**If you have any other questions, please contact us and we will be happy to help.**

Size: px
Start display at page:

Download "**If you have any other questions, please contact us and we will be happy to help.**"

Transcription

1 Attention GGRC Public Partnerships, LLC 7776 S Pointe Pkwy W Suite 5 Phoenix, AZ 8544 Worker First name, Last name Worker Mailing Address, Address 2 Worker City, State, Zip Dear Worker This packet includes a wide-range of information to support your continued success working with PPL. Each worker is required to submit a completed Worker Packet to PPL before you are eligible to provide services. This packet includes all of the documents that are needed. Should you have any questions please feel free to contact us. **If you have any other questions, please contact us and we will be happy to help.** Thank you, Public Partnerships, LLC (PPL) Please mail or fax these completed forms back to Public Partnerships ATTN CA GGRC Public Partnerships 7776 S Pointe Pkwy W, Suite 5 Phoenix, AZ orfax to (855)

2 Keep this form CA GGRC Worker Application Packet Dear Worker, Thank you for applying. GGRC has contracted with PCG Public Partnerships, LLC (PPL) to act as a Financial Management Service (FMS) provider for participants who choose to participant-direct their services. PPL will send out payment once all correct forms have been received and processed. You are not permitted to work prior to your participant receiving their good to go call from PPL. Please fill out the forms and have your Participant sign off on the forms as needed. When finished, please fax the forms back to PPL at (855) You may also them to us at CAGGRCenrollment@pcgus.com. Your Participant will receive a phone call once the paperwork has been processed to inform them of next steps. Should you require instructions or additional documents, please visit our website Click on Select a Program in the upper-right hand corner of the page. Then select California from the drop-down menu. Next, click on the California Golden Gate Regional Center Program. Lastly, click on Program Documents link on the right hand side of the page. In addition, please visit fms.publicpartnerships.com to view and sign up for our online Web Portal. This will allow you the availability to submit and approve online timesheets and invoices as well as review and print check stubs. You may also contact our customer service department at (877)522-53, Monday through Friday from 8am to 6pm PST. We look forward to working with you! Sincerely, Public Partnerships, LLC

3 Keep this form CA GGRC Worker Application Packet Service Eligibility and Forms Required Respite 465 Workers (465) o Pay rates are dependent upon county you work in; PPL will deduct the necessary employer and employee taxes. o Worker cannot negotiate Rate Nursing Services (46) o There are three tiers of nursing care Home Health Aide, Vocational Nurse, and Registered Nurse o Worker will need to provide proof (copy) of their license(s) showing valid certification and expiration date along with their employment packet. Any worker who is providing Participant-Directed Repite andor Nursing services must fill out and return these forms Employment Agreement (Pages 4-6) This document describes the responsibilities and duties of both the employer (family member or adult participant) and the worker (you). Send one signed copy to PPL and the employer must keep the other signed copy. Both worker & employer need to sign this form Criminal Background Check Authorization & Training Form (Page 7) This must be filled out by your employer. It tells PPL whether or not a criminal background check is required. It also informs us if there are any special trainings that your employer requires for you to complete CPR andor First Aid training (copy of card must be submitted if option is selected). This is in addition to the OIG check that is required for all workers. USCIS Form I-9. Department of Homeland Security - Employment Eligibility Verification (Pages 8 and 9) This form is used to confirm your immigration and US citizenship information. Your employer will verify your identity by signing Section 2 of this form. Federal law requires that all employers & workers complete this form. IRS Form W-4 (Page ) This document will be used by Public Partnerships to determine the amount of Federal Income taxes to deduct from your payment. 2

4 Keep this form CA GGRC Worker Application Packet California Employee s Withholdings Allowance Certificate (Page 3) This document will be used by Public Partnerships to determine the amount of California state taxes to deduct from your payment. Tax Questionnaire (Page 7) This form is used to calculate your Medicaid and Social Security Tax withholdings. In addition, the form is used to collect information about your relationship to your employer to determine whether you meet certain taxes. Please Note If you are also going to provide Participant-Directed Transportation services (47) for the participant, please include the below information as well. Front and Back Copy of your Driver s License. Front and Back Copy of valid insurance card or Insurance Declaration Page showing your name as the insured. Optional Form Direct Deposit Form (Page 8) This form will establish direct deposit of your paycheck with PPL. You can use direct deposit with a bank account, debit card or pay card. If the direct deposit form is not received, payment will be issued via a paper check and mailed to the address PPL has on file. 3

5 PPL CA GGRC EMPLOYMENT AGREEMENT Return to PPL ALL FOUR PAGES OF THIS DOCUMENT ARE REQUIRED TO BE RETURNED TO PPL SIGNED BY THE EMPLOYER AND THE WORKER. Please also keep a copy for your records. Parties to Agreement This agreement confirms the conditions of employment between the following parties within the Golden Gate Regional Center (GGRC) Program Worker First and Last Print Worker Name Employer First and Last Print Employer Name (GGRC Vendor Name) Mutual Responsibilities The parties agree to follow the policies and procedures of the program. The Worker and Employer agree to hold harmless, Worker release, Name and Here forever discharge GGRC and Public Partnerships, LLC (PPL) from any claims andor damages that might arise out of any action or omissions by the Worker, Employer, or Participant. Employer Name Here The Employer shall. Verify worker qualifications, including ability to work in the United States. Please see the Form I-9 and Instructions in the packet. 2. Schedule worker to provide services for payment only after being authorized by PPL 3. Orient, train, direct, and supervise the worker; 4. Establish a mutually agreeable schedule for the worker s services; 5. Provide a safe workplace free from excess hazards, employment discrimination, and harassment; 6. Request worker to perform permitted and planned for duties, as determined in Individual Program Plan. The worker shall not perform prohibited services such as administering medication, dressing wounds, and tube feeding unless certified to do so; 7. Notify worker in advance if services are not required or if Participant is no longer eligible for services; 8. Verify services provided by worker by reviewing and approving timesheets and ensuring timely submission to PPL; 9. Ensure the worker submits timesheets to PPL within 3 days of service being delivered;. Ensure that pended timesheets are resolved with PPL within 6 days after the date hisher worker provided service. If not, the employer is responsible for compensating the worker.. Ensure that there is no misrepresentation of time, services, workers, andor other information. The Worker shall. Not be the parent, step-parent, conservator, or legal guardian of the Participant (if providing Respite care); 2. Be at least 8 years of age (if providing Respite Care); 3. Be punctual, neatly dressed, and respectful of employer s person, belongings, family members and acquaintances; 4. Use Participant semployer s personal property only if agreed upon by both parties; 5. Submit accurate timesheets and documentation to Employer for review and signature; 4

6 Return to PPL PPL CA GGRC EMPLOYMENT AGREEMENT 6. Notify the Employer in advance if not able to provide services as scheduled or if quitting employment; 7. Report any allegations or suspicions of abuse, neglect, or exploitation immediately to GGRC; 8. Maintain confidentiality of all ParticipantEmployer information, and only release information with the written consent of the Employer; 9. Ensure that there is no misrepresentation of time, services, workers, andor other information. Worker understands and acknowledges the following. Worker is employed by the Employer and not by either PPL or GGRC. 2. Employment is at-will. No guarantee or promise of continued employment is intended or implied by this agreement. 3. Workers MAY NOT work more than 4 hours per work week per Employer. 4. Worker MAY NOT work more than 8 hours per day per Employer. 5. Worker shall only perform work within the amount authorized by GGRC as stated within the Participant s Individual Program Plan. Worker shall not be compensated by GGRC or PPL for any work performed in excess of the authorized amount. 6. Workers are required to submit timesheets within 3 days of date worked in order to be paid. 7. PPL is required to report certain information on newly-hired workers to the California Department of Employment Security and as required by Federal and State Child Support Enforcement Laws. 8. PPL will verify that the Worker does not appear on the Office of Inspector General s (OIG) list of Excluded IndividualsEntities (LEIL). In the event that the Worker appears on this list, the Worker will not be permitted to work or be paid in this program. Both Worker and Employer acknowledge the following Any false claims, statements, documents, or concealment of material facts by Employer or Worker may be considered Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State laws. Compensation The Worker agrees and understands that all pay rates for Respite, Transportation, and Nursing services are set by the Golden Gate Regional Center for each respective participant and rates are dependent upon the county the participant resides in. Please check off ALL services that the worker will be performing for the participant. Service Category CHECK ALL THAT APPLY Respite (465) Nursing (46) Transportation (47) 5

