and personal contact(s) to (1) disclose to EDUStaff the information
as listed in the reference questions below, (2) disclose to EDUStaff any unprofessional conduct by me, and (3)
make available to EDUStaff copies of all documents in my personnel record relating to any reported
unprofessional conduct.
I release my current and former employer(s) (and their employees acting on their behalf), and personal contact(s)
from any liability for providing the information described above.
I waive any written notice required in connection with the provision of such information.
Michigan Public Act 189 (1996) Section 380.1230(b): Unprofessional Conduct Definition: Public Act 189 defines
“unprofessional conduct” as one or more acts of misconduct, one or more acts of immorality, moral turpitude,
inappropriate behavior involving a minor, or commission of a crime involving a minor. A criminal conviction is not
an essential element of determining whether or not a particular act constitutes unprofessional conduct.
Bullard-Plawecki Employee Right to Know Act, MCLA 423.506: Any written notice required under section 6 is
waived in connection with the provision of such information.

Applicant Signature: Date:

4120 Brockton Dr SE P: 8779746338

E Grand Rapids, MI 49512 F: 8779746339
http://www.edustaff.org
 880600

Edustaff, LLC Innovative Staffing Solutions for a Better Classroom Experience

Previous Employer Statement

Can you certify that NO DOCUMENTATION OF Yes No
UNPROFESSIONAL CONDUCT exists with the
person's personnel file? (If "no", attach supporting
documentation)

Employer Signature: Date:

4120 Brockton Dr SE P: 8779746338

E Grand Rapids, MI 49512 F: 8779746339
http://www.edustaff.org
 880600

Edustaff, LLC Innovative Staffing Solutions for a Better Classroom Experience

EMPLOYEE REFERENCE CHECK FORM

The following individual has applied for a position with Edustaff, LLC and has authorized completion of the "Previous
Employer Statement" section of this form, and copies of any existing relevant unprofessional conduct documentation.

Applicant Name Wolniakowski,

Attn Human Resources Michael
Address TEMPO 1 PRESS
11131 WATERS EDGE DR Date of Birth 11/02/1974
ORLAND PARK IL 60525 SSN xxx-xx-0854

Please complete, sign, and return the attached form (and any appropriate supporting documentation) by any of the
following means:
MAIL: Attn: Reference Processing EMAIL: [email protected]
Edustaff, LLC FAX: 8779746339
4120 BROCKTON DR SE SUITE 200
GRAND RAPIDS MI 49512
If preferred, this can also be done online if you are kind enough to either send us an email address or call 8779746338
so you can be provided a link to do so.

Legal References and Applicant's Release

As a condition for employment with EDUStaff, LLC, to be contracted within an educational entity,
I authorize my current and former employer(s) and personal contact(s) to (1) disclose to EDUStaff the information
as listed in the reference questions below, (2) disclose to EDUStaff any unprofessional conduct by me, and (3)
make available to EDUStaff copies of all documents in my personnel record relating to any reported
unprofessional conduct.
I release my current and former employer(s) (and their employees acting on their behalf), and personal contact(s)
from any liability for providing the information described above.
I waive any written notice required in connection with the provision of such information.
Michigan Public Act 189 (1996) Section 380.1230(b): Unprofessional Conduct Definition: Public Act 189 defines
“unprofessional conduct” as one or more acts of misconduct, one or more acts of immorality, moral turpitude,
inappropriate behavior involving a minor, or commission of a crime involving a minor. A criminal conviction is not
an essential element of determining whether or not a particular act constitutes unprofessional conduct.
Bullard-Plawecki Employee Right to Know Act, MCLA 423.506: Any written notice required under section 6 is
waived in connection with the provision of such information.

Applicant Signature: Date:

4120 Brockton Dr SE P: 8779746338

E Grand Rapids, MI 49512 F: 8779746339
http://www.edustaff.org
 880600

Edustaff, LLC Innovative Staffing Solutions for a Better Classroom Experience

Previous Employer Statement

Can you certify that NO DOCUMENTATION OF Yes No
UNPROFESSIONAL CONDUCT exists with the
person's personnel file? (If "no", attach supporting
documentation)

Employer Signature: Date:

4120 Brockton Dr SE P: 8779746338

E Grand Rapids, MI 49512 F: 8779746339
http://www.edustaff.org