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 you complete this packet. The employer s signature is needed on some of the forms. You or your employer need to return the packet to Outreach when complete. Outreach s job is to make sure you are eligible to work, conduct a background check, pay you, and process taxes. The participant will be notified when your paperwork has been processed. Once notified, you can begin work! Please call us if you have questions or if you need assistance. Outreach Health Services Mon-Fri, 8 am 5 pm (excluding holidays) Phone: 984-242-7200 or 877-901-5827 Toll-Free Fax: 866-463-7589 Email: outreach.nc@outreachhealth.com Web: www.outreachhealthnc.com FORM Employee Checklist Employee Application Criminal Record Check Consent Form Participant-Employee Agreement Employee Packet Forms PURPOSE Use this as a guide to make sure you complete all of the required employee forms. This form is a requirement to complete in North Carolina. It also provides Outreach with your contact information for payroll. A Consent Form is also attached. This gives Outreach permission to conduct a background check. Please fully complete the application. Signing this form gives Outreach permission to conduct a national criminal history check and receive the results. This form outlines the role and responsibilities of each party. It also establishes employee wage and work hours. By signing this form, the employee agrees to follow policies and procedures. I-9 Employment Eligibility Verification This form documents that you are eligible to work in the United States. You must complete section 1 of this form. The participant completes section 2 by examining your supporting documents from either list A or lists B and C. Please attach the supporting documents. W-4 Employee s Withholding Allowance Certificate NC4 or NC4EZ Completion of this form determines deductions for federal income tax from your pay, so Outreach can make deposits on your behalf, based on exemptions/allowances claimed. This form determines state deductions so Outreach can make deposits on your behalf. Only ONE of the state tax forms needs to be completed. Complete the tax form that applies to your tax status.
Employee Relationship Form Direct Deposit Pay Card This form determines if you are exempt from paying certain payroll taxes. Complete the Direct Deposit Form to have your pay directly deposited into your bank account. Please attach a voided check Complete this form if you would like your pay deposited on a pay card which is similar to a debit card. Additional Materials: Instructions for Electronic Time Entry Signs and Symptoms of Abuse, Neglect and Exploitation Preventing Medicaid Fraud Employee Training Materials Universal Precautions, Safe Lifting, HIPAA and Confidentiality Payroll Calendar Paper Time Sheets 797 Earned Income Credit Information
New Employee Packet Checklist Printed name of Participant Printed Name of Employee Last Four Digits of Participant s Social Security Number This checklist is your guide for completing all new employee hire forms. Please call Outreach if you have questions or need assistance call 1-984242-7200 or toll free 1-877-901-5827. Please return the initialed form with the completed packet. Participant Employee 1. Employee Application 2. Participant-Employee Agreement 3. I-9 Employment Eligibility Verification *Please attach two forms of supporting identification 4. IRS W-4 *Please attach Social Security Card for IRS name verification unless attached with the I-9 5. NC4 or NC4-EZ 6. Employee Relationship Form 7. Direct Deposit or Pay Card Employer Signature Date Employee Signature Date EmployeePacketChecklist_05.11.15
Employment Application Application Date: Participant you are applying to work for: Agency referred by: Last Name First Name Middle Initial Street Address City State/Zip Best Contact Phone # E-mail Address Date of Birth Are you at least 18 years old? Yes Education: Highest Grade Completed: High School 9 1 11 1 College, Trade or Business 1 5 Graduate Studies Employment History (starting with the most recent position) Dates employed Reason for leaving Job Title Employer Supervisor Supervisor Phone# Address Starting Salary Ending Salary Duties and Responsibilities Dates employed Reason for leaving Job Title Employer Supervisor Supervisor Phone# Address Starting Salary Ending Salary Duties and Responsibilities May we contact your current and former employers for references? Do you have any experience as a caregiver? Please Describe Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation? Have you ever been convicted of a crime, excluding misdemeanors and a summary offense, which has not been annulled, expunged or sealed by court? (A yes response does not automatically disqualify your application.) I am an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, vetran status, sexual orientation or preference, or physical or mental disability. Applicant's Signature: Date: 04/2015 hd