7 Return to PPL PPL CA GGRC EMPLOYMENT AGREEMENT Note If you will provide Nursing or Transportation- mileage, the worker must submit the appropriate licenses to PPL for verification. This must be done before the worker may provide these services. Title Criteria ¹ Home Health Aid (Nurse's Aid or Certified as a home health aid or nurse's aid Assistant) by California Department of Public Health² Valid license as a licensed vocation nurse by the California State Board of Vocational Licensed Vocational Nurse Nurse and Psychiatric Technician Examiners Valid license as a registered nurse by the Registered Nurse California State Board of Registered Nurses ) Valid driver s licenses 2) Copy of Auto Transportation Mileage Insurance ¹ California Code of Regulations, Title 7, Section (a) (46), (5), and (66) ² Formerly "California Department of Health Services" Employment Eligibility USCIS Form I-9 The Employer is responsible for proper execution of USCIS Form I-9, as defined in Instructions for Employment Eligibility Verification, Department of Homeland Security. The employer must retain the original Form I-9. PPL will provide Form I-9 in employment packets and respond to any questions from Employers and Employees in completing the form. PPL will merely retain a forwarded copy in PPL maintained employee files. Payment for Services and Work Performed PPL shall pay the Worker for services provided by the Worker and verified by the Employer in accordance with the Participant s Individual Program Plan. Workers are required to submit timesheets within 3 days of the date worked in order to be paid. Information needed to enable resolution of pended timesheets must be provided to PPL no later than 6 days after the date worked otherwise it will be the Employer s responsibility to pay the worker. Termination of Agreement Either party may terminate this agreement by notifying the other party and PPL, in writing by submitting the Notice of Termination form 5 days prior to formal separation of employment. Employer Signature and Date Signed Signatures By signing below, the Employer and Worker agree to the above terms and conditions. Employer Signature Employer (GGRC Vendor) Signature Worker Signature Worker Signature MMDDYYYY Date MMDDYYYY Date Worker Signature and Date Signed 6

8 Return to PPL Criminal Background Check Section CAGGRC Criminal BackgroundTraining Form Indicate if requiring Criminal Background Check I require to undergo a State and Federal Select (Worker s Name) Background Check prior to employment. your preference I DO NOT require a criminal background check prior to employment. Training Section Indicate if worker is required to have the following certifications andor trainings (Check all that apply) CPR Select the First Aid appropriate box(es) Other I do not require this level of certification of my worker Obtain proof of trainings andor certifications checked above and submit proof to Public Partnerships, LLC. Worker Signature Worker Signature MMDDYYYY Date Worker Last Name Last Name (Print) Worker First Name First Name (Print) Employer Signature ParticipantEmployer Signature MMDDYYYY Date Employer Last Name Last Name (Print) Employer First Name First Name (Print) Note This is a required form. It must be returned to PPL even if your employer does not require additional trainings or a criminal background check to be ran. 7

9 Employment Eligibility Verification USCIS Form I-9 Department of Homeland Security U.S. Citizenship and Immigration Services OMB No Expires 3326 START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section. Employee Information and Attestation (Employees must complete and sign Section of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) Worker First Name Address (Street Number and Name) Apt. Number Worker Address City or Town State Worker City Date of Birth (mmddyyyy) MMDDYYYY Middle Initial Other Names Used (if any) First Name (Given Name) Worker Last Name CA U.S. Social Security Number Address Zip Code Worker Zip Telephone Number Worker Address Worker # I am aware that federal law provides for imprisonment andor 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) A citizen of the United States Check one box A noncitizen national of the United States (See instructions) A lawful permanent resident (Alien Registration NumberUSCIS Number). Some aliens may write "NA" in this field. An alien authorized to work until (expiration date, if applicable, mmddyyyy) (See instructions) For aliens authorized to work, provide your Alien Registration NumberUSCIS Number OR Form I-94 Admission Number. Alien Registration NumberUSCIS Number 3-D Barcode Do Not Write in This Space OR 2. Form I-94 Admission Number If you obtained your admission number from CBP in connection with your arrival in the United States, include the following Foreign Passport Number Country of Issuance Some aliens may write "NA" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee Worker Signature Date (mmddyyyy) MMDDYYYY Preparer andor Translator Certification (To be completed and signed if Section is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Last Name (Family Name) Address (Street Number and Name) Date (mmddyyyy) First Name (Given Name) City or Town State Zip Code Employer Completes Next Page Form I N Page 7 of 9

10 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 examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title Document Title Document Title Issuing Authority Document Number Expiration Date (if any)(mmddyyyy) Issuing Authority Document Number Expiration Date (if any)(mmddyyyy) Issuing Authority Document Number Expiration Date (if any)(mmddyyyy) Document Title Issuing Authority Document Number Expiration Date (if any)(mmddyyyy) Document Title 3-D Barcode Do Not Write in This Space Issuing Authority Document Number Expiration Date (if any)(mmddyyyy) Certification I attest, under penalty of perjury, that () 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 (mmddyyyy) (See instructions for exemptions.) Signature of Employer or Authorized Representative Employer Signature Last Name (Family Name) First Name (Given Name) Date (mmddyyyy) Title of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire (if applicable) (mmddyyyy) C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title Document Number Expiration Date (if any)(mmddyyyy) 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 Date (mmddyyyy) Print Name of Employer or Authorized Representative Form I N Page 8 of 9

11

12 Form W-4 (26) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 26 expires February 5, 27. See Pub. 55, Tax Withholding and Estimated Tax. Note If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $,5 and includes more than $35 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $,,. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earnersmultiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status. on your tax return only if you are unmarried and pay more than 5% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 5, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 55 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 4-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 55 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 55 for details. Nonresident alien. If you are a nonresident alien, see Notice 392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 55 to see how the amount you are having withheld compares to your projected total tax for 26. See Pub. 55, especially if your earnings exceed $3, (Single) or $8, (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter if { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $,5 or less. C Enter for your spouse. But, you may choose to enter -- if you are married and have either a working spouse or more than one job. (Entering -- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter if you have at least $2, of child or dependent care expenses for which you plan to claim a credit... F (Note Do not include child support payments. See Pub. 53, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $7, ($, if married), enter 2 for each eligible child; then less if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $7, and $84, ($, and $9, if married), enter for each eligible child.. G H Add lines A through G and enter total here. (Note This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $5, ($2, if married), see the Two-EarnersMultiple Jobs Worksheet on page 2 that apply. to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. Your first name and middle initial Last name Worker First Name Home address (number and street or rural route) Worker Address City or town, state, and ZIP code Worker City, State Zipcode OMB No Your social security number 3 Single Married Married, but withhold at higher Single rate. Note If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 26, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.)! " " # $ Worker Last Name Worker Signature 8 Employer s name and address (Employer Complete lines 8 and only if sending to the IRS.) 9 Office code (optional) Employer identification number (EIN) Employer Name and Address Employer EIN Number For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22Q Form W-4 (26) Date MMDDYYYY 2

