F200023 G5 Employment Compliance Certification

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) Return all pages of this form to HR Operations (Select one transmittal format, and submit only once):

a.  E-mail at hroperations@worldbank.org        

b.  Fax +1 (202) 522-7026

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 15 May 2025

Certification of Employer Actions

World Bank Group UPI:*

Date of G5 Entry into household:*

The following form certifies that documents referenced below are accurate and meet the requirements outlined below. Missing or incomplete documentation could result in the revocation of G5 visa privileges for any current G5 domestic workers and impact eligibility for future G5 visa domestic workers.  Falsification of such documents may result in appropriate disciplinary action up to and including dismissal from the World Bank Group.

As the registered employer of G5 domestic worker*

I certify the following has been provided to the G5 domestic worker:

Copy of executed Employment Contract with the G5 employee in English, including copy in the G5’s native language if English is not the native language*

Personal bank account in the name of the G5 worker only and no other individuals*

ACA compliant Medical Insurance Policy provided for employee*

Medical Insurer*

Copy of Signed World Bank Code of Conduct*

Copy of Signed G5 Dependent Children Protection Document (if applicable) 

Social Security Number for G5 employee*

Certification of Payroll Provider Actions

Payroll Provider*

I certify my contracted payroll provider has agreed to provide the following services for my G5 domestic worker on my behalf.

Maintain permanent record of weekly or bi-weekly time sheets certifying hours worked, hourly wage paid, overtime (if any), and deductions taken (if any)*

Prepare and generate weekly or bi-weekly pay slips to G5 employee that correspond to signed time sheets as stipulated by the employment contract*

Weekly or bi-weekly automatic payroll processing and direct deposit of payroll to G5 domestic worker bank account*

Produce federal forms W3/W2 wage and tax statements *

Collection of and remittance of all federal and state employment taxes for all tax quarters*

Evidence of Worker’s Compensation Insurance Policy (DC and MD domiciled employers only) together with payment documentation. Acceptable payment documentation includes Insurance Company payment receipt, cancelled check or bank EFT advice*

Filing end of year federal and state employment tax forms for current tax year*

Supplemental Insurance Certification: (check box if applicable)

Payroll deductions and remittance of health, life, and disability insurance*

Payroll deductions and remittance of Worker’s Compensation insurance *

Confirming I have attached a copy of the contract with a payroll provider*

G4 Employer Name*

G5 Employee Name*

G5 Employee Contact Phone Number*

G5 Employee Email Address*

After filling this document, G4 employer 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.