Online Application

Application Form

* Last Name

* First Name

MI

SSN

Address

Address2

Apt/Floor

City

State

Zip

Country

Date Of Birth

Other names used (example: married, middle name)

* Home #

Daytime Evening

* Mobile #

Daytime Evening

* Email Address

Aliases

Place Of Birth

Mother's Maiden Name

Emergency Contact Name

Emergency Contact Number

Emergency Contact Address

Emergency Contact City

Emergency Contact State

Are you over 18?
Yes No

Are you either a U.S. citizen or an alien lawfully permitted to work in the U.S. ?
Yes No

* APPLYING FOR:

REFERRAL SOURCE:

Document Upload

ID Front

ID Back

Social Security Card Front

Social Security Card Back

Reference 1

Reference 2

Certificate

Physical

Drug Screen

PPD/QFT/TSPOT

Rubela / Rubeola /MMR

Flu Vaccine

Covid Document

Direct Deposit

Others

Previous Work History

Name of Company

Address

City

State

Zip

Position

Supervisor Name and Title

May We Contact?
Yes No

Dates Employed:

To

Description of Work

Reason for considering change

Telephone No.

Name of Company

Address

City

State

Zip

Position

Supervisor Name and Title

May We Contact?
Yes No

Dates Employed:

To

Description of Work

Reason for considering change

Telephone No.

REFERENCE (Doctors, Lawyers, Teachers, RN, Bank, Minister, etc.)

Give at least two references; not relatives. work related references are prefered. if not available, references should be someone that stands out in the community.

	Name	Address	Telephone No.	Occupation
1.
2.
3.

Applicant's Authorizations

* Read carefully before signing

A physical examination is required of all job applications, which includes testing for drug use, to verify fitness to work after a job offer is extended, but prior to beginning work. The results of such an examination will not be used to disqualify an applicant except to the extent that any disability discovered would, even with reasonable accommodation, preclude the safe adequate performance of the job in question.

I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts on my application may result in immediate dismissal.

I understand that in making this application for employment, People Care or any agent acting on the behalf may request an investigative consumer report containing information obtained through personal interviews with third parties such as neighbors, friends, business associates, financial sources, and acquaintances. This inquiry includes information as to character, general reputation, personal characteristics, and mode of living, whichever may be applicable.

I further understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation.

I authorize all persons, schools, companies, corporations and law enforcement agencies to release any information concerning my background, and I hereby release them and People Care from any and all claims of liability in law and inequity that may arise out of obtaining such information.

I understand that this application does not constitute an employment contract with People Care and me and that, if hired, my employment is for No fixed duration and can be terminated at any time with or without notice or cause either at my option or People care's.

* Date

*This application will be considered for 30 days from the date it is submitted. Should you wish to be considered for employment after that date, you must submit a new application.

Do not write bellow this line

For Personal Department Use Only

(Check As Applicable)

Rejected

Accepted Pending Background check

Rejected Following Background Check

Final Acceptance Following Background Check

Dept.:

Position:

Will Report To:

Wage/Salary:

Approved By

PPD Agreement

I understand that I am required to complete a two(2)-step PPD for Tuberculosis before I can be assigned to care for a patient. If I am a tranee, the first step will need to be completed before the first day of class. The second step will be completed at the end of class.

* Date

Dress Code Agreement

I, agree to wear a scrub-like top and white pants/skirt. I agree not to wear a sleeveless or halter top, or low cut knock lines. Shoes sneaker will be all white and close toed. I must wear my uniform the last five (5) days of class. I will not wear large or dangling earing while in class. I will keep my nails short(maximum length:1/4th) past tip of finger, No acrylics, tips, wraps, or artificial nail(s) appropriate for safe patient care. I will have my nails trimmed by the last five(5) days of class. I will not wear a "Du-Rag". I agree to these terms while servicing a patient.

* Date

Availability Form

Available To Start Date

Earliest Start Time

Latest End Time

1.I am looking for :

Part Time Full Time Per Diem

2.Can You Cook :

Yes No

3.Are You Available For Live Ins :

Yes No

4.Can You Work With Male Patient? :

Yes No Available But Prefer Female

7.Availability(please add a preffered start and end time; weakend rotation is required):

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sundday
Start Time
End Time
Live ins

9.Are You Available To Work With Dementia Patients :

Yes No

10.Are You Available To Work With Mentally Ill Patients :

Yes No

11.Are You Familier With Kosher clients/practices? :

Yes No

The field provider is instructed to call our office to obtain work. There are part time and full time positions available. Most of the work available is part-time assignments. There is No guarantee of full time assignments. If a particular case is terminated, the worker is instructed to call the office immediately to be placed on a new or emergency assignment, if one is available. This creates a system whereby the aide continues working and our patients receive the st care we can provide. There should be a plan of care to follow. If ther is NO master plan in the home, you MUST call your Case Coordinator and Visiting Nurse to report this.

