Employment Application

Thank you for your interest in applying to CityCARE Home Health.

The entire application can be completed online using a computer or cell phone and will take approximately 20 minutes.

Please, fill out the forms below

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2
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Frequently Asked Questions

WHAT ARE THE AGENCIES HOURS?

The Agency Office’s days and hours of operation are Monday to Sunday from 8:00 AM to 4:00 PM. We are on call 24 hours a day and 7 days a week. Unless it is an emergency please call us only during regular office hours.

WHERE ARE YOUR CLIENTS?

CityCARE Home Health services clients in all seven Connecticut counties. Fairfield, New Haven, Middlesex, New London, Windham, Hartford, Litchfield.

WHEN WILL I BE PAID?

City CARE Home Health has a standard 40-hour work week, which is Monday through Sunday, beginning on Monday at 12:01 am and ending on Sunday at 12:00 midnight. The Agency's pay period covers a 7-day timeframe, which starts at 12:01 am on the Monday and ends at 12 Midnight Sunday. Payday is every Friday and occurs 52 times a year. In order to make sure payroll is processed properly and to comply with Connecticut State Laws you must use the telephone clock in/out system. Pay checks will be ready for pickup at the Agency Office by appointment during office hours on Friday. This paycheck will include all hours worked the previous week.

HOW DO I GET A WORK ASSIGMENT?

  • Work assignments for in-home employees are scheduled by the Office Manager. They are offered on the basis of services required, qualifications/expertise needed and availability of employee(s).
  • Keep your contact information current with the Agency office. We must be able to reach you easily and often on short notice.
  • When you receive and accept an assignment, you agree to the hours that the job requires. Should the requirements of that job change, you will be given first option of keeping that assignment, if you are willing to work within the changes. On the other hand, if you are not able to work within the new changes, another employee will be assigned.
  • You may refuse an assignment but doing so does not mean a replacement assignment will become available; or, if one does, it doesn't mean that the replacement assignment will be given to you. There is no guarantee of work assignments, as requests for service are unpredictable and can be sporadic.
  • Sometimes assignments come up on very short-notice. Being willing to accept these last-minute assignments and/or being available to cover for sick employees, will increase your chances of receiving assignments.

DO YOU OFFER DIRECT DEPOSIT?

Direct deposit is offered to all City Care Home Health employees. If you do not wish to receive a direct deposit, Wisely cards are available free of charge and can be funded electronically. Finally, you have the option of picking up a paper check from our office.

WHAT IS THE CLOCK IN SYSTEM?

In accordance with City CARE Home Health Policy # 6.60 - Payroll, employees shall accurately record all hours worked by clocking in/out from the clients home phone. Be sure you clock in and out accurately at the beginning and end of your work shift. Your Supervisor will review your clock in/out time before it is forwarded to payroll for processing. While we make an effort to correct any clock in/out errors which we notice, your payroll hours may not include the times you failed to punch in/out. In such cases payroll correction will be made the following week. Falsifying clock in/out times are grounds for immediate Termination of Employment.

MAY I USE MY CELL PHONE WHEN I AM WITH A CLIENT?

You are not permitted to make or accept telephone calls or texts while you are on duty at clients’ homes, unless they are from Managerial Staff, or an emergency/urgent situation develops. If you carry a cell phone with you, when you are on duty, be sure to either turn it off or put it on "vibrate" to ensure clients are not disturbed. Advise others to phone the Agency Office and leave a message, should they need to reach you, while you are on duty. The Agency Office will contact you with the message. Personal phone calls and/or texting may be done on your breaks or between assignments. Long distance calls may not be made using Agency phones, unless the call is business-related. Neither may Long distance calls be made using a client's phone.

WHAT IF I CANNOT MAKE MY ASSIGMENT?