(Please print clearly) Criminal Record Check Consent Form Name of Participant you are applying to work for: Phone: 877-901-5827 Fax: 866-463-7589 Name Date of Birth Social Security # (First) (Middle) (Last) Street Address City State Zip Indicate Previous Names Used: (Include maiden name and any other names which you have used or been known by) How long have you resided in this state? If less than 5 years, list previous addresses: City State ZIP City State ZIP Authorization to Obtain and Consent to Release Criminal History/Driving Record Reports: I give permission to Designees of the Host Agency on behalf of Outreach Health Services to conduct a criminal background check to investigate my criminal history and driving record. I understand that the scope of this investigation will be limited to a criminal history background report, driving record report and Inspector General Report. The information obtained from these reports will remain confidential and will be used by Outreach Health Services, the Host Agency, and clients of the host agency for which I could potentially provide service or employment for, consideration of entering into a contract with me for the purchase of services. In accordance with the provisions of Sections 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208, you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. I understand that the results from my criminal background check, Inspector General report, and/or driving record check, may result in my ineligibility to contract with a potential employer because of Medicaid regulations. Representative(s) of the Host Agency administration will make this determination. Furthermore, I understand that any falsification or willful omission of fact made in connection with the criminal background check may be sufficient grounds for rejection of my eligibility to contract with the Host Agency and/or Outreach Health Services and considered as cause for possible dismissal and/or discharge. In addition, I give permission for the host agency or designee, to release the results of my Criminal Background Check and/or driver s record check to Outreach Health Services individuals who will be direct consumers of my services, and individuals who are guardians or family members of direct consumers of my services. This consent to obtain and release will be used in conjunction with my application for employment or ongoing employment with Outreach Health Services, the Host Agency and persons who will be directly receiving my care. If hired or currently employed I understand that this authorization will remain on file and will serve as an ongoing authorization, to the extent permitted by law, for a consumer report to be lawfully obtained at any time in connection with my employment. I release from liability all persons, companies, and corporations supplying that information and Outreach Health Services against any liability that might result from making such background checks. A copy of this form is as valid as the original. I acknowledge that I have received a summary of my rights under the Fair Credit Reporting Act. Applicant s Signature Date
Participant/Employer-Employee Agreement This agreement is between (Participant) and, employee. The purpose of the agreement is to outline roles and responsibilities of each party, describe employee job duties and identify the hourly wage for the employee. Please review each item. 1. The employee s wage per hour is. Wages are subject to state and Federal withholding taxes. A new Participant Employer Agreement will be signed if the wage changes. 2. The employee will work hours a week. Hours worked are subject to change at the direction of the participant but must never exceed authorized hours on the Plan of Care unless approved by the Care Advisor. 3. The employee is an employee of the participant (named above) and not Outreach Health Services of North Carolina, LLC (Outreach). 4. This is an at-will employment agreement. The employer or the employee can cancel this agreement at any time, for any reason. If the employee can no longer work, it is essential to give advanced notice (two weeks) so the participant can recruit, hire and train a replacement. 