CHRC Demographic Information

Height

Weight

Eye Color:

Hair Color:

Race

This information will not be considered in any employment decisions, and is requested for required demographic submissions to governmental agencies. People Care is an Equal Opportunity Employer.

Valid Photo Identification:

Valid Supplementary Identification:

Have you ever been convicted of a crime?

Yes No

Would you give consent to have your background checked?

Yes No

* Date

DOH CHRC 102 (1/07)

NYS Department of Health
ACKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL
HISTORY RECORD INFORMATION
THIS FORM IS TO BE RETAINED BY THE AGENCY- DO NOT FORWARD TO THE DOH CHRC UNIT.
[email protected]

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

Section 2 - Attestation
1.	I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).
2.	I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.
3.	I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law.
4.	I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.
5.	I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI.
6.	I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.
7.	I certify to the best of my knowledge and belief that I (check as appropriate): Have Have not been convicted of a crime in New York State or any other jurisdicti Do Do not have a final finding of patient or resident abuse If you have checked either "Have" and/or "Do", please provide a brief explanation. (Optional)
8.	My current mailing or home address is indicated in Section 1 of this form
9.	I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).
NOTE: a criminal conviction will not necessarily be a bar to employment. People Care will carefully determine eligibility on a case by case basis, considering factors such as the nature of and details concerning the conviction(s); the duties and responsibilities of the position applied for; when the conviction(s) occurred, etc.

* Date

Date

Section 3 - Agency Authorized Person Information

Agency Name

PFI/Operating License Number

Print Name of Authorized Person

Title

* Date

PEOPLE CARE
CONSENT FOR INFORMATION TO BE POSTED TO THE HOME CARE REGISTRY

People Care would like to inform you that effective september 25, 2009 the new york state department of health stablished a Home care Registry for all personal care Aides and home Health Aides. The goal of this statute is to protect vulnerable New Yorks by insuring that only properly trained individuals who are suitable for employement in hoe care are employed by home care agencies to provide home care.

The Registry requires People Care to enter either the last four(4) digits of your social security number or your city of birth, mother's first name, and mother's maiden name. Your signature below acknowledges your consent and understanding. COMPLETE ONE OF THE FOLLOWING OPTIONS BELOW. (PLEASE PRINT LEGIBLY)

Last 4 digits of Social Security Number:

OR

1. City of birth:

2. Mothers First Name:

3. Mothers Maiden Name:

In addition to the above information, People Care is required to enter the following information about you into the Registry:

Full name; current home address;gender; date of birth; name of each state-approved education or training program successfully completed, the name of the entity providing the program, and the date on which the program was completed; and history of work in home care service through any home care service entity, including dates of employement and name of entity providing the employment.

You may request a copy of your information entered into the Registry by People Care to ensure accuracy.

My Signature below acknowledges my consent and understanding for People Care to enter my personal information indicated on this form into the Registry.

Date

PRINT NAME LEGIBLY:

if you do not provide us with the required information, you will not be able to be entered into the registry and therefore will not be able to work as a HHA or PCA.

Employment Eligibility Verification
Department Of Homeland Security

U.S. Citizenship and Immigration Services

Start Here : Employees must ensure that the form instructiona are available to employees when completing this form. Employers are liable for falling to comply with the requirements for completing this form. See below and the instrucitons.

Anti-Discimination Notice: All Employees can choose which acceptable documentation to present for form 1-9. Employers cannot ask employees for documentation to verify information to section 1, or specify which acceptable documentation employee must present for Section2 or Supplement B , reverification and rehire. Threating employees differently based on their citizenship, immigration status or national origin may be illegal.

Section 1 - Employee Information and Attestation

Check One Of The Following Boxes To Atleast To Your Citizenship Or Immigration Status:

1. A Citizen of the United States

2. A noncitizen national of the United States(See Instruction)

3. A Lawful Permanent resident

4. A non citizen

If you check item number 4. Enter One on of these:

USCIS A-Number

Or

Form I-94 Admission Number

Or

Foreign Passport Number and Country of issuance

I am Aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information including my selection of the box attesting to the citizenship or immigration status, is true and correct.

* Date

Section 2 - Employer Review And Verification
Employers or their authorized representetive must complete and sign section 2 within 3 bussiness days after the employee's first day of employement, and must physically examine, or examine consistent with an alterntive procedure authorized by the secretary of DHS, documents from list A or a combination of documentation from list B and list C. Enter any additional documentation in the additional information box : see instruction:

Section 2 - Employer Review And Verification

Employers or their authorized representetive must complete and sign section 2 within 3 bussiness days after the employee's first day of employement, and must physically examine, or examine consistent with an alterntive procedure authorized by the secretary of DHS, documents from list A or a combination of documentation from list B and list C. Enter any additional documentation in the additional information box : see instruction:

List A

Document Title 1
Issuing Athority
Document Number(if any)
Expriration Date(if any)
Document Title 2(if any)
Issuing authority
Document Number(if any)
Expriration Date(if any)
Document Number 3(if any)
Issuing Authority
Document Number(if any)
Expiration Date(if any)

Or

List B	AND	List C

Additional information

Check Here if you used an alternative procedure authorized by DHS to examine documents

Certification: I attest, under of perjury , that (1) I have examined the documentation presented by the above-named employee, (2) The above listed documentation appears 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.

