OMB NO. 1115-0217 U.S. Department of Justice Immigration and Naturalization Service Election Form to Participate in Employment Eligibility Confirmation Pilot Programs INSTRUCTIONS PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. Title IV, Subtitle A of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Pub. L. 104-208, 110 Stat. 3009 (IIRIRA), requires the Immigration and Naturalization Service (INS), in cooperation with the Social Security Administration (SSA), to conduct three pilot programs of employment eligibility confirmation: 1) the Basic Pilot; 2) Citizen Attestation Pilot; and 3) Machine-Readable Document Pilot. Participation in the pilot programs is voluntary on the part of employers, except for the executive and legislative branches of the federal government and certain employers found to be in violation of sections 274A or 274B of the Immigration and Nationality Act (INA), in states where the pilot(s) are conducted. No fee will be charged for participating in the pilots, but employers will be responsible for providing equipment required to make inquiries. Equipment needed for participation in the Basic and Machine-Readable Pilots includes a personal computer with a modem, and a touch-tone telephone (and modem, if the same device) on a telephone line which results in only one phone number being recognized as the originating phone number, regardless of whether it is controlled through a switch, private branch exchange, or direct outward dialing (this should be an analog voice grade line). Equipment required for the Citizen Attestation Pilot is a personal computer with a modem. Additional equipment may be needed for the Machine-Readable Document Pilot. INS may limit employer participation due to limited resources. This document is your election to participate in employment verification pilots being conducted by INS and the SSA. Its purpose is to identify the level of employer interest in the three pilots in order to assist INS in implementing the pilots in the most advantageous way based on available resources. Although you must complete and return this election form if you wish to be considered for participation in a pilot, returning the form neither obligates you to participate in any pilot nor obligates INS to select you for participation. Employers selected to participate in a pilot must execute a Memorandum of Understanding (MOU) with INS and SSA (if applicable) that will provide the specific terms and conditions governing that pilot. If you are a U.S. employer (or recruiter or referrer for a fee) who is subject to the employment eligibility verification requirements of section 274A of the INA, and you wish to be considered, please complete Form I-876 (Election Form) and mail to the U.S. Immigration and Naturalization Service, SAVE Program, 425 I Street, NW, ULLICO, 4th Floor, Washington, DC 20536. You may also fax this form to the SAVE Program at (202) 514-9981. You will be contacted by an INS representative concerning your participation in an employment verification pilot program. Privacy Act Notice. The authority for collecting this information is the Immigration and Nationality Act, as amended by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, 110 Stat. 3009. This information will be used to identify the level of employer interest in the three Employment Eligibility Confirmation Pilot Programs: the Basic Pilot, Citizen Attestation Pilot, and Machine-Readable Document Pilot. These pilot programs mandated by IIRIRA are to test three methods of providing an effective, non-discriminatory work eligibility verification procedure focusing on electronic verification. The information collected will assist the INS and the SSA to implement the pilots in the most advantageous way based on available resources. Reporting Burden. INS tries to create forms and instructions that are accurate, easily understood, and which impose the least possible burden on you in providing us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, 60 minutes; 2) completing the form, 15 minutes; and 3) assembling and filing (recordkeeping) the form, 15 minutes, for an average of 90 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536; OMB No. 1115-0217. DO NOT MAIL YOUR COMPLETED APPLICATION TO THIS ADDRESS. Form I-876 (Rev. 09/18/00) Y American LegalNet, Inc. www.USCourtForms.com OMB NO. 1115-0217 U.S. Department of Justice Immigration and Naturalization Service Election Form to Participate in Employment Eligibility Confirmation Pilot Programs Which pilot program(s) do you elect? A. The Basic Pilot You may elect the Basic Pilot only if you are located in California, Texas, New York, Florida and Illinois. B. The Citizen Attestation Pilot Employers in all states (including the District of Columbia, Puerto Rico, Guam and the Virgin Islands of the U.S.), may elect to participate in the Citizen Attestation Pilot, but INS reserves the right to limit the pilot to certain states based on the level of employer interest and on further determinations as to state licensing procedures. C. The Machine-Readable Document Pilot You may elect the Machine-Readable Document Pilot only if you are located in Iowa. Employer name: Employer address: County in which employer resides: If you hire at locations other than the above address, please list all the locations you want to participate in the pilot(s). (Attach additional sheet(s) if necessary). (Note: INS will determine when it is feasible to provide for extensions outside Pilot states based on available resources). Employer Identification Number: Standard Industry Code (if known): Person(s) to be contacted concerning employment verification pilot: Telephone number(s): For the Basic Pilot or the Machine-Readable Document Pilot, provide the site phone number for each site from which verification will take place: Number of company employees: Are you a federal executive branch employer?: Are you a federal legislative branch employer?: Do you wish to be considered for a waiver of the document presentation requirement for your U.S. citizen or national employees? (Note: This question is to be answered only by employers electing the Citizen Attestation Pilot.) Form I-876 (Rev. 09/18/00) Y Page 2 American LegalNet, Inc. www.USCourtForms.com