5. Roles and Responsibilities of each party: a. Participant/representative responsibilities include, but are not limited to: Hiring, scheduling, orienting, training, supervising and terminating the employee. Treating the employee with respect. Coaching the employee and consistently giving the employee feedback up to and including termination, if applicable. Training the employee. The following training materials have been provided: -Signs and Symptoms of Abuse & Neglect and Exploitation -Preventing Medicaid Fraud -Employee Training Booklet: Universal Precautions, Safe Lifting and HIPAA & Confidentiality Reviewing the Plan of Care with the employee. Submitting employee time worked accurately and timely online or by paper time sheets. Monitoring that the employee only works approved hours according to Plan of Care, does not work over time and does not work when in the hospital, acute rehabilitation or skilled nursing facility. Notifying Outreach immediately if an employee is terminated. Reviewing the Outreach Employment Resource Guide with the employee. The Guide gives information about Federal and state employment law and regulations and Outreach s policies and procedures. The Handbook is also available on the Outreach website. Other responsibilities as outlined in the Participant Agreement. Participant/Employer-EmployeeAgreement_04172015
Participant/Employer-Employee Agreement b. The employee responsibilities include, but are not limited to: Providing safe and excellent care to the participant. Submitting time worked, either online or by faxing paper time sheet. Working hours and performing tasks approved on the participants Plan of Care. The employee is considered a mandated reporter and must immediately report any concerns of abuse, neglect or exploitation to the appropriate authority (the police or 911), the Department of Social Services county in which the participant lives. If additional help is needed call the North Carolina Department of Health and Human Services CARELINE 1-800-662-7030, and the participant s Care Advisor or Outreach. Reporting concerns of Medicaid Fraud to the North Carolina Division of Medical Assistance 1-877-362-8471 and Outreach or my Care Advisor. Immediately report all incidents, accidents and work place injuries involving the employee or the participant. If an employee is injured on the job, it should also be reported to the participant (employer). Work place injuries must be reported to the Outreach Employee Injury Line 877-901-5824. Notifying Outreach immediately if there is a change in name, address, telephone and any criminal convictions occurring after date of hire. Reporting any customer service concerns or complaints to Outreach. c. Outreach responsibilities include, but are not limited to: Sending the participant required employee paperwork, if needed (all forms are on the Outreach website). Helping in the completion of required paperwork, if needed. Processing employee paperwork and determining employee eligibility and conducting background check. Providing workers compensation to participants who have two or more employees according to state law. Paying the employee and processing employee taxes and benefits. Assisting the employee with work place injury protocol, if needed. Sending a W-2 to employee within Federal timelines. 6. The participant and employee understand that the employee will only be paid for approved hours on the Plan of Care. Both parties understand that Outreach is not financially responsible for payment of services in situations where: The participant becomes ineligible for Medicaid or does not meet the spend-down. The participant/representative allows an employee to work unauthorized overtime (hours in excess of 40 approved time. The participant/representative allows the employee to work more hours than approved or for tasks not approved on the participant s Plan of Care. The employee works before approved to do so by Outreach. The participant is in the hospital, acute rehabilitation unit or skilled nursing facility. The employee or employer submits time worked in advance. Participant/Employer-EmployeeAgreement_04172015
Participant/Employer-Employee Agreement 7. The participant and employee both agree to follow the payroll schedule of due dates and deadline as provided at the time of this agreement and thereafter as the schedule changes. Work time must be submitted every Monday by midnight. Time submitted late may not be paid until the next pay-period. 8. The participant and employee understand that a delay in Medicaid or service eligibility sometimes occurs. While the Participant is authorized for Medicaid, eligibility may not show on NCTracks. If this happens, Outreach will pay the employee for two pay periods. If the delay continues, payment may be stopped. Both the participant and employee be notified before this occurs as well as the Care Advisor. The participant s and employee s signature indicate acceptance of the terms and conditions outlines in this agreement. Print Participant or Legal Guardian Name Print Employee Name Participant/LG Signature Date Employee Signature Date Participant/Employer-EmployeeAgreement_04172015
Please pay close attention to the following Federal form. This form is detailed and needs your close attention to complete correctly. Incomplete forms may result in penalties. Call for assistance if needed. We are here to help!
