F00101 Extension of I-94 for G5 Domestic Employee

Instructions: 

Welcome to the World Bank Group HR Forms Instructions page. 

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

1)   Please enter all information electronically except the signature blocks.

2)   Print form using button on the last page of the form.

3)   Sign in the signature blocks where provided.

4)   Return all four pages of this form with all other required documents as specified in the checklist to HR Operations at G2-202.

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 26 Jan 2024

Staff Information

World Bank Group UPI*

Staff Member Name (LAST, First, Middle)*

G5 Domestic Name (LAST, First, Middle)*

Telephone*

Date*

Address*

City*

State / Province*

Postal / Zip Code *

Case Number (if applicable): #HD

Domestic Employee Info

UPI*

I confirm that the following domestic employee is working exclusively in my household, that I am in G4 status, and that I am complying with all U.S., state, and local laws and regulations concerning G5 domestic employees, including minimum or prevailing wage requirements, payment of Social Security, Federal and State income taxes, and Unemployment Insurance Coverage. 

I further confirm that I am in compliance with the World Bank Group’s G4 Code of Conduct Regarding Employment of G5 Domestic Employees.

I confirm I have checked my domestic's passport and it is valid for at least one year from today's date.

Staff Member (G4)'s Name

Domestic's (G5) Name

Domestic's (G5) Passport Nationality*

Domestic's (G5) Passport Number*

Domestic's (G5) Social Security No.

Staff member's (G4) Social Security No.

Staff member's (G4) Employer Identification No. for Unemployment Insurance (required by DC, VA, MD)

Workers’ Compensation Insurance No. (required by DC and MD, specify if you are a VA resident):

Please check one option

She/he lives at:

Address*

City*

State*

Zip Code*

Given below are brief details of the type of duties the domestic performs or will perform:*

Date*

Signature of Staff member (G4 applicant)

Signature

Date*

Signature of Staff member (G4 applicant)

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.

THE WORLD BANK/IFC/M.I.G.A.

OFFICE MEMORANDUM

Date

To: U.S. Department of State, Visa Services Directorate

From:*

Telephone:*

Subject:           Extension of Visa Status for G5 Domestic Employee

1. This memorandum confirms that the following individual is my domestic employee:

Domestic's Name (LAST, First Middle)*

Domestic's (G5) Passport Nationality*

2. I am an employee of the World Bank Group/IFC/MIGA. My name, address and telephone number in the United States are:

Name*

Address*

City*

State*

Zip Code*

Phone *

Date*

Signature of Staff member (G4 applicant)