13 Form W-4 (26) Page 2 Deductions and Adjustments Worksheet Note Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. Enter an estimate of your 26 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of % (7.5% if either you or your spouse was born before January 2, 952) of your income, and miscellaneous deductions. For 26, you may have to reduce your itemized deductions if your income is over $3,3 and you are married filing jointly or are a qualifying widow(er); $285,35 if you are head of household; $259,4 if you are single and not head of household or a qualifying widow(er); or $55,65 if you are married filing separately. See Pub. 55 for details... $ $2,6 if married filing jointly or qualifying widow(er) 2 Enter { $9,3 if head of household } $ $6,3 if single or married filing separately 3 Subtract line 2 from line. If zero or less, enter $ 4 Enter an estimate of your 26 adjustments to income and any additional standard deduction (see Pub. 55) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 26 Form W-4 worksheet in Pub. 55.) $ 6 Enter an estimate of your 26 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $4,5 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-EarnersMultiple Jobs Worksheet, also enter this total on line below. Otherwise, stop here and enter this total on Form W-4, line 5, page Two-EarnersMultiple Jobs Worksheet (See Two earners or multiple jobs on page.) Note Use this worksheet only if the instructions under line H on page direct you here. Enter the number from line H, page (or from line above if you used the Deductions and Adjustments Worksheet) 2 Find the number in Table below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65, or less, do not enter more than If line is more than or equal to line 2, subtract line 2 from line. Enter the result here (if zero, enter -- ) and on Form W-4, line 5, page. Do not use the rest of this worksheet Note If line is less than line 2, enter -- on Form W-4, line 5, page. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in 26. For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 26. Enter the result here and on Form W-4, line 6, page. This is the additional amount to be withheld from each paycheck 9 $ Table Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $ - $6, 6, - 4, 4, - 25, 2 25, - 27, 3 27, - 35, 4 35, - 44, 5 44, - 55, 6 55, - 65, 7 65, - 75, 8 75, - 8, 9 8, -,, - 5, 5, - 3, 2 3, - 4, 3 4, - 5, 4 5, and over 5 If wages from LOWEST paying job are Enter on line 2 above $ - $9, 9, - 7, 7, - 26, 2 26, - 34, 3 34, - 44, 4 44, - 75, 5 75, - 85, 6 85, -, 7, - 25, 8 25, - 4, 9 4, and over Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 342(f)(2) and 69 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and 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 may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If wages from HIGHEST paying job are Enter on line 7 above $ - $75, $6 75, - 35,, 35, - 25,,3 25, - 36,,34 36, - 45,,42 45, and over,6 If wages from HIGHEST paying job are Enter on line 7 above $ - $38, $6 38, - 85,, 85, - 85,,3 85, - 4,,34 4, and over,6 You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 63. The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

14 Sample DE4 for a Single Worker This form can be used to manually compute your withholding allowances, or you can electronically compute them at Type or Print Your Full Name Worker First and Last Name Home Address (Number and Street or Rural Route) Worker Home Address City, State, and ZIP Code Worker City, State and ZIP Code EMPLOYEE S WITHHOLDING ALLOWANCE CERTIFICATE. Number of allowances for Regular Withholding Allowances, Worksheet A Your Social Security Number Worker SSN Filing Status Withholding Allowances SINGLE or MARRIED (with two or more incomes) MARRIED (one income) HEAD OF HOUSEHOLD Number of allowances from the Estimated Deductions, Worksheet B Total Number of Allowances (A + B) when using the California Withholding Schedules for 26 OR 2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C OR 3. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Use Worksheet Instructions A, B, & C on the following page (Check box here) Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status. Signature Worker Signature Date MMDDYYYY Employer s Name and Address California Employer Account Number cut here Give the top portion of this page to your employer and keep the remainder for your records. YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM. IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR. PURPOSE This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation. You should complete this form if either () You claim a different marital status, number of regular allowances, or different additional dollar amount to be withheld for California PIT withholding than you claim for federal income tax withholding or, (2) You claim additional allowances for estimated deductions. THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES. The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, andor the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source. CHECK YOUR WITHHOLDING After your Form W-4 andor DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form. EXEMPTION FROM WITHHOLDING If you wish to claim exempt, complete the federal Form W-4. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption is good for one year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted by February 5 each year to continue your exemption. If you are not having federal income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new Form W-4 by December. DE 4 Rev. 44 (-6) (INTERNET) Page of 4 CU

15 EXEMPTION FROM WITHHOLDING (continued) Under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act, you may be exempt from California income tax on your wages if (i) your spouse is a member of the armed forces present in California in compliance with military orders; (ii) you are present in California solely to be with your spouse; and (iii) you maintain your domicile in another state. If you claim exemption under this act, check the box on Line 3. You may be required to provide proof of exemption upon request. IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB). IF YOU ARE CALLING FROM WITHIN THE UNITED STATES (voice) (TTY) IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free) The California Employer s Guide (DE 44) provides the income tax withholding tables. This publication may be found on the Employment Development Department (EDD) website at To assist you in calculating your tax liability, please visit the FTB website at NOTIFICATION If the IRS instructs your employer to withhold federal income tax based on a certain withholding status, your employer is required to use the same withholding status for state income tax withholding. The burden of proof rests with the employee to show the correct California Income Tax Withholding. Pursuant to Section 434-(e) of the California Code of Regulations, the FTB or the EDD may, by special direction in writing, require an employer to submit a Form W-4 or DE 4 when such forms are necessary for the administration of the withholding tax programs. PENALTY You may be fined $5 if you file, with no reasonable basis, a DE 4 that results in less tax being withheld than is properly allowable. In addition, criminal penalties apply for willfully supplying false or fraudulent information or failing to supply information requiring an increase in withholding. This is provided by Section 3 of the California Unemployment Insurance Code and Section 976 of the Revenue and Taxation Code. DE 4 Rev. 44 (-6) (INTERNET) Page 2 of 4

16 INSTRUCTIONS ALLOWANCES* When determining your withholding allowances, you must consider your personal situation Do you claim allowances for dependents or blindness? Will you itemize your deductions? Do you have more than one income coming into the household? TWO-EARNERTWO-JOBS When earnings are derived from more than one source, underwithholding may occur. If you have a working spouse or more than one job, it is best to check the box SINGLE or MARRIED (with two or more incomes). Figure the total number of allowances you are entitled to claim on all jobs using only one DE 4 form. Claim allowances with one employer. Do not claim the same allowances with more than one employer. Your withholding will usually be most accurate when all allowances are claimed on the DE 4 or Form W-4 filed for the highest paying job and zero allowances are claimed for the others. MARRIED BUT NOT LIVING WITH YOUR SPOUSE You may check the Head of Household marital status box if you meet all of the following tests () Your spouse will not live with you at any time during the year; (2) You will furnish over half of the cost of maintaining a home for the entire year for yourself and your child or stepchild who qualifies as your dependent; and (3) You will file a separate return for the year. HEAD OF HOUSEHOLD To qualify, you must be unmarried or legally separated from your spouse and pay more than 5% of the costs of maintaining a home for the entire year for yourself and your dependent(s) or other qualifying individuals. Cost of maintaining the home includes such items as rent, property insurance, property taxes, mortgage interest, repairs, utilities, and cost of food. It does not include the individual s personal expenses or any amount which represents value of services performed by a member of the household of the taxpayer. WORKSHEET A REGULAR WITHHOLDING ALLOWANCES (A) Allowance for yourself enter... (A) (B) Allowance for your spouse (if not separately claimed by your spouse) enter... (B) (C) Allowance for blindness yourself enter.... (C) (D) Allowance for blindness your spouse (if not separately claimed by your spouse) enter... (D) (E) Allowance(s) for dependent(s) do not include yourself or your spouse... (E) (F) Total add lines (A) through (E) above... (F) INSTRUCTIONS 2 ADDITIONAL WITHHOLDING ALLOWANCES If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year s FTB Form 54 as a model to calculate this year s withholding amounts. Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not taxed on this worksheet. You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $,, or fraction of $,, by which you expect your estimated deductions for the year to exceed your allowable standard deduction. WORKSHEET B ESTIMATED DEDUCTIONS. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in the schedules in the FTB Form Enter $8,88 if married filing joint with two or more allowances, unmarried head of household, or qualifying widow(er) with dependent(s) or $4,44 if single or married filing separately, dual income married, or married with multiple employers Subtract line 2 from line, enter difference... = Enter an estimate of your adjustments to income (alimony payments, IRA deposits) Add line 4 to line 3, enter sum... = Enter an estimate of your nonwage income (dividends, interest income, alimony receipts) If line 5 is greater than line 6 (if less, see below); Subtract line 6 from line 5, enter difference... = Divide the amount on line 7 by $,, round any fraction to the nearest whole number Enter this number on line of the DE 4. Complete Worksheet C, if needed. 9. If line 6 is greater than line 5; Enter amount from line 6 (nonwage income) Enter amount from line 5 (deductions)..... Subtract line from line 9, enter difference.... Complete Worksheet C *Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California Personal Income Tax (PIT) withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner in a domestic partner relationship within the meaning of Section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center at DE 4 Rev. 44 (-6) (INTERNET) Page 3 of 4