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 before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number - - I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. QR Code - Section 1 Do Not Write In This Space 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee Today's Date (mm/dd/yyyy) Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next Page Form I-9 07/17/17 N Page 1 of 3
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 Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.") Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status 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 Issuing Authority Document Number Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions) Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name 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) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy) C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative Form I-9 07/17/17 N Page 2 of 3
LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A LIST B LIST C Documents that Establish Both Identity and Employment Authorization OR Documents that Establish Identity AND Documents that Establish Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I-9 07/17/17 N Page 3 of 3
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. 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. You may claim exemption from withholding for 2018 if both of the following apply. For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability. If you re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding. General Instructions If you aren t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. You can also use the calculator at www.irs.gov/w4app to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you re having withheld compares to your projected total tax for 2018. If you use the calculator, you don t need to complete any of the worksheets for Form W-4. Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040- ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/ W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/w4app to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim. Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status. Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year. Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of Form W-4 Department of the Treasury Internal Revenue Service Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Employee s Withholding Allowance Certificate Whether you re entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No. 1545-0074 2018 2 Your social security number Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note: If married filing separately, check Married, but withhold at higher Single rate. 4 If your last name differs from that shown on your social security card, check here. You must call 800-772-1213 for a replacement card. 5 Total number of allowances you re claiming (from the applicable worksheet on the following pages)... 5 6 Additional amount, if any, you want withheld from each paycheck.............. 6 $ 7 I claim exemption from withholding for 2018, 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............... 7 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.) 8 Employer s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.) 9 First date of employment Date 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)
Form W-4 (2018) Page 3 Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself.............................. A B Enter 1 if you will file as married filing jointly....................... B C Enter 1 if you will file as head of household....................... C D Enter 1 if: D E F { You re single, or married filing separately, and have only one job; or } You re married filing jointly, have only one job, and your spouse doesn t work; or Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. Child tax credit. See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $69,801 ($101,401 if married filing jointly), enter 4 for each eligible child. If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter 2 for each eligible child. If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter 1 for each eligible child. If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter -0-....... E Credit for other dependents. If your total income will be less than $69,801 ($101,401 if married filing jointly), enter 1 for each eligible dependent. If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter 1 for every two dependents (for example, -0- for one dependent, 1 if you have two or three dependents, and 2 if you have four dependents). If your total income will be higher than $175,550 ($339,000 if married filing jointly), enter -0-....... F G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here.. G H Add lines A through G and enter the total here...................... H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income and want to increase your withholding, see the Deductions, For accuracy, Adjustments, and Additional Income Worksheet below. complete all If you have more than one job at a time or are married filing jointly and you and your spouse both worksheets work, and the combined earnings from all jobs exceed $52,000 ($24,000 if married filing jointly), see the that apply. Two-Earners/Multiple Jobs Worksheet on page 4 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 above. Deductions, Adjustments, and Additional Income Worksheet Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage income. 