*Date Of Employement

*First Name, last name and title of the employer

Date

Employer's bussiness or Organization Name:
PEOPLE CARE INC.

Employer's business or Organization Address:
1649 61st street , Brooklyn, NY 11204

LIST OF ACCEPTABLE DOCUMENTS

All documents containing an expiration date must be unexpired.

* Docuements extended by the issuing authority are considered unexpired.

Employees may present one selection from List A or a

combination of one selection from List B and one selection from List C

Examples of many of these documents appear in the Handbook for Employers(M-274)

Refer to the Employement Authorization Extensions page on 1-9 for more information.

Translator Certificate

Supplement A,

Prepare and/or Translator Certificate for section 1

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

Supplement A

OMB No: 1615-0047

Expires 07/31/2026

Last Name (Family Name) from section 1.

First Name (Given Name) from section 1.

Middle Initial (if any) from section 1.

Instructions: this Supplement must be completed by any prepare and/or translator who assist an employee in completing section 1 of form I-9. The prepare and/or translator must enter the employees name in the spaces provided above. Each prepare or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9

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.

Date(mm/dd/yyyy)

Last Name (Family Name) from section 1.

First Name (Given Name) from section 1.

Middle Initial (if any) from section 1.

Address(Street Number and Name)

City or Town

State

Zip Code

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.

Date(mm/dd/yyyy)

Last Name (Family Name) from section 1.

First Name (Given Name) from section 1.

Middle Initial (if any) from section 1.

Address(Street Number and Name)

City or Town

State

Zip Code

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.

Date(mm/dd/yyyy)

Last Name (Family Name) from section 1.

First Name (Given Name) from section 1.

Middle Initial (if any) from section 1.

Address(Street Number and Name)

City or Town

State

Zip Code

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.

Date(mm/dd/yyyy)

Last Name (Family Name) from section 1.

First Name (Given Name) from section 1.

Middle Initial (if any) from section 1.

Address(Street Number and Name)

City or Town

State

Zip Code

New York Urban Youth Job Program

*Only Fill Out If You Are 16-24 Years Old

I am currently unemployed, I was unemployed prior to completing this application or I do not have enough paid work or work that is adequate with respect to my skill and training.

Yes No

If No, please give start date

I am enrolled in high school :

Yes No

I am 16 Or 17 Year Old And Have The Permission Of My Parent Of Guardian To Submit This Application :

Yes No

Parent or Guardian Name

Parent Or Guardian Phone Number

I am Currently Attending High School, Enrolled in a high school equivalency(HSE) Program, or have obtained a high school diploma.

Yes No

I am 18 24 Years Old:

I have a high school diploma, a GED or HSE Diploma, Satisfactorily completed a TASC exam, or I am enrolled in a TASC program.
Yes No

Categories:

I am pregnant or a parent of child
I am over 18 do not have a high school diploma of GED/HSE diploma.
I am a member of a family that is recieving assistance from Temporary Assistance for needy families(TANF).
I am a member of a family that is recieving SNAP benefits(food stamps).
I am a member of a family that is recieving SSI benefits.
I am recieving a free of reduced cost school lunch.
I have served in jail or prison, or am on probation or parole.
I currently or was foster care of the custody of the Office of children and family services.
I am a veteran
I am a daughter or son of a parent who is currently in jail or prison or has been within the past two years.
I am a daughter or son of a parent who is collecting unemployement insurance.
I live in the public housing or recieve housing assistance such as a section 8 voucher, am homeless.
I consider myself to have a different risk factor not identified in the above list.

Agreement:

I swear that I currently meet the qualifications listed above in the New York Youth Program: Youth Certification Qualifications section. I understand that I must provide private, personal information on this application to qualify for the program. I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with. I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor. I believe the information submitted in this application is true, correct and complete. I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details. I am aware that there are consequences for filing false documents or other information with the government. I agree to the statements above.

Date

Please Fill In These Forms And Legibly

Company Name

Have You Worked For This Employer Before :

Yes No

If Yes, Enter last day of employment:

Are You A Re-Hire :

Yes No

Have You Been unemployed for atleast 27 weeks, and collected unemployement insurance for part or all of that time period? :

Yes No

If Yes, What State Did You Recieve Unemployement Compensation In?:

Have You or your family recieved SNAP benefits(Food Stamps) in the 6 months before you were hired? :

Yes No Not Sure

OR recieved SNAP benefits for atleast 3 months period, but you are No longer recieved it?