When you are not able to work because of short-term illness or other reasons, you must contact your Supervisor, as soon as you are aware that you cannot report for duty, in order that a substitute can be arranged, if necessary. As a minimum, you are required to give at least 48-hours’ notice. If you become aware, during non-office hours, that you cannot cover your assignment(s), you must contact the Supervisor on call. If you do not contact a Supervisor and fail to report for your assignment, you will be considered a "no-show" and may be subject to disciplinary action.


    JOB/EMPLOYMENT APPLICATION

    CityCARE Home Health 20 Washington Ave North Haven, CT 06473

    JOB/EMPLOYMENT APPLICATION

    Personal Information

    Name
    Address

    Please list all addresses where you have resided in the past seven years

    Phone
    Electronic
    Date of Birth
    SSN
    Gender

    Language

    Education

    Formal


    Informal

    Do you currently have a CNA/PCA/HHA license?

    Other

    Restrictions

    Work Limitations

    List any work limitations that you may have and briefly describe:


    Availability for Work

    Hours & Days Available for Work


    Indicate Days and List Hours Available for Work:


    Client Types and Work Duties

    Type of Position(s) Preferred

    Live-in care usually requires that you to in a client’s home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:

    Clients Not Willing/Able to Work With
    Duties Not Willing/Able to Perform
    Experience
    Assignment Location

    Transportation

    Type
    Type
    Transporting Clients

    Investigations

    Have you ever been convicted of a crime in a state court or federal court in any state. If “yes”, please explain
    Have you ever been investigated for abuse, neglect or domestic violence? If “yes”, explain:
    Were you subject to any decision imposing disciplinary action by a licensing agency in any state, or the District of Columbia. If “yes” please explain.


    Reference Information

    Work Related #1 (Last Position)
    Work Related #2 (2 nd Last Position)
    Personal #1

    JOB/EMPLOYMENT APPLICATION

    I certify that I have read and understand this application. The answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. Additionally, any prospective employee who makes a false written statement regarding prior criminal convictions or disciplinary action can be guilty of a class A misdemeanor.

    I authorize former employers, references and any other individual/organizations to provide information to CityCARE Home Health and I hereby release and discharge any of the above and CityCARE Home Health from any liability of any kind or nature. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and completion of a background check. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

    PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    CityCARE Home Health 20 Washington Ave North Haven, CT 06473

    Pre-Employment Background Check Authorization

    Understand that as part of the employment process, CityCARE Home Health needs to complete a background check on me regarding:

    1. Criminal record;
    2. Sex and violent offenders record;
    3. Employment verification;
    4. Education verification;
    5. License verification;
    6. Motor vehicle Records;
    7. Personal/professional reference verification;
    8. Medical suitability;
    9. Social security verification;
    10. Drugs/alcohol.
    • I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to CityCARE Home Health or its authorized agent(s).
    • I understand that this authorization is to be part of the written and signed employment application.
    • I also understand that i do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
    • I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
    • I further authorize that a photocopy of this authorization may be considered as valid as the original.
    • I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with CityCARE Home Health is contingent upon successful complection of a background check.

    Name
    Phone Number
    Former Name(s)
    Date(s) Used
    Current Address *
    Date of Birth
    Social Security Number *
    Current driver’s license number
    State

    List any other cities, states and dates of residency during last 10 years

    CityCARE Home Health complies with state and federal regulations for conducting criminal background checks and sexual offender investigations: Our background check will include a review of any application materials prepared or requessted by the agency and completed by the prospective employee; an in-person interview of the registry established and maintained pursuant to section 54-257 a review of criminal conviction information obtained through a search of current criminal matters of public record in this state based on the prospective employee’s name and date of birth; If the prospective employee has esided in this state less than three years prior to the date of the application with the agency, a review of criminal conviction information from the state or states where such prospective employee resided during such three-year period; a review of any other information that the agency deems necessary in order to evaluate the suitability of the prospective employee for the position.