17 WORKSHEET C TAX WITHHOLDING AND ESTIMATED TAX. Enter estimate of total wages for tax year Enter estimate of nonwage income (line 6 of Worksheet B) Add line and line 2. Enter sum Enter itemized deductions or standard deduction (line or 2 of Worksheet B, whichever is largest) Enter adjustments to income (line 4 of Worksheet B) Add line 4 and line 5. Enter sum Subtract line 6 from line 3. Enter difference Figure your tax liability for the amount on line 7 by using the 26 tax rate schedules below Enter personal exemptions (line F of Worksheet A x $9.9) Subtract line 9 from line 8. Enter difference..... Enter any tax credits. (See FTB Form 54) Subtract line from line. Enter difference. This is your total tax liability Calculate the tax withheld and estimated to be withheld during 26. Contact your employer to request the amount that will be withheld on your wages based on the marital status and number of withholding allowances you will claim for 26. Multiply the estimated amount to be withheld by the number of pay periods left in the year. Add the total to the amount already withheld for Subtract line 3 from line 2. Enter difference. If this is less than zero, you do not need to have additional taxes withheld Divide line 4 by the number of pay periods remaining in the year. Enter this figure on line 2 of the DE NOTE Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not agree to withhold the additional amount, you may increase your withholdings as much as possible by using the single status with zero allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on Form 54-ES with the FTB to avoid a penalty. SINGLE OR MARRIED WITH DUAL EMPLOYERS IF THE TAXABLE INCOME IS COMPUTED TAX IS OVER BUT NOT OVER $ $7,85... $7,85 $8,6... $8,6 $29, $29,372 $4, $4,773 $5,53... $5,53 $263, $263,222 $35, $35,866 $526, $526,443 $,,... $,, and over THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 26 ONLY OF AMOUNT OVER... PLUS*.% $ $. 2.2% $7,85 $ % $8,6 $ % $29,372 $ % $4,773 $, % $5,53 $2, % $263,222 $24, % $35,866 $3, % $526,443 $56, % $,, $2, MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS IF THE TAXABLE INCOME IS COMPUTED TAX IS OVER BUT NOT OVER $ $5,7... $5,7 $37,22... $37,22 $58, $58,744 $8, $8,546 $3,6... $3,6 $526, $526,444 $63, $63,732 $,,... $,, $,52, $,52,886 and over OF AMOUNT OVER... PLUS*.% $ $. 2.2% $5,7 $ % $37,22 $ % $58,744 $, % $8,546 $3, % $3,6 $4, % $526,444 $48, % $63,732 $6, % $,, $6, % $,52,886 $3,63.86 UNMARRIED HEAD OF HOUSEHOLD TAXPAYERS IF THE TAXABLE INCOME IS OVER BUT NOT OVER $ $5,7... $5,7 $37,22... $37,22 $47, $47,982 $59, $59,383 $7,42... $7,42 $357,98... $357,98 $429, $429,578 $75, $75,962 $,,... $,, and over COMPUTED TAX IS OF AMOUNT OVER... PLUS*.% $ $. 2.2% $5,7 $ % $37,22 $ % $47,982 $, % $59,383 $, % $7,42 $2, % $357,98 $32, % $429,578 $4, % $75,962 $75, % $,, $4,44.53 IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA INCOME TAX RETURN OR CALL THE FTB IF YOU ARE CALLING FROM WITHIN THE UNITED STATES (voice) (TTY) IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free) *marginal tax The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, California Code of Regulations, and the Revenue and Taxation Code, including Section The Information Practices Act of 977 requires that individuals be notified of how information they provide may be used. Further information is contained in the instructions that came with your last California income tax return. DE 4 Rev. 44 (-6) (INTERNET) Page 4 of 4

18 Answer Questions -6 by selecting the appropriate "yes" or "no"answer

19 Optional Form Direct Deposit Form Employee Name (REQUIRED) Worker Name PAYEE INFORMATION ParticipantEmployer Name (REQUIRED)* Employer Name Employee s PPL ID (if known) Social SecurityTax Identification # (REQUIRED) E *If change is for all ParticipantsEmployers, please write all Participants in the ParticipantEmployer Name field DIRECT DEPOSIT SETUP Request Type (REQUIRED) (Check one Box Account Type (REQUIRED) (Check one Box Only) Only) New Request Change Request Checking Pay Card Cancellation Request* Savings *Cancellation requests do not require supporting bank documentation. Do NOT Send the Paper Remittance Advice, I will review these using the PPL Web Portal. VOIDED CHECK Attach a Voided Check Here *Not required for cancellation requests If selecting Savings Account or Pay Card, submit documentation from your financial entity confirming your account and routing numbers. Starter checks with account holder s name and address written on the face of the check are acceptable as well. If documentation does not fit into this square, please submit an additional page. If I request the Direct Deposit payment selection, I authorize PPL to deposit my payment directly into my account using an Automated Clearing House (ACH) transaction. I recognize that if I fail to provide complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously made. I certify I have read and agree to comply with PPL rules governing payments and electronic transfers. I authorize PPL to withdraw from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to PPL. If I decide to cancel direct deposit, I will contact PPL Customer Service and provide both the account and routing numbers of my account. Worker Signature Payee Signature Date MMDDYYYY

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate Form W-4 (2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial

More information

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate Form W-4 (2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial

More information

Employment Eligibility Verification

Employment Eligibility Verification Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No. 1615-0047 Expires 08/31/2019 START HERE: Read instructions carefully

More information

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Form W-4 (2015) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial

More information

EMPLOYEE INFORMATION SHEET

EMPLOYEE INFORMATION SHEET EMPLOYEE INFORMATION SHEET PLEASE PRINT CLEARLY COMPANY: EMPLOYEE #: SOCIAL SECURITY NUMBER: - - NAME: First MI LAST STREET: CITY: AS APPEARS ON SOCIAL SECURITY CARD STATE: ZIP CODE: TELEPHONE NUMBER:

More information

XXXXXX NON-UNION VOUCHER. White - Payroll Company Yellow - Accounting Department Pink - Employee TIME CLOCK RATE ALLOWANCES SPECIAL COMPENSATIONS

XXXXXX NON-UNION VOUCHER. White - Payroll Company Yellow - Accounting Department Pink - Employee TIME CLOCK RATE ALLOWANCES SPECIAL COMPENSATIONS XXXXXX NON-UNION VOUCHER DATE PRODUCTION & PROJECT NAME 1 2 3 LAST NAME FIRST NAME MI STREET ADDRESS CITY STATE ZIP DATE OF BIRTH: IF MINOR PHONE IF NEW IF NEW EMPLOYEE ADDRESS SOCIAL SECURITY NUMBER WORK

More information

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate

Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate Form W-4 (2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial

More information

New Employee Welcome Letter and Orientation Checklist

New Employee Welcome Letter and Orientation Checklist Lafayette DQ Restaurants P.O. Box 302 Delphi, IN 46923 Phone: (765) 447-1089 Fax: (765) 535-5001 New Employee Welcome Letter and Orientation Checklist Welcome to the DQ family! In order to start training

More information

New Employment & Sign-up Checklist for Managers and Departmental Representatives

New Employment & Sign-up Checklist for Managers and Departmental Representatives FLORIDA A&M UNIVERSITY New Employment & Sign-up Checklist for Managers and Departmental Representatives Executive Service A&P USPS OPS Faculty (Please complete Section II Only) Employee Name: Class Title:

More information

Missouri Department of Revenue Employee s Withholding Allowance Certificate

Missouri Department of Revenue Employee s Withholding Allowance Certificate Form MO W-4 Missouri Department of Revenue Employee s Withholding Allowance Certificate This certificate is for income tax withholding and child support enforcement purposes only. Type or print. Full Name

More information

Employment Eligibility Verification

Employment Eligibility Verification Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No. 1615-0047 Expires 08/31/2019 START HERE: Read instructions carefully

More information

YOU DO NOT NEED TO PRINT THIS PAGE. Substitute Records Requirements. Social Security Card (copies not accepted)

YOU DO NOT NEED TO PRINT THIS PAGE. Substitute Records Requirements. Social Security Card (copies not accepted) YOU DO NOT NEED TO PRINT THIS PAGE. Appointment Date & Time: Name: Date: Substitute Records Requirements I-9 (only complete page 1) W-4 Social Security Card (copies not accepted) Driver s License Direct

More information

EMPLOYER INFORMATION SHEET

EMPLOYER INFORMATION SHEET General EMPLOYER INFORMATION SHEET Business Name: Business Address: City, State, Zip: Filing Name (if different): Filing Address (if different): City, State, Zip: Contact Name: Phone: Fax: Email: Company

More information

Western States Office and Professional Employees Pension Fund

Western States Office and Professional Employees Pension Fund Western States Office and Professional Employees Pension Fund FEDERAL INCOME TAX WITHHOLDING TAX WITHHOLDING ELECTION Please complete the attached W-4P Withholding Certificate for Pension or Annuity Payments.

More information

RAYMOND CENTRAL PUBLIC SCHOOLS SUBSTITUTE TEACHER DATA SHEET

RAYMOND CENTRAL PUBLIC SCHOOLS SUBSTITUTE TEACHER DATA SHEET RAYMOND CENTRAL PUBLIC SCHOOLS SUBSTITUTE TEACHER DATA SHEET PLEASE NOTE: We need a voided check for payment by Direct Deposit and we must have an email address. Thank you. W-4 Form I-9 Form - 2 forms

More information

Southeast ID#: Name: SSN: PREVIOUS CIVIL OR COLLEGE DISCIPLINE

Southeast ID#: Name: SSN: PREVIOUS CIVIL OR COLLEGE DISCIPLINE /Student Employment Work Referral Southeast ID#: Name: SSN: STUDENT EMPLOYEE ELIGIBILITY AND RESPONSIBILITIES 1. You must complete, and have on file with Student Financial Services, employment eligibility

More information

New Employee Information

New Employee Information HOUSTON S PREMIER POKER DESTINATION New Employee Information Before you will be scheduled the following MUST be completed: 1. Your new hire packet must be filled out completely and correctly and handed

More information

DIVERSIFIED Edgewood Road, NE Cedar Rapids, IA

DIVERSIFIED Edgewood Road, NE Cedar Rapids, IA DIVERSIFIED --------------------- 4443 Edgewood Road, NE Cedar Rapids, IA 52499 800-755-5801 www.divinvest.com Federal Tax Withholding Election Form Instructions To change your federal income tax withholding,

More information

Employment Application

Employment Application P.O. Box 643 Benavides, Tx 78341 (361) 256-4726 Office (361) 256-4728 Fax Scorp1144@yahoo.com Scorpion Exploration & Production, Inc. Full Name Mailing Address Employment Application Applicant Information

More information

EMPLOYER WITH EMPLOYEES - PAYROLL INTAKE FORM

EMPLOYER WITH EMPLOYEES - PAYROLL INTAKE FORM EMPLOYER WITH EMPLOYEES - PAYROLL INTAKE FORM CONTACT INFORMATION Payroll Client (First, Last): Phone #: ( ) - Legal Business Name: Business DBA (If Applicable): Business Type: LLC Partnership Corp S-Corp

More information

Jersey Assistance for Community Caregiving (JACC) Program PEP Enrollment Packet

Jersey Assistance for Community Caregiving (JACC) Program PEP Enrollment Packet Public Partnerships Jersey Assistance for Community Caregiving (JACC) Program Phone: 1-866-239-2778 Paperwork Fax: 1-866-547-2481 Paperwork E-mail: njpplfax@pcgus.com Website: www.publicpartnerships.com

More information

NO CONFLICT ATTESTATION. In order to qualify to act as the Personal Assistant for this Consumer, I attest to the ALL of following:

NO CONFLICT ATTESTATION. In order to qualify to act as the Personal Assistant for this Consumer, I attest to the ALL of following: NO CONFLICT ATTESTATION In order to qualify to act as the Personal Assistant for this Consumer, I attest to the ALL of following: 1. I am NOT the Consumer s Designated Representative. 2. The Consumer is

More information

Withholding Certificate for Pension or Annuity Payments

Withholding Certificate for Pension or Annuity Payments Withholding Certificate for Pension or Annuity Payments Type or Print Your Full Name Your Social Security Number Home Address (Number and Street or Rural Route) Claim or Identification Number (if any)

More information

SURRENDER REQUEST FORM. Policy Number: Insured:

SURRENDER REQUEST FORM. Policy Number: Insured: SURRENDER REQUEST FORM Section A Policy Information (You Must Complete This Section) Policy Number: Insured: (First Name) (Last Name) Sec tion B Surrender Request and Withholding Election (You Must Complete

More information

MAYOR BYRON W. BROWN S SUMMER YOUTH INTERNSHIP PROGRAM APPLICATION

MAYOR BYRON W. BROWN S SUMMER YOUTH INTERNSHIP PROGRAM APPLICATION MAYOR BYRON W. BROWN S SUMMER YOUTH INTERNSHIP PROGRAM February 1, 2018 Dear Applicant: Thank you for your interest in applying for my 2018 Summer Youth Internship Program. This is truly a wonderful opportunity

More information

Employee Data Form. [ ] ] ] [ ] ] [ ] _] _]_ ] Home Address Apt City State Zip Code County. Ethnicity: Are you Hispanic/Latino?

Employee Data Form. [ ] ] ] [ ] ] [ ] _] _]_ ] Home Address Apt City State Zip Code County. Ethnicity: Are you Hispanic/Latino? Employee Data Form Baltimore City Public Schools Office Of Human Capital 200 E. North Avenue, Room 110 Baltimore, Maryland 21202 www. s New /Rehire employees are required to complete this form as part

More information

Student Employee New Hire Packet

Student Employee New Hire Packet Student Employee New Hire Packet New Hire Checklist: o Authorization to Hire Form o Student Application o Federal W-4 Form o NJ State W-4 Form o I-9 Form o Social Security Card (for Payroll purposes) o

More information

How Do I Adjust My Tax Withholding?

How Do I Adjust My Tax Withholding? Contents Department of the Treasury Internal Revenue Service What s New for 2011... 2 Reminder.... Publication 919 Introduction... 3 Cat. No. 63900P How Do I Adjust My Tax Withholding? Checking Your Withholding...

More information

Please complete and sign all forms in the PRE-EMPLOYMENT FORMS section.

Please complete and sign all forms in the PRE-EMPLOYMENT FORMS section. NATIONAL HOME HEALTH SERVICES EMPLOYMENT FORMS 5811 Dempster St Morton Grove, IL 60053 Phone: (847) 329-9933 Fax: (847) 930-0375 APPLICANT NAME POSITION APPLYING FOR DATE Please complete and sign all forms

More information

Graveyard Productions, LLC

Graveyard Productions, LLC Graveyard Productions, LLC Check here if you are under 18 years old Recruitment Application- 2018 PLEASE PRINT LEGIBLY Applicant Information Full Name: Date: Last First M.I. Address: Street Address Apartment/Unit

More information

Employment Application

Employment Application Print Name (First, ( M., Last): Employment Application PERSONAL INFORMATION Date: Street Address: Apt. Unit/# Home Phone: City State Zip Cell Phone: Email Address: Are you authorized to work in the U.S.?