Yes No Not Sure

If Yes, to either question, enter name to primary reciepent:

And City state benefits were recieved?:

Are you member of a family that recieved Temporary Assistance For Needy Families(TANF) assistance for at least 18 months before you were hired? :

Yes No Not Sure

OR

Did your family stop being eligible for Temporary Assistance For Needy Families(TANF) assistance within 2 years before being hired, because you reached the maximum time those benefits can be recieved?

Yes No Not Sure

If Yes, to either question, enter name to primary reciepent:

And City state benefits were recieved?:

Are you Veteran of the US Armed Force

Yes No

If Yes,

Date of conviction

Date of release

What is the federal or state?

Where You Reffered to an employer by?

A Vocational Rehab approved by the state?

Yes No

An employement network under the ticket to work program?

Yes No

The dept. of veteran afairs? :

Yes No

Print Name

Employement Start Date

This company participates in various federal and state tax credit programs. This Information in No way will negatively impact any hiring, retention decision. Your responses to the questions will only be shared with your employer's management and federal, state, or local govern mental agencies as needed in administration of these 5 programs. By completing this form, you knowingly and voluntarily waive any objection to providing your social security number. Any information provided will be used in a manner consistent with the American Disability Act. Under penalty of perjury, I certify that this information is tand correct to the best of my knowledge. I hereby authorize this company's management, and federal, state, and local government agencies to provide information I to Tax Opportunities America and/or SWA, to determine eligibility. I understand that the information above may be subject to verification.

Date

APPLICANT'S AUTHORIZATION - READ CAREFULLY BEFORE SIGNING

A physical examination is required of all job applicants to verify fitness to work.

I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts on my application may result in denial of the consumer directed personal assistance program. (CDPAP)

A physical examination is required of all job applications, which includes testing for drug use, to verify fitness to work after a job offer is extended, but prior to beginning work. The results of such an examination will not be used to disqualify an applicant except to the extent that any disability discovered would, even with reasonable accommodation, preclude the safe adequate performance of the job in question.

I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts on my application may result in immediate dismissal.

I understand that in making this application for employment, People Care or any agent acting on the behalf may request an investigative consumer report containing information obtained through personal interviews with third parties such as neighbors, friends, business associates, financial sources, and acquaintances. This inquiry includes information as to character, general reputation, personal characteristics, and mode of living, whichever may be applicable.

I further understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation.

I authorize all persons, schools, companies, corporations and law enforcement agencies to release any information concerning my background, and I hereby release them and People Care from any and all claims of liability in law and inequity that may arise out of obtaining such information.

I understand that this application does not constitute an employment contract with People Care and me and that, if hired, my employment is for no fixed duration and can be terminated at any time with or without notice or cause either at my option or People care's.

* Date

ATTESTATION TO COMPLY WITH CDPAP REGULATIONS

* Costumer

* Date

* Name of personal assistant

I understand that it's against the New York State CDPAP regulation to work as a personal assistant in the people care CDPAP program if i am a spouse or parent of the consumer I am NOT the parent or spouse of the consumer.
I am at least 18 years of age.
I agree to complete a pe-employment physical before I begin work, then annually.
I am NOT the designated Representative of the consumer enrolled in the CDPAP program.
I am not an employee of people Care, an agent, or an affiliated individual. The consumer hires me.
I understand that if my relationship with the consumer changes and if I reside with the consumer, I will inform people care immmediately.
I understand that I must not work for a consumer admitted to a hospital, a nursing home, or any other health-related facility. I can ONLY work for the consumer while they are at home. And I will inform People Care if the consumer is hospitalized.
I will utilize "Electronic Visit Verification" to clock in and out. I understand duty sheets will not be accepted.
I will notify People Care in case of am address change of the consumer or if the consumer takes a vacation.

I have read all the above statement and will comply with these requirements. I also understand that failure to abide by the above rules could be considered Medicaid Fraud and could subject me to investigation and possible criminal prosection by the office of the Attorney General Medicaid Fraud Control Unit and the Medicaid Inspector General.

* Date

Supplement B,
Reverification and Rehire (formerly Section 3)

Department of Homeland Security
U.S. Citizenship for Section 1

Instruction: This supplement replaces section 3 on the previous version of form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the field above. Use a new section for reverification or rehire. Review the Form I-9 instructions before completing the page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employer: Guidance for completing Form I-9(M-274)

Date of Rehire (if applicable)	New Name (if applicable)
Date	Last Name	First Name	Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Entyer the document information in the spaces below.

Document Title

Document Number (if any)

Expiration Date (if any)

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 present documentation I examined appears to be genuine and to relate to the individual who presented it.

Date

Name of Employer or Authorized Representative

Date of Rehire (if applicable)	New Name (if applicable)
Date	Last Name	* First Name	Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Entyer the document information in the spaces below.