1 Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income. See Pub. 505 for details...................... 1 $ 2 Enter: { $24,000 if you re married filing jointly or qualifying widow(er) $18,000 if you re head of household $12,000 if you re single or married filing separately }........... 2 $ 3 Subtract line 2 from line 1. If zero or less, enter -0-................. 3 $ 4 Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or blindness (see Pub. 505 for information about these items)................ 4 $ 5 Add lines 3 and 4 and enter the total...................... 5 $ 6 Enter an estimate of your 2018 nonwage income (such as dividends or interest)......... 6 $ 7 Subtract line 6 from line 5. If zero, enter -0-. If less than zero, enter the amount in parentheses... 7 $ 8 Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter in parentheses. Drop any fraction............................ 8 9 Enter the number from the Personal Allowances Worksheet, line H above.......... 9 10 Add lines 8 and 9 and enter the total here. If zero or less, enter -0-. If you plan to use the Two-Earners/ Multiple Jobs Worksheet, also enter this total on line 1, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1......................... 10
Web 2-15 NC-4 Employee s Withholding Allowance Certificate PURPOSE - Complete Form NC-4, Employee s Withholding Allowance Certificate, so that your employer can withhold the correct amount of State income tax from your pay. If you do not provide an NC-4 to your employer, your employer is required to withhold based on single with zero allowances. FORM NC-4 EZ - You may use this form if you intend to claim either: exempt status, or the N.C. standard deduction and no tax credits or only the credit for children. FORM NC-4 NRA - If you are a nonresident alien you must use Form NC-4 NRA. FORM NC-4 BASIC INSTRUCTIONS - Complete the Allowance Worksheet. The worksheet will help you figure the number of withholding allowances you are entitled to claim. The worksheet is provided for employees to adjust their withholding allowances based on N.C. itemized deductions, federal adjustments to income, N.C. additions to federal adjusted gross income, N.C. deductions from federal adjusted gross income, and N.C. tax credits. However, you may claim fewer allowances if you wish to increase the tax withheld during the year. If your withholding allowances decrease, you must file a new NC-4 with your employer within 10 days after the change occurs. Exception: When an individual ceases to be head of household after maintaining the household for the major portion of the year, a new NC-4 is not required until the next year. TWO OR MORE JOBS - If you have more than one job, figure the total number of allowances you are entitled to claim on all jobs using one Form NC-4 Allowance Worksheet. Your withholding will usually be most accurate when all allowances are claimed on the NC-4 filed for the higher paying job and zero allowances are claimed for the other. You should also refer to the Multiple Jobs Table to determine the additional amount to be withheld on line 2 of Form NC-4 (See Allowance Worksheet). NONWAGE INCOME - If you have a large amount of nonwage income, such as interest or dividends, you should consider making estimated tax payments using Form NC-40 to avoid underpayment of estimated tax interest. Form NC-40 is available on our website at www.dornc.com under individual income tax forms. HEAD OF HOUSEHOLD - Generally you may claim head of household status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. Note: Head of Household for State tax purposes is the same as for federal tax purposes. QUALIFYING WIDOW(ER) - You may claim qualifying widow(er) status only if your spouse died in either of the two preceding tax years and you meet the following requirements: 1. Your home is maintained as the main household of a child or stepchild for whom you can claim a federal exemption; and 2. You were entitled to file a joint return with your spouse in the year of your spouse s death. MARRIED TAXPAYERS - For married taxpayers, both spouses must agree as to whether they will each complete the Allowance Worksheet based on married filing jointly or married filing separately. For married taxpayers completing the Allowance Worksheet based on married filing jointly, you will consider the sum of both spouses incomes, adjustments, additions, deductions, and credits on the Allowance Worksheet to determine the number of allowances. For married taxpayers completing the worksheet on the basis of married filing separately, each spouse will consider only his or her portion of income, adjustments, additions, deductions, and credits on the Allowance Worksheet to determine the number of allowances. All NC-4 forms are subject to review by the North Carolina Department of Revenue. Your employer may be required to send this form to the North Carolina Department of Revenue. CAUTION: If you furnish an employer with an Employee s Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a penalty of 50% of the amount not properly withheld. NC-4 Web 11-13 Cut here and give this certificate to your employer. Keep the top portion for your records. 