    ACKNOWLEDGMENT OF HANDBOOK

    CityCARE Home Health 20 Washington Ave North Haven, CT 06473

    Acknowledgment of Handbook

    I have been oriented to CityCARE Home Health Employee Handbook. I understand the Agency’s policies and procedures and hereby agree to abide by them. I also understand that all jobs are “Per Diem” positions and, being such, are not permanent.

    Employee’ Name
    Todays Date

    EMPLOYEE NON-SOLICITATION

    CityCARE Home Health 20 Washington Ave North Haven, CT 06473

    Employee non-solicitation

    During the term of employment of the person signing below (“Employee”) with CityCare Home Health Corp. (“CityCare”) and for 120 days thereafter, whether for compensation or not, Employee (directly or indirectly, either as an employee, employer, consultant, agent, principal, partner, stockholder, corporate officer, director, or in any other individual or representative capacity):

    1. Shall not lure away or hire, or encourage any other person or entity to lure away or hire, any employee of CityCare to perform services for any other person or entity, or attempt to lure away any such employee to leave their job with City Care; or
    2. Shall not try to take or actually take, or help any other person or entity to try to take or actually take any client of CityCare to do business with or seek to do business with any other person or entity; and shall not seek or attempt to cause any client of CityCare to reduce, terminate, or otherwise modify its relationship with CityCare.

    Employee hereby agrees to account for and pay over, the compensation, earnings, profits, monies, accruals, or other benefits derived or received by Employee as a result of any transaction constituting a breach of any of the covenants provided in this agreement.

    mployee understands that it is impossible to measure in money the damages that will accrue to CityCare in the event that Employee breaches these covenants, thus CityCare shall also be entitled to such equitable relief (including specific performance) without the requirement to post bond in order to restrain the Employee from violating such covenant.

    The remedies provided for in this agreement are cumulative and in addition to any other rights and remedies CityCare may have under law or in equity.

    This agreement is binding on and is for the benefit of the parties and their respective successors and assigns. The obligations of Employee under this agreement may not be assigned without CityCare’s written consent. This agreement may only be changed or modified by an instrument in writing signed by all of the parties to this agreement. A failure of either party to insist upon strict compliance of any term of this agreement shall not be deemed a waiver of such provision or any other provisions of this agreement. This agreement may be executed on separate pages by each person and reproductions of signatures (e.g., .pdf, .jpg) shall be as enforceable as an original.



    CITYCARE:
    CITYCARE HOME HEALTH CORP.

    EMPLOYEE:

    Name/Title:
    Todays Date:

    Department of Homeland Security

    U.S. Citizenship and Immigration Services

    OMB No. 1615-0047; Expires 08/31/12

    Form I-9, Employment

    Eligibility Verification

    Instructions
    Read all instructions carefully before completing this form.


    Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. 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 documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.

    What Is the Purpose of This Form?

    The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.

    When Should Form I-9 Be

    When Should Form I-9 Be Used?

    All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9

    Filling Out Form I-9

    Section 1, Employee

    This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

    Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

    Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an mployment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present

    in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).

    Preparer/Translator Certification

    The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally.

    Section 2, Employer

    For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.

    If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.

    Employers must record in Section 2:

    1. Document title;
    2. Issuing authority;
    3. Document number;
    4. Expiration date, if any; and
    5. The date employment begins.

    Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9.

    For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."

    Section 3, Updating and Reverification

    Employers must complete Section 3 when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section1 (if any). Employers CANNOT specify which document(s) they will accept from an employee.

    A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

    B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

    C. If an employee is rehired within three years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B; and:

    1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C);

    2. Record the document title, document number, and expiration date (if any) in Block C; and

    3. Complete the signature block.

    Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3.

    What Is the Filing Fee?

    There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.

    USCIS Forms and Information

    To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.

    Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218.General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.

    Photocopying and Retaining Form I-9

    A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.Photocopying and Retaining Form I-9Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.