Document Title

Document Number (if any)

Expiration Date (if any)

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 present documentation I examined appears to be genuine and to relate to the individual who presented it.

* Date

Name of Employer or Authorized Representative

Date of Rehire (if applicable)	New Name (if applicable)
Date	Last Name	* First Name	Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Entyer the document information in the spaces below.

Document Title

Document Number (if any)

Expiration Date (if any)

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 present documentation I examined appears to be genuine and to relate to the individual who presented it.

* Date

Name of Employer or Authorized Representative

CONSUMER DIRECTED PERSONAL ASSITANCE PROGRAM
CONSENT TO TRANSFER NECESSARY PERSONAL ASSISTANT
MEDICAL DOCUMENTATION

I,

,consent to allow

to provide a copy of my health status and Immunization record identified in 18 NYCRR section

766.11(c) and (d) to

. This Record must be maintained

on file with the fiscal intermediary pursuant to 10 NYCRR section 502.28(i) . This consent will exprire one(1) year from the date of signature, below.

* Date

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Form 8850 (Rev. March 2016) Department of the Treasury Internal Revenue Service	Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.	OMB No. 1545-1500

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
Check here if any of the following statements apply to you.
- I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
- I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
- I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
- I am at least age 18 but not age 40 or older and I am a member of a family that:
  1. Received SNAP benefits (food stamps) for the past 6 months; or
  2. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is No longer eligible to receive them.
- During the past year, I was convicted of a felony or released from prison for a felony.
- I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
- I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.
Check here if you are a member of a family that:
- Received TANF payments for at least the past 18 months; or
- Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
- Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Signature-All Applicants Must Sign

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

* Date

Please fill in these forms and legibly

Company Name

Have you worked for this Employer before?	Are you Re-hire?	Yes No
If Yes , enter the last day of employment

Have you been unemployed for at least 27 weeks,and collected Unemployment Insurance for part or all of that time period ?		Yes No
If YES,what state did you recieve umemployment compensation in?		( Enter state where UI compensationwas recieved )

Have you or your family ,recieved SNAP benifits(Food Stamps) in the 6 months beforo you were hired?		Yes No Not Sure
OR recieved SNAP Benifits for at least a 3 month period ,but you are No longer recieving it?		Yes No Not Sure
if YES to either question ,enter Name of Primary Recipient
And the City, State where the benifits were recieved

Are you a member of a famoily thet recvieved Temporary Assistance for Needy Families(TANF) assistance for at least 18 months before you were hired?		Yes No Not Sure
OR did your family stop being eligible for Temporary Assistance for Needy Families(TANF) assistance within years before being hired,because you reached the maximum time those benifits can be recieved?		Yes No Not Sure
if Yes to either question ,enter Name of Primary Recipient:
And the City, State where the benifits were recieved

Are you a Veteran of the US Armed Forces ?		Yes No
If Yes:
Are you a member of a family that recieved SNAP (Food Stample Benifits)	Yes No
Are you entitled to compensation for a service-connected disability?	Yes No
Were you discharged from active duty within last year?	Yes No
Were you unemployed for a combined total of 6 months before you were hired?	Yes No

Did you recieve Supplemental Security Income (SSI Benifits) for any month , ending within the 60 days, before you were hired ?

Yes No

Were you convicted of a	Felony during	the year before you	were hired?			Yes No
if Yes: Date of Conviction		Date of release		Was this federal or state?

Were you referred to an employer by:
A Vocational Rehab Agency approved by the state?	Yes No
An Employement Network under the Ticker to Work Program?	Yes No	I'm Not Sure
The Dept. of Vetran Affairs?	Yes No

Print Name:	Employement Start Date	Social Security Number #	Date of Birth

This company participates in various federal and state tax credit programs. This information in No way will negatively impact any hiring, retention decision. Your responses to the questions will only be shared with your employer's management and federal, state, or local govern mental agencies as needed in administration of these 5 programs. By completing this form, you knowingly and voluntarily waive any objection to providing your social security number. Any information provided will be used in a manner consistent with the American Disability Act. Under penalty of perjury, I certify that this information is true and correct to the best of my knowledge. I hereby authorize this compan's management, and federal, state, and local government agencies to provide information I to Tax Opportunities America and/or SWA, to determine eligibility. I understand that the information above may be subject to verification.

* Date

Employee's Withholding Certificate

Form W-4
Department of the Treasury Internal Revenue Service

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.

OMB No. 1545-0074

2023

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4); or
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ..

TIP: To be accurate, submit a 2023 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500 ....
Add the amounts above and enter the total here .............		3

Step 4 (optional): Other Adjustments

(a.)	Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income ........	4(a)
(b.)	Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here .......................	4(b)
(c.)	Extra withholding. Enter any additional tax you want withheld each pay period ..	4(c)

Step 5: Sign
Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

* Date

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 10220Q

Form W-4 (2023)

Step 2(b)-Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1

Two jobs. If you have two jobs or you're married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the "Higher Paying Job" row and the "Lower Paying Job" column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .

2

Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.

a	Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the "Higher Paying Job" row and the annual wages for your next highest paying job in the "Lower Paying Job"column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .
b	Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the "Higher Paying Job" row and use the annual wages for your third job in the "Lower Paying Job" column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
c	Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .

3

Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . .

Step 4(b)-Deductions Worksheet (Keep for your records.)

1	Enter an estimate of your 2023 itemized deductions (from Schedule A (Form 1040)). Such deductions may 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 . . . .. . . . . . . . . . .
2	Enter: { $25,900 if you're married filing jointly or qualifying widow(er) $19,400 if you're head of household $12,950 if you're single or married filing separately } . . . . . . . .
3	If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater than line 1, enter "-0-" . . . . . . . .. . . . . . . . . . . .
4	Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . .
5	Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . .

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with No other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Married Filing Jointly or Qualifying Widow(er)

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0-9,999	$10,000 - 19,999	$20,000 - 29,999	$30,000 - 39,999	$40,000 - 49,999	$50,000 - 59,999	$60,000 - 69,999	$70,000 - 79,999	$80,000 - 89,999	$90,000 - 99,999	$100,000 - 109,999	$110,000 - 120,000
$0 - 9,999 $10,000 - 19,999 $20,000 - 29,999	$0 110 850	$110 1,110 1,860	$850 1,860 2,800	$860 2,060 3,000	$1,020 2,220 3,160	$1,020 2,220 3,160	$1,020 2,220 3,160	$1,020 2,220 3,160	$1,020 2,220 3,910	$1,020 2,970 4,910	$1,770 3,970 5,910	$1,870 4,070 6,010
$30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999	860 1,020 1,020	2,060 2.220 2,220	3,000 3,160 3,160	3,200 3,360 3,360	3,360 3,520 3,520	3,360 3,520 4,270	3,360 4,270 5,270	4,110 5,270 6,270	5,110 6,270 7,270	6,110 7,270 8,270	7,110 8,270 9,270	7,210 8,370 9,370
$60,000 - 69,999 $70,000 - 79,999 $80,000 - 99,999	1,020 1,020 1,020	2,220 2,220 2,820	3,160 3,160 4,760	3,360 4,110 5,960	$1,020 2,220 7,120	5,270 6,270 8,120	6,270 7,270 9,120	7,270 8,270 10,120	8,270 9,270 11,120	9,270 10,270 12,120	10,270 11,270 13,150	10,370 11,370 13,450
$100,000 - 149,999 $150,000 - 239,999 $240,000 - 259,999	1,870 2,040 2,040	4,070 4,440 4,440	6,010 6,580 6,580	7,210 7,980 7,980	8,370 9,340 9,340	9,370 10,540 10,540	10,510 11,740 11,740	11,710 12,940 12,940	12,910 14,140 14,140	14,110 15,340 15,340	15,310 16,540 16,540	15,600 16,830 17,590
$260,000 - 279,999 $280,000 - 299,999 $300,000 - 319,999	2,040 2,040 2,040	4,440 4,440 4,440	6,580 6,580 6,580	7,980 7,980 7,980	9,340 9,340 9,340	10,540 10,540 11,300	11,740 11,740 13,300	12,940 13,700 15,300	14,140 15,700 17,300	16,100 17,700 19,300	18,100 19,700 21,300	19,190 20,790 22,390
$320,000 - 364,999 $365,000 - 524,999 $525,000 and over	2,100 2,970 3,140	5,3000 6,470 6,840	8,240 9,710 10,280	10,440 12,210 12,980	12,600 14,670 15,640	14,600 16,970 18,140	16,600 19,270 20,640	18,600 21,570 23,140	20,600 23,870 25,640	22,600 26,170 28,140	24,870 28,470 30,640	26,260 29,870 32,240