More information

Packet A - Forms. If you have any questions, please contact Human Resources at

Packet A - Forms. If you have any questions, please contact Human Resources at Packet A - Forms 2018 TEMPORARY NEW HIRE PAPERWORK Welcome to Union College! This packet contains new hire forms necessary for you to become established as a Union College employee. Please fill out and

More information

Human Resources Department Mary Lou Glaesmann, Asst. Supt. for HR

Human Resources Department Mary Lou Glaesmann, Asst. Supt. for HR Human Resources Department Mary Lou Glaesmann, Asst. Supt. for HR Welcome! This document contains the paperwork you will be required to complete and bring to your HR orientation. Below are some helpful

More information

Name: MCO (circle one): AG UHC VSHP (Blue Care) Worker Training Checklist. I-9 Criminal Attestation Tax Exempt W-4. Additional Comments:

Name: MCO (circle one): AG UHC VSHP (Blue Care) Worker Training Checklist. I-9 Criminal Attestation Tax Exempt W-4. Additional Comments: 414 Union ST, Ste 1100 Nashville, TN 37219 Fax - Worker United Health Care Fax: 877.432.4103 (FOR DOCUMENTS ONLY. NO TIMESHEETS TO THIS NUMBER) Customer Service: 888.866.1154 To: Fax: Phone: Member Name:

More information

APPLICATION CHECKLIST

APPLICATION CHECKLIST PERF/TRF RETIREMENT APPLICATION State Form 945 (R30 / 2-15) Approved by State Board of Accounts, 2015 INDIANA PUBLIC RETIREMENT SYSTEM Telephone: (888) 286-3544 (Toll-free) Web site: www.inprs.in.gov Use

More information

INSTRUCTIONS FOR PAPERWORK ALL FORMS MUST BE SIGNED AND DATED PLEASE PRINT ONE-SIDED SHEETS

INSTRUCTIONS FOR PAPERWORK ALL FORMS MUST BE SIGNED AND DATED PLEASE PRINT ONE-SIDED SHEETS INSTRUCTIONS FOR PAPERWORK ALL FORMS MUST BE SIGNED AND DATED PLEASE PRINT ONE-SIDED SHEETS CFISD EMPLOYEE INFORMATION SHEET Must be LEGIBLE Fill in all blanks You MUST bubble an answer for Part 1-Ethnicity

More information

Decatur County Schools

Decatur County Schools Decatur County Schools 100 West Street Bainbridge, Georgia 39817 (229) 248-2200 Fax (229) 248-2252 This application will remain active for one year from date received unless requested to reactivate after

More information

A - EMPLOYEE INFORMATION SUBMISSION AND CERTIFICATION

A - EMPLOYEE INFORMATION SUBMISSION AND CERTIFICATION Office/Client Number New Employee Packet Employer Information: Choose your option for submitting employee information. For detailed instructions for these options, refer to the PEO New Employee Packet

More information

Form W-4 (2018) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/formw4. Purpose.

More information

What s In My Paycheck? compensation package: all of the wages (salary, bonus, commission) and benefits provided by an employer. What s In My Paycheck?

What s In My Paycheck? compensation package: all of the wages (salary, bonus, commission) and benefits provided by an employer. What s In My Paycheck? compensation package: all of the wages (salary, bonus, commission) and benefits provided by an employer wages: money paid or received for work or services completed, usually by the hour, day, or week hourly

More information

Branson Public Schools

Branson Public Schools Branson Public Schools Dr. Don Forrest, Assistant Superintendent of Business Services 1756 Bee Creek Rd Branson, MO 65616 Phone: 417.334.6541 uww.branson.k12.mo.us Fax: 417.332.2510 Amy Mulvaney, Administrative

More information

Employee Packet Forms

Employee Packet Forms Welcome!! Outreach Health Services looks forward to working with you. This Employee Packet has the forms and information you need to become an employee. The participant, who is your employer, can help

More information

Name: MCO (circle one): AG UHC VSHP (Blue Care) Worker Training Checklist. I-9 Criminal Attestation Tax Exempt W-4. Additional Comments:

Name: MCO (circle one): AG UHC VSHP (Blue Care) Worker Training Checklist. I-9 Criminal Attestation Tax Exempt W-4. Additional Comments: 414 Union ST, Ste 1100 Nashville, TN 37219 Fax - Worker United Health Care Fax: 877.432.4103 (FOR DOCUMENTS ONLY. NO TIMESHEETS TO THIS NUMBER) Customer Service: 888.866.1154 To: Fax: Phone: Member Name:

More information

Permanent home address (number and street or rural route) Single or Head of household

Permanent home address (number and street or rural route) Single or Head of household Department of Taxation and Finance Employee s Withholding Allowance Certificate New York State New York City Yonkers IT-2104 First name and middle initial Last name Your social security number Permanent

More information

TYPE OF APPLICATION (select one): PERSONAL ASSISTANT COMMUNITY SPECIALIST SUPPORT BROKER

TYPE OF APPLICATION (select one): PERSONAL ASSISTANT COMMUNITY SPECIALIST SUPPORT BROKER Missouri Self-Directed Supports EMPLOYEE APPLICATION Based on the pre-employment information you provided, we have pre-populated this application and most of the forms included in your enrollment packet.

More information

Store# Name (First, Middle, Last) SSN # Date of Birth. City State Zip. Hire Date Position Rate of pay/annual Salary. Select... Rehire.

Store# Name (First, Middle, Last) SSN # Date of Birth. City State Zip. Hire Date Position Rate of pay/annual Salary. Select... Rehire. Store# Name (First, Middle, Last) SSN # Date of Birth Address Apt/Lot City State Zip Hire Date Position Rate of pay/annual Salary Rehire nmlkj Yes nmlkj No Select... Native American If yes, please list

More information

We (The Jeffrey Corporation) are making you a contingent job offer to work at Burger King Store #.

We (The Jeffrey Corporation) are making you a contingent job offer to work at Burger King Store #. Date Dear Applicant, We (The Jeffrey Corporation) are making you a contingent job offer to work at Burger King Store #. Part of the hiring/re-hiring process requires that we verify your eligibility to

More information

ATTENTION: NEW NC-4 WITHHOLDING FORMS ENCLOSED

ATTENTION: NEW NC-4 WITHHOLDING FORMS ENCLOSED North Carolina Department of Revenue ATTENTION: NEW NC-4 WITHHOLDING FORMS ENCLOSED IMMEDIATE ACTION REQUIRED North Carolina Department of Revenue TO: IMPORTANT NOTICE: NEW NC-4 REQUIRED FOR PAYMENTS BEGINNING

More information

EMPLOYEE PORTAL PASSWORD SET UP

EMPLOYEE PORTAL PASSWORD SET UP EMPLOYEE PORTAL PASSWORD SET UP Here are some helpful tips to make sure you have access to paystubs and W2 s. Please be sure you include an email address in your new hire paperwork. The first page titled

More information

Blank Forms (Volume 1)

Blank Forms (Volume 1) Blank Forms (Volume 1) These forms are provided for congregational use and may be copied. Payroll Congregational Payroll Information Employment Eligibility Verification (I-9) Payroll Authorization Form

More information

December, Following is an overview of the payroll tax rates and other payroll related information in effect in 2019:

December, Following is an overview of the payroll tax rates and other payroll related information in effect in 2019: 1 December, 2018 It s time again for the annual payroll letter. The following pages include payroll and other miscellaneous information that may be helpful in fulfilling your payroll and related reporting

More information

LS Contracting Group, Inc. General Contractor & Specialty Restoration

LS Contracting Group, Inc. General Contractor & Specialty Restoration LS Contracting Group, Inc. General Contractor & Specialty Restoration 5660 N. Elston Ave. Chicago, IL 60646 p: (773) 774-1122 f: (773) 774-5660 lscontracting.com EMPLOYMENT APPLICATION CHECKLIST Name:

More information

Personal Fact Sheet (This information is not to be requested before employment)

Personal Fact Sheet (This information is not to be requested before employment) Personal Fact Sheet (This information is not to be requested before employment) Self-disclosure of this information is requested for Affirmative Action, insurance and other purposes. It will not in any