    Privacy Act Notice

    The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

    This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

    This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

    Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

    Paperwork Reduction Act

    An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

    Department of Homeland Security

    U.S. Citizenship and Immigration Services

    OMB No. 1615-0047; Expires 08/31/12

    Form I-9, Employment

    Eligibility Verification

    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 documents have a future expiration date may also constitute illegal discrimination.


    Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)

    Print Name:

    Last *

    First *

    Middle Initial

    Maiden Name

    Address (Street Name and Number) *

    Apt. #

    Date of Birth (month/day/year) *

    City *

    State *

    Zip Code *

    Social Security # *

    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): *

    until (expiration date, if applicable - month/day/year)

    Employee's Signature *

    Date (month/day/year) *


    Preparer and/or Translator Certification(To be completed and signed if Section 1 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.

    Preparer's/Translator's Signature

     

    Print Name

     

    Address (Street Name and Number, City, State, Zip Code)

     

    Date (month/day/year)

     

    CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

    (month/day/year)

     

    and that to the best of my knowledge themarried employee is authorized to work in the United States. (State

    employment agencies may omit the date the employee began employment.)

    Signature of Employer or Authorized Representative

     

    Print Name

     

    Title

     

    Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

     

    Date (month/day/year)

     


    Form W-4 (2019)

    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 youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal orfinancial situation changes.

    Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.

    • For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and
    • For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.

    If you’reexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2019 expires February 17, 2020. SeePub. 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 2019 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 not subject to withholding 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 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.Note thatif 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 filing jointly 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 amountof nonwage income not subject to withholding, such as interest ordividends, 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 Additional 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 nonresidentalien, see Notice 1392, Supplemental FormW-4 Instructions for Nonresident Aliens, beforecompleting 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 may 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 may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. 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 if you are filing a joint return.

    Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can't be claimed, such as a qualifying child who doesn't meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. 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

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

    Form W-4

    Department of the Treasury Internal Revenue Service

    Employee’s Withholding Allowance Certificate

    Whether you’re entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

    OMB No. 1545-0074
    2019

    1. Your first name and middle initial *

    Last name *

    2. Your social security number *

    Home address (number and street or rural route) *

    3.

    Note: If married filing separately, check “Married, but withhold at higher Single rate.”

    City or town, state, and ZIP code

    4.

    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 2019, 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.) *
    Date *
    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

    10.

    Employer identification number (EIN)

    Form W-4 (2019)
    Page 2

    ncome includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.

    Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter “-0-” on lines E and F if you use Worksheet 1-6.

    Deductions, Adjustments, and Additional Income Worksheet

    Complete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

    You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.

    Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

    Two-Earners/Multiple Jobs Worksheet

    Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you

    don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.
    Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

    Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate.

    Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

    Two-Earners/Multiple Jobs Worksheet

    Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary.

    New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9,

    and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/css/employers.

    If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows.

    Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders.

    Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date.

    Box 10. Enter the employer's employer identification number (EIN).

    Form W-4 (2019)
    Page 3

    Personal Allowances Worksheet (Keep for your records.)

    A

    Enter “1” for yourself

    B

    Enter “1” if you will file as married filing jointly

    C

    Enter “1” if you will file as head of household

    D

    Enter “1” if:

    • 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.
    E

    Child tax credit. See Pub. 972, Child Tax Credit, for more information.

    • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.

    • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each eligible child.

    • If your total income will be from $179,051 to $200,000 ($345,851 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-”

    F

    Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.

    • If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.

    • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 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 $179,050 ($345,850 if married filing jointly), enter “-0-”

    G

    Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that

    worksheet here. If you use Worksheet 1-6, enter “-0-” on lines E and F

    H

    Add lines A through G and enter the total here

    For accuracy, complete all worksheetsthat apply.

    • 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 not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.
    • If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the 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 not subject to withholding.