Single or Married Filing Separately

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0-9,999	$10,000 - 19,999	$20,000 - 29,999	$30,000 - 39,999	$40,000 - 49,999	$50,000 - 59,999	$60,000 - 69,999	$70,000 - 79,999	$80,000 - 89,999	$90,000 - 99,999	$100,000 - 109,999	$110,000 - 120,000
$0 - 9,999 $10,000 - 19,999 $20,000 - 29,999	$400 930 1,020	$930 1,570 1,660	$1,020 1,660 1,990	$1,020 1,890 2,990	$1,250 2,890 3,990	$1,870 3,510 4,610	$1,870 3,510 4,610	$1,870 3,510 4,710	$1,870 3,610 4,910	$1,970 3,810 5,110	$2,040 3,880 5,180	$2,040 3,880 5,180
$30,000 - 39,999 $40,000 - 59,999 $60,000 - 79,999	1,020 1,870 1,870	1,890 3,510 3,510	2,990 4,610 4,680	3,990 5,610 5,880	4,990 3,520 7,080	5,610 7,500 7,900	5,710 7,700 8,100	5,910 7,900 8,300	6,110 8,100 8,500	6,310 8,300 8,700	6,380 8,370 8,970	6,380 8,370 9,770
$80,000 - 99,999 $100,000 - 124,999 $125,000 - 149,999	1,940 2,040 2,040	3,780 3,880 3,880	5,080 5,180 5,180	6,280 6,380 6,520	7,480 7,580 8,520	8,300 8,400 10,140	8,500 9,140 11,140	8,700 10,140 12,140	9,100 11,140 13,320	10,100 12,140 14,620	10,970 13,040 15,790	11,770 14,140 16,890
$150,000 - 174,999 $175,000 - 199,999 $200,000 - 249,999	2,040 2,720 2,970	4,420 5,360 5,920	6,520 7,460 8,310	8,520 9,630 10,610	10,520 11,930 12,910	12,170 13,860 14,840	13,470 15,160 16,140	14,770 16,460 17,440	16,070 17,760 18,740	17,370 19,060 20,040	18,540 20,230 21,210	19,640 21,330 22,310
$250,000 - 399,999 $400,000 - 449,999 $450,000 and over	2,970 2,970 3,140	5,920 5,920 6,290	8,310 8,310 8,880	10,610 10,610 11,380	12,910 12,910 13,880	14,840 14,840 16,010	16,140 16,140 17,510	17,440 17,440 19,010	18,740 18,740 20,510	20,040 20,040 22,010	21,210 21,210 23,380	22,310 22,470 24,680

Head of Household

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0-9,999	$10,000 - 19,999	$20,000 - 29,999	$30,000 - 39,999	$40,000 - 49,999	$50,000 - 59,999	$60,000 - 69,999	$70,000 - 79,999	$80,000 - 89,999	$90,000 - 99,999	$100,000 - 109,999	$110,000 - 120,000
$0 - 9,999 $10,000 - 19,999 $20,000 - 29,999	$0 760 910	$760 1,820 2,110	$910 2,110 2,400	$1,020 2,220 2,510	$1,020 2,220 2,680	$1,020 2,390 3,680	$1,190 3,390 4,680	$1,870 4,070 5,360	$1,870 4,070 5,530	$1,870 4,240 5,730	$2,040 4,440 5,930	$2,040 4,440 5,930
$30,000 - 39,999 $40,000 - 59,999 $60,000 - 79,999	1,020 1,020 1,870	2,220 2,240 4,070	2,510 3,530 5,360	2,790 4,640 6,610	3,790 5,640 7,810	4,790 6,780 9,010	5,790 7,980 10,210	6,640 8,860 11,090	6,840 9,060 11,290	7,040 9,260 11,490	7,240 9,460 11,690	7,240 9,460 12,170
$80,000 - 99,999 $100,000 - 124,999 $125,000 - 149,999	1,870 2,040 2,040	4,210 4,440 4,440	5,700 5,930 5,930	7,010 7,240 7,240	8,210 8,440 8,860	9,410 9,640 10,860	10,610 10,860 12,860	11,490 12,540 14,540	11,690 13,540 15,540	12,380 14,540 16,830	13,370 15,540 18,130	14,170 16,480 19,230
$150,000 - 174,999 $175,000 - 199,999 $200,000 - 449,999	2,040 2,720 2,970	4,460 5,920 6,470	6,750 8,210 9,060	8,860 10,320 11,480	10,860 12,600 13,780	12,860 14,900 16,080	15,000 17,200 18,380	16,980 19,180 20,360	18,280 20,480 21,660	19,580 21,780 22,960	20,880 23,080 24,250	21,980 24,180 25,360
$450,000 and over	3,140	6,840	9,630	12,250	14,750	17,250	19,750	21,930	23,430	24,930	26,420	27,730

Department of Taxation and Finance Employee's Withholding Allowance Certificate IT-2104
New York State , New York City , Yonkers

Are you a resident of New York City? Yes No

Are you a resident of Yonkers? Yes No

Complete the worksheet on page 4 before making any entries.

1	Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19)
2	Total number of allowances for New York City (from line 31)

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3	New York State amount
4	New York City amount
5	Yonkers amount

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

* Date

Penalty - A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Employer: Keep this certificate with your records.

Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A Employee claimed more than 14 exemption allowances for NYS .............

B Employee is a new hire or a rehire.......