1. Total number of allowances you are claiming (Enter zero (0), or the number of allowances from Page 2, line 16 of the NC-4 Allowance Worksheet) 2. Additional amount, if any, withheld from each pay period (Enter whole dollars) Social Security Number Employee s Withholding Allowance Certificate North Carolina Department of Revenue Marital Status First Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) M.I. Last Name Single Head of Household Married or Qualifying Widow(er),. 00 Address County (Enter first five letters) City State Zip Code (5 Digit) Country (If not U.S.) Employee s Signature I certify, under penalties provided by law, that I am entitled to the number of withholding allowances claimed on line 1 above. Date
Employee Relationship Form Print Employee Name Print Employer Name INSTRUCTIONS: Each employee must disclose the relationship with the FEIN Holder/Employer before employment begins. This information is required to begin employment. Please complete each section and sign at the bottom of the form. 1) RELATIONSHIP DISCLOSURE: What is your existing relationship to the employer above? For example, if the employer is your biological son, you would check Parent. Please Check One: Parent (Exempt from FICA, SUTA and FUTA) Spouse of (Exempt from FICA, SUTA and FUTA) Child under age 21 (Exempt from FICA, SUTA and FUTA) Grandparent (Exempt from FICA, SUTA and FUTA) I have no Relationship 2) I acknowledge the following: If I am considered an exempt employee, I understand that I do not have to pay FICA (Social Security and Medicare) FUTA (Federal Unemployment) and SUTA (State Unemployment). This means I will not earn Social Security history work credits which apply towards Social Security benefits. You can earn a maximum of four credits each year, based on you age. Most people need 40 credits to qualify for retirement benefits. Please refer to IRS Publication 15- Family employees at www.irs.gov more information. Federal and state taxation rules change frequently. Outreach encourages you to talk with your tax advisor to better understand how IRS Publication 15-Family employees effects your taxes. This may change the way you complete your W-4 (and/or applicable state form. Please submit a revised W-4 for withholding adjustments if your tax situation changes. Please check if the employer lives in the employee s home. NOTE: If the living situation changes Outreach MUST be notified immediately Employer/Representative Signature / Date Employee Signature / Date / Date of Birth NC_RelationshipForm_09.09.2017
Money Network Application and Deposit Agreement State: CARD HOLDER INFORMATION Social Security Number: First Name: Date of Birth: Last Name: Address: es s esses City: State: Zip: Phone: Account Number: Money Network Payroll Debit Card: (* Account number is NOT the card number, please use account number included with packet) The Money Network Payroll Debit Card ( Card ) provides a dependable, safe, optional, and convenient way to receive and access my pay on and after each payday morning with the following features: (i) eliminates the need to pick up my paycheck, wait for it to be mailed, or pay for it to be cashed; (ii) immediate, worldwide access wherever the Card is accepted for ATM cash withdrawals, bank branch withdrawals, and store purchases (including cash back ); (iii) money transfers to a personal or joint checking account; and (iv) free balance inquiries by phone or online. There is no monthly service charge for the Card as long as I am employed by Employer. Many Card transactions are free (and I need never incur a fee to access 100% of my wages,to the penny, using the Money Network Service), but there are fees for other transactions. The Terms and Conditions, fee schedule, and other disclosures related to the Money e e e e e e e e e e s e e e e e se e se e s e e e e e e e e e e e s s e e e e I may begin to use the Money Network Service. Money Network Check: The Money Network Check ( Check ) is a paycheck that I can easily complete on or after each payday morning wherever I am, eliminating the need to pick up my paycheck, wait for it to be mailed, or pay for it to be cashed. The Check can be deposited into my personal bank account or cashed for free at Money Network check-cashing partners. e e e e s e e e s e e e e e e e es s es e e e es e e e e e e s e e e e Y e s e s e e e e e e e e e s e s e e e es e Y e e s e e e e ess e e e e e e e ss e e e se e e e e e e e e e es e e e s e e e e e delay in the availability of my debit card funds. Employee Signature: Date: Employee Printed Name:
Money Network Card Fee Schedule SPENDING MONEY MN Account Portable Account ATM Withdrawals (see below for ATM balance inquiry and decline fees) / U.S In-Network ATMs To find participating In-Network ATMs, use the Money Network mobile app (available at the App Store TM and Google Play TM ), visit moneynetwork.com or call Customer Service. An additional surcharge may be separately charged by an owner or operator of an ATM. ATM Withdrawals (see below for ATM balance inquiry and decline fees) / U.S Out-of-Network ATMs An additional surcharge may be separately charged by an owner or operator of an ATM. ATM Withdrawals (see below for ATM balance inquiry and decline fees) / Non-U.S. ATMs An additional surcharge may be separately charged by an owner or operator of an ATM. A foreign transaction conversion fee of 2% will apply to non-u.s. transactions. A Cross Border Transaction Fee of 0.8% will also apply. See Foreign Transaction Fees in your Account Holder Agreement for details. $0.00 $0.00 $1.75 $1.75 $2.50 $2.50 Bank Teller Over-the-Counter Cash Withdrawal (at any bank that displays the logo shown on your card) $0.00 $0.00 Money Network TM Check (use, order, or stop payment; cash at participating check-cashing locations) To find participating locations, use the Money Network mobile app (available at the App Store TM and Google Play TM ), visit moneynetwork.com or call Customer Service. Signature Point-of-Sale Transactions (for purchases, declines and returns) / U.S. and Non-U.S. A foreign transaction conversion fee of 2% will apply to non-u.s. transactions. A Cross Border Transaction Fee of 0.8% will also apply. See Foreign Transaction Fees in your Account Holder Agreement for details. PIN Point-of-Sale Transactions - with or without Cash Back (for purchases, declines and returns) / U.S and Non-U.S. A foreign transaction conversion fee of 2% will apply to non-u.s. transactions. A Cross Border Transaction Fee of 0.8% will also apply. See Foreign Transaction Fees in your Account Holder Agreement for details. $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Transfer Funds to a U.S. Bank Account (ACH transfer) $0.00 $0.00 Transfer Funds from your Account to a Secondary Card $0.00 $0.00 MANAGING MONEY MN Account Portable Account Monthly Account Maintenance Fee (applies only to Portable Accounts) N/A $2.95 Balance Inquiries and Alerts / via Mobile App, Automated Phone System, Customer Service, Online ess s s e e Your wireless carrier s standard messaging and data rates may apply. Balance Inquiries and Declines at ATM I U.S. ATMs (In-Network and Out-of-Network) An additional surcharge may be separately charged by an owner or operator of an ATM. Balance Inquiries and Declines at ATM I Non-U.S. ATMs An additional surcharge may be separately charged by an owner or operator of an ATM. $0.00 $0.00 $1.75 $1.75 $2.50 $2.50 Customer Service 24/7 $0.00 $0.00 Replacement Card with Standard Delivery $6.00 $6.00 e e e ee e e e e $13.00 $13.00 Monthly Paper Statement by Mail You may view statements online at no charge. You may also call to request transaction information or a printed 60-day history at no charge. $2.95 $2.95 Request a secondary card for a Family Member, Dependant or Caregiver $2.00 $2.00
ADDING MONEY MN Account Portable Account Payroll Direct Deposit $0.00 $0.00 e e s e s e e e s s e $0.00 $0.00 Load Cash at Participating Reload Locations (fee set by each reload location) use the Money Network mobile app (available at the App Store TM and Google Play TM ), visit moneynetwork.com or call Customer Service. TRANSACTION LIMIT SCHEDULE VARIES VARIES ATM Withdrawal Limit $600 per transaction and per day (ATM owner may have lower limits) Transactions at Point-of-Sale (POS) Money Network Check Limit Bank Teller Over the Counter Cash Withdrawal $3,000 per transaction and per day $9,999.99 per check (some check-cashing locations may have lower limits) $8,000 per transaction and per day (bank may have lower limits) s e s e s $4,000 per day; $8,000 per calendar month Retail or Reload Agent Loads $2,500 per transaction and per day; $5,000 per calendar month e e e $8,000 at any time (no limit for employer payroll loads ACH Transfer to a Bank Account Transfer to Secondary Card $8,000 per transaction $1,000 per transaction 1 Your Money Network Account will automatically convert to a Portable Account upon termination of your employment with the employer through whom you initially enrolled to receive your Money Network Card in accordance with your Account Holder Agreement. In the event of an automatic conversion, you may avoid the Monthly Account Maintenance Fee for the Portable Account by withdrawing or spending the funds in your Money Network Account.