More information

Warrick County School Corporation

Warrick County School Corporation Warrick County School Corporation SUPERINTENDENT S OFFICE P.O. Box 809/Boonville, Indiana 47601/812-897-0400 Welcome to the Warrick County School Corporation Welcome to the one of the best school corporations

More information

Dedicated to Providing the Highest Level of Public Safety Services to our Community

Dedicated to Providing the Highest Level of Public Safety Services to our Community FIRE CHIEF Lonnie E. Click Dedicated to Providing the Highest Level of Public Safety Services to our Community COMMISSIONERS Earl W. Bill Houchin Jerry F. Morris Gerald D. Sleater INTRODUCTION Thank you

More information

Form1040-ES/V (OCR) Department of the Treasury Internal Revenue Service

Form1040-ES/V (OCR) Department of the Treasury Internal Revenue Service Form1040-ES/V (OCR) Department Treasury Internal Revenue Service Purpose of This Package Use this package to figure and pay your estimated tax. If you are not required to make estimated tax payments for

More information

SPORT CLIPS PAYROLL INFORMATION FORM CLIENT NAME: TO BE COMPLETED BY EMPLOYEE: Employee Name: Employee

SPORT CLIPS PAYROLL INFORMATION FORM CLIENT NAME: TO BE COMPLETED BY EMPLOYEE: Employee Name: Employee SPORT CLIPS PAYROLL INFORMATION FORM CLIENT NAME: TO BE COMPLETED BY EMPLOYEE: Employee Name: Employee Email: Local Tax (IF APPLICABLE): SSN: City or County Township or Borough School District PA EMST:

More information

Property Tax Refund (Credit) Claim. You must file this form, or Arizona Form 204, by April 17, 2018.

Property Tax Refund (Credit) Claim. You must file this form, or Arizona Form 204, by April 17, 2018. DO NOT STAPLE ANY ITEMS TO THE CLAIM. Arizona Form 140PTC You must file this form, or Arizona Form 204, by April 17, 2018. 82F Check box 82F if filing under extension 95 Check box 95 if amending claim

More information

EMP NAME: DEPT CODE LOCATION: B/G CHK: N/A COMPLETED START DATE: PAY RATE: TAX CODES: ( FILLED BY OFFICE ONLY ) LIVE IN WORK IN LST

EMP NAME: DEPT CODE LOCATION: B/G CHK: N/A COMPLETED START DATE: PAY RATE: TAX CODES: ( FILLED BY OFFICE ONLY ) LIVE IN WORK IN LST APPLICATION MGR: EMP # EMP NAME: DEPT CODE LOCATION: B/G CHK: N/A COMPLETED START DATE: PAY RATE: DAYS TO WORK: Mon Tues Wed Thurs Fri Sat Sun SCHEDULED HOURS: - PART TIME FULL TIME (30 hours or more )

More information

IRS Use Only Do not write or staple in this space. For the year Jan. 1 Dec. 31, 2004, or other tax year beginning

IRS Use Only Do not write or staple in this space. For the year Jan. 1 Dec. 31, 2004, or other tax year beginning F or m Department of the Treasury Internal Revenue Service 14 U.S. Individual Income Tax Return 24 Label (See instructions.) Use the IRS label. Otherwise, please print or type. Presidential Election Campaign

More information

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Employee s Withholding Allowance Certificate

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Employee s Withholding Allowance Certificate Form W-4 (2018) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/formw4. Purpose.

More information

GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

GREEK CATHOLIC UNION OF THE USA (Herein called GCU) GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA 15009-9513 1-800-722-4428 IMMEDIATE ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member

More information

Prepare, print, and e-file your federal tax return for free!

Prepare, print, and e-file your federal tax return for free! Prepare, print, and e-file your federal tax return for free! www.freetaxusa.com Form 1040 Department of the Treasury Internal Revenue Service (99) U.S. Individual Income Tax Return 2017 OMB No. 1545-0074

More information

Bring all completed forms to your paperwork session. Any questions that you may have about the forms, we will be happy to address at the session.

Bring all completed forms to your paperwork session. Any questions that you may have about the forms, we will be happy to address at the session. Directions for completing the New Hire Paperwork On-Line: Please print all pages (12 forms) 1-Employment Eligibility Verification Form: complete and sign/date Section 1. If your social security card states

More information

Bring all completed forms to your paperwork session. Any questions that you may have about the forms, we will be happy to address at the session.

Bring all completed forms to your paperwork session. Any questions that you may have about the forms, we will be happy to address at the session. Directions for completing the New Hire Paperwork On-Line: Please print all pages (12 forms) 1-Employment Eligibility Verification Form: complete and sign/date Section 1. If your social security card states

More information

Person ID Name. Job Code

Person ID Name. Job Code REQUEST FOR PERSONNEL ACTION ACTION REQUESTED FOR POSITION (Please check the box to the left of the action you are requesting): New Position Modify (Change) Position Continue Current Position Delimit Assignment

More information

Cash Balance Benefit Program Retirement Benefit Application CB 586 (rev 04/17)

Cash Balance Benefit Program Retirement Benefit Application CB 586 (rev 04/17) Cash Balance Benefit Program Retirement Benefit Application CB 586 (rev 04/17) Use this form if you are eligible to apply for a retirement benefit (age 55 or older). Please read the instructions before

More information

FORMS TO BE COMPLETED AND SUBMITTED TO HUMAN RESOURCES. The College requires all Employees complete and submit the following documents:

FORMS TO BE COMPLETED AND SUBMITTED TO HUMAN RESOURCES. The College requires all Employees complete and submit the following documents: FORMS TO BE COMPLETED AND SUBMITTED TO HUMAN RESOURCES The College requires all Employees complete and submit the following documents: 1. I-9 Employment Eligibility Verification: Complete the I-9 Form

More information

15055 Fairfield Meadows Dr. # Office: Fax:

15055 Fairfield Meadows Dr. # Office: Fax: Dear Potential Advantage Labor Employee, Here is the application that you have requested. We greatly look forward to working with you to find employment. However, we will need all the information below

More information

Draft Not for Reproduction 05/18/2016

Draft Not for Reproduction 05/18/2016 Instructions for Request for Reduced Fee Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-942 OMB No. 1615-0116 Expires 05/31/2015 What Is the Purpose of Form I-942?

More information

CDS Participant's New Attendant Check List

CDS Participant's New Attendant Check List CDS Participant's New Attendant Check List Participant : The person receiving care through the Medicaid-funded program Consumer Directed Services (CDS). This person is the employer of the attendant. May

More information

Note: forms may be faxed to our accounting department at (239)

Note: forms may be faxed to our accounting department at (239) Date: To: Re: Information package and Certificate of Insurance In order to establish your company as a vendor, we must have the attached Information Packet completed and returned along with an original

More information

2019 English Applica on

2019 English Applica on 2019 English Applica on (Please Print) Date: First Name Last Name Social Security Address Apt. City State Zip Code Home Phone Cell Phone E-Mail Please place a check by your response or provide the appropriate

More information

Cut here and give this certificate to your employer. Keep the top portion for your records.