    1

    Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your

    income. See Pub. 505 for details

    2

    Enter:

    $24,400 if you’re married filing jointly or qualifying widow(er)

    $18,350 if you’re head of household

    $12,200 if you’re single or married filing separately

      

    3

    Subtract line 2 from line 1. If zero or less, enter “-0-”

    4

    Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any

    additional standard deduction for age or blindness (see Pub. 505 for information about these items)

    5

    Add lines 3 and 4 and enter the total

    6

    Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest)

    7

    Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses

    8

    Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.

    Drop any fraction

    9

    Enter the number from the Personal Allowances Worksheet, line H, above

    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 of that worksheet on page 4. Otherwise, stop here and

    enter this total on Form W-4, line 5, page 1

    Form W-4 (2019)
    Page 4

    Two-Earners/Multiple Jobs Worksheet


    Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

    1

    Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used theDeductions,

    Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of thatworksheet)

    2

    Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re

    married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages

    for you and your spouse are $107,000 or less, don’t enter more than “3”

    3

    If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and

    on Form W-4, line 5, page 1. Do not use the rest of this worksheet

    Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additionalwithholding amount necessary to avoid a year-end tax bill.

    4

    Enter the number from line 2 of this worksheet

    5

    Enter the number from line 1 of this worksheet

    6

    Subtract line 5 from line 4

    7

    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

    9

    Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every 2

    weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019. Enter

    the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

    Table 1
    Married Filing JointlyAll Others
    If wages from LOWEST paying job are—Enter on line
    2 above
    If wages from LOWEST paying job are—Enter on line
    2 above
    $0 - $5,0000$0 - $7,0000
    5,001 - 9,50017,001 - 13,0001
    9,501 - 19,500213,001 - 27,5002
    19,501 - 35,000327,501 - 32,0003
    35,001 - 40,000432,001 - 40,0004
    40,001 - 46,000540,001 - 60,0005
    46,001 - 55,000660,001 - 75,0006
    55,001 - 60,000775,001 - 85,0007
    60,001 - 70,000885,001 - 95,0008
    70,001 - 75,000995,001 - 100,0009
    75,001 - 85,00010100,001 - 110,00010
    85,001 - 95,00011110,001 - 115,00011
    95,001 - 125,00012115,001 - 125,00012
    125,001 - 155,00013125,001 - 135,00013
    155,001 - 165,00014135,001 - 145,00014
    165,001 - 175,00015145,001 - 160,00015
    175,001 - 180,00016160,001 - 180,00016
    180,001 - 195,00017180,001 and over17
    195,001 - 205,00018
    205,001 and over19
    Table 2
    Married Filing JointlyAll Others
    If wages from HIGHEST paying job are—Enter on line
    7 above
    If wages from HIGHEST paying job are—Enter on line
    7 above
    $0 - $24,900$420$0 - $7,200$420
    24,901 - 84,4505007,201 - 36,975500
    84,451 - 173,90091036,976 - 81,700910
    173,901 - 326,9501,00081,701 - 158,2251,000
    326,951 - 413,7001,330158,226 - 201,6001,330
    413,701 - 617,8501,450201,601 - 507,8001,450
    617,851 and over1,540507,801 and over1,540
        
        
        
        
        
        
        
        
        
        
        
        
        

    Privacy Act and Paperwork Reduction Act Notice. We ask for the information on thisform to carry out the Internal Revenue laws of the United States. Internal Revenue Codesections 3402(f)(2) and 6109 and their regulations require you to provide thisinformation; 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 singleperson who claims no withholding allowances; providing fraudulent information maysubject you to penalties. Routine uses of this information include giving it to theDepartment of Justice for civil and criminal litigation; to

    cities, states, the District ofColumbia, and U.S. commonwealths and possessions for use in administering their taxlaws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose thisinformation to other countries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal law enforcement and intelligenceagencies to combat terrorism.You aren’t required to provide the information requested on a form that’s subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating

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