Cut here and give this certificate to your employer. Keep the top portion for your records. Web 12-18 NC-4 Employee s Withholding Allowance Certificate PURPOSE - Complete Form NC-4 so that your employer can withhold the correct amount of State income tax from your pay. If you do not provide an

More information

EFG Tax Return(s)

EFG Tax Return(s) Caution: Forms printed from within Adobe Acrobat products may not meet IRS or state taxing agency specifications. When using Acrobat 5.x products, uncheck the "Shrink oversized pages to paper size" and

More information

COLCHESTER SCHOOL DISTRICT

COLCHESTER SCHOOL DISTRICT COLCHESTER SCHOOL DISTRICT APPLICATION FOR SUBSTITUTING Administrative Offices, 125 Laker Lane P.O. Box 27, Colchester, VT 05446-0027 Phone (802) 264-5999 Fax (802) 863-4774 Name: Telephone No.: Mailing

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT Community Values, Local Choices AN EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT Applicant: We appreciate your interest in C&K Market, Inc. (C&K). A clear understanding of your background and work

More information

INFORMATION & INSTRUCTIONS Applying for Retirement under the Traditional Benefit Package S U R S STATE UNIVERSITIES RETIREMENT SYSTEM

INFORMATION & INSTRUCTIONS Applying for Retirement under the Traditional Benefit Package S U R S STATE UNIVERSITIES RETIREMENT SYSTEM INFORMATION & INSTRUCTIONS Applying for Retirement under the Traditional Benefit Package S U R S STATE UNIVERSITIES RETIREMENT SYSTEM State Universities Retirement System of Illinois This application is

More information

TTC Form T3-107) ct Deposit (TTC Form T3-21)

TTC Form T3-107) ct Deposit (TTC Form T3-21) TO: Adjunct Instructor FROM: Human Resources, Fredric Yeadon (843-574-6825) RE: Adjunct Instructor Packet Welcome to Trident Technical College! Please complete the following paperwork before reporting

More information

Certification by U.S. Person Residing in the United States for Streamlined Domestic Offshore Procedures

Certification by U.S. Person Residing in the United States for Streamlined Domestic Offshore Procedures Form 14654 (June 2016) Department of the Treasury - Internal Revenue Service Certification by U.S. Person Residing in the United States for Streamlined Domestic Offshore Procedures Name(s) of taxpayer(s)

More information

Employee (Caregiver) Packet (Keep this folder for your records)

Employee (Caregiver) Packet (Keep this folder for your records) Employee (Caregiver) Packet (Keep this folder for your records) You will need to complete the following steps in order to hire an employee. Enrollment forms to enroll and hire a Support Broker can be found

More information

APPL1CM ION i-or EMPLOYMENT

APPL1CM ION i-or EMPLOYMENT APPL1CM ION i-or EMPLOYMENT PERSONAL INFORMATION DATE NAME (LAST NAME FIRST) SOCIAL SECURITY NO. PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER PRESENT ADDRESS CITY STATE ZIP CODE PERMANENT ADDRESS

More information

Instructions for the Requester of Form W-9 (Rev. December 2000)

Instructions for the Requester of Form W-9 (Rev. December 2000) Instructions for the Requester of Form W-9 (Rev. December 2000) Request for Taxpayer Identification Number and Certification Section references are to the Internal Revenue Code unless otherwise noted.

More information

1040 U.S. Individual Income Tax Return 2017

1040 U.S. Individual Income Tax Return 2017 F or Department of the Treasury Internal Revenue Service (99) 14 U.S. Individual Income Tax Return 17 m OMB No. 1545-74 IRS Use Only Do not write or staple in this space. For the year Jan. 1 Dec. 31, 17,

More information

2017 New Hire Forms Directions & Resources

2017 New Hire Forms Directions & Resources 2017 New Hire Forms Directions & Resources Federal W4 Forms Complete form; filling in all spaces in sections 1-7, remembering to sign and date form. State W4 Forms Complete Employee Withholding Allowance

More information

Withholding Certificate for Pension or Annuity Payments

Withholding Certificate for Pension or Annuity Payments Web 10-17 PURPOSE Form NC 4P is for North Carolina residents who are recipients of income from pensions, annuities, and certain other deferred compensation plans. Use the form to tell payers whether you

More information

TAX PRIMER FOR PARENTS COMPLETING A PFS

TAX PRIMER FOR PARENTS COMPLETING A PFS TAX PRIMER FOR PARENTS Use this primer to get an understanding of which few tax forms will be most helpful to you as you complete your PFS. This primer doesn t provide an overview of every possible tax

More information

1040 U.S. Individual Income Tax Return 2017

1040 U.S. Individual Income Tax Return 2017 F or Department of the Treasury Internal Revenue Service (99) 14 U.S. Individual Income Tax Return 217 m OMB No. 1545-74 IRS Use Only Do not write or staple in this space. For the year Jan. 1 Dec. 31,

More information

Cut here and give this certificate to your employer. Keep the top portion for your records.

Cut here and give this certificate to your employer. Keep the top portion for your records. Web 10-17 NC-4 Employee s Withholding Allowance Certificate PURPOSE - Complete Form NC-4 so that your employer can withhold the correct amount of State income tax from your pay. If you do not provide an

More information

Do your taxes online with H&R Block. Do your taxes online with H&R Block. Do your taxes online with H&R Block.

Do your taxes online with H&R Block. Do your taxes online with H&R Block. Do your taxes online with H&R Block. Send Friend (2004) FDFRNDOL-1WV 1.0 Send a friend to us. We'll thank you both with cash! 5 for you. 10 for your friend! Easy-to-follow instructions: 1. 2. 3. Give one of the forms below to a friend and

More information

WITHHOLDING TABLES MAINE INDIVIDUAL INCOME TAX

WITHHOLDING TABLES MAINE INDIVIDUAL INCOME TAX WITHHOLDING TABLES MAINE INDIVIDUAL INCOME TAX 2000 Effective January 1, 2000 REMEMBER: A person required to withhold must continue to file quarterly withholding tax returns until the account is canceled,

More information

U.S. Nonresident Alien Income Tax Return. Of what country were you a citizen or national during the tax year?

U.S. Nonresident Alien Income Tax Return. Of what country were you a citizen or national during the tax year? 1040NR U.S. nresident Alien Income Tax Return OMB. 1545-0089 2002 Form For the year January 1 December 31, 2002, or other tax year Department of the Treasury Internal Revenue Service beginning, 2002, and

More information

Your first name and initial Spouse s first name and initial (and last name - only if different) Your last name

Your first name and initial Spouse s first name and initial (and last name - only if different) Your last name Illinois Department of Revenue 2017 Form IL-1040-X Amended Individual Income Tax Return Step 1: Personal information A Print or type your current Social Security number(s), name(s), and address. Your Social

More information

CHENANGO BROKERS, LLC.

CHENANGO BROKERS, LLC. CHENANGO BROKERS, LLC. BROKERAGE AGREEMENT 2 WEST FRONT STREET P.O. BOX 460 HANCOCK, N.Y. 13783-0460 607-637-1710 Chenango Brokers, LLC Brokerage Agreement 65 West Front St ~ PO Box 460 Hancock, NY 13783

More information

P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles

P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles If you have a disability and need this form in large print or another format, please call our helpline

More information

TAX PRIMER FOR PARENTS COMPLETING A PFS

TAX PRIMER FOR PARENTS COMPLETING A PFS FOR PARENTS Use this primer to get an understanding of which few tax forms will be most helpful to you as you complete your PFS. This primer doesn t provide an overview of every possible tax form you might

More information

SHIP P.O. Box St. Paul, MN 55164

SHIP P.O. Box St. Paul, MN 55164 SENIOR HEALTH INSURANCE COMPANY OF PENNSYLVANIA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-450-5824 Dear Policyholder: If you choose to assign your long term care insurance benefits to a covered

More information

Form OR-W-4 Oregon Employee s Withholding Allowance Certificate. Social Security number (SSN) City

Form OR-W-4 Oregon Employee s Withholding Allowance Certificate. Social Security number (SSN) City Page 1 of 4, 150-101-402 (Rev. 12-18) 19611901010000 Important information Complete Form OR-W-4 if: You re a new employee. You filed a 2018 or 2019 federal Form W-4 with your employer and didn t file a

More information

][A01: ][Form 7 ][FRPS FDSTRQ ][08/27/09 ][ ][STD_INST ][TT33/

][A01: ][Form 7 ][FRPS FDSTRQ ][08/27/09 ][ ][STD_INST ][TT33/ Distribution/Direct Rollover Request Refer to the Participant Distribution Guide while completing this form. Use blue or black ink only. All pages must be returned excluding the Participant Distribution

More information

Cash Balance Benefit Program Termination Benefit Application CB 585 (rev 02/16)

Cash Balance Benefit Program Termination Benefit Application CB 585 (rev 02/16) Cash Balance Benefit Program Termination Benefit Application CB 585 (rev 02/16) California State Teachers Retirement System P.O. Box 15275, MS 65 Sacramento, CA 95851-0275 800-228-5453 CalSTRS.com Please

More information