B First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Are dependent health insurance benefits available for this employee? Yes No

If Yes, enter the date the employee qualifies (mm-dd-yyyy):

Employer's name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)	Employer identification number

has changed. Common reasons for completing a new Form IT-2104 each year include the following:

You started a new job.
You are No longer a dependent.
Your individual circumstances may have changed (for example, you were married or have an additional child).
You moved into or out of NYC or Yonkers.
You itemize your deductions on your personal income tax return.
You claim allowances for New York State credits.
You owed tax or received a large refund when you filed your personal income tax return for the past year.
Your wages have increased and you expect to earn $107,650 or more during the tax year.
The total income of you and your spouse has increased to $107,650 or more for the tax year.
You have significantly more or less income from other sources or from another job.
You No longer qualify for exemption from withholding.
You have been advised by the Internal Revenue Service that you are entitled to fewer allowances than claimed on your original federal Form W-4 (submitted to your employer for tax year 2019 or earlier), and the disallowed allowances were claimed on your original Form IT-2104.
You are a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program.

Exemption from withholding

You cannot use Form IT-2104 to claim exemption from withholding. To claim exemption from income tax withholding, you must file Form IT-2104-E, Certificate of Exemption from Withholding, with your employer. You must file a new certificate each year that you qualify for exemption. This exemption from withholding is allowable only if you had No New York income tax liability in the prior year, you expect none in the current year, and you are over 65 years of age, under 18, or a full-time student under 25. You may also claim exemption from withholding if you are a military spouse and meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act and the Veterans Benefits and Transition Act. If you are a dependent who is under 18 or a full-time student, you may owe tax if your income is more than $3,100.

Withholding allowances

You may not claim a withholding allowance for yourself or, if married, your spouse. Claim the number of withholding allowances you compute in Part 1 and Part 4 of the worksheet on page 4. If you want more tax withheld, you may claim fewer allowances. If you claim more than 14 allowances , your employer must send a copy of your Form IT-2104 to the New York State Tax Department. You may then be asked to verify your allowances. If you arrive at negative allowances (less than zero) on lines 1 or 2 and your employer cannot accommodate negative allowances, enter 0 and see Additional dollar amount(s) below.

Income from sources other than wages - If you have more than $1,000 of income from sources other than wages (such as interest, dividends, or alimony received), reduce the number of allowances claimed on line 1 and line 2 (if applicable) of the IT-2104 certificate by one for each $1,000 of nonwage income. If you arrive at negative allowances (less than zero), see Withholding allowances above. You may also consider making estimated tax payments, especially if you have significant amounts of nonwage income. Estimated tax requires that payments be made by the employee directly to the Tax Department on a quarterly basis. For more information, see the instructions for Form IT-2105, Estimated Tax Payment Voucher for Individuals, or see Need help? on page 7.

Other credits (Worksheet line 14) - If you will be eligible to claim any credits other than the credits listed in the worksheet, such as an investment tax credit, you may claim additional allowances.

Find your filing status and your New York adjusted gross income (NYAGI) in the chart below, and divide the amount of the expected credit by the number indicated. Enter the result (rounded to the nearest whole number) on line 14.

Single and NYAGI is:	Head of household and NYAGI is:	Married and NYAGI is:	Divide amount of expected credit by:
Less than $215,400	Less than $269,300	Less than $323,200	63
Between $215,400 and $1,077,550	Between $269,300 and $1,616,450	Between $323,200 and $2,155,350	68
Between $1,077,550 and $5,000,000	Between $1,616,450 and $5,000,000	Between $2,155,350 and $5,000,000	96
Between $5,000,000 and $25,000,000	Between $5,000,000 and $25,000,000	Between $5,000,000 and $25,000,000	100
Over $25,000,000	Over $25,000,000	Over $25,000,000	110

Example: You are married and expect your New York adjusted gross income to be less than $323,200. In addition, you expect to receive a flow-through of an investment tax credit from the S corporation of which you are a shareholder. The investment tax credit will be $160. Divide the expected credit by 63. 160/63 = 2.5397. The additional withholding allowance(s) would be 3. Enter 3 on line 14.

Married couples with both spouses working - If you and your spouse both work, you should each file a separate IT-2104 certificate with your respective employers. Your withholding will better match your total tax if the higher wage-earning spouse claims all of the coupl's allowances and the lower wage-earning spouse claims zero allowances. Do not claim more total allowances than you are entitled to. If your combined wages are:

less than $107,650, you should each mark an X in the box Married, but withhold at higher single rate on the certificate front, and divide the total number of allowances that you compute on line 19 and line 31 (if applicable) between you and your working spouse.
$107,650 or more, use the chart(s) in Part 5 and enter the additional withholding dollar amount on line 3.

Taxpayers with more than one job - If you have more than one job, file a separate IT-2104 certificate with each of your employers. Be sure to claim only the total number of allowances that you are entitled to. Your withholding will better match your total tax if you claim all of your allowances at your higher-paying job and zero allowances at the lower-paying job. In addition, to make sure that you have enough tax withheld, if you are a single taxpayer or head of household with two or more jobs, and your combined wages from all jobs are under $107,650, reduce the number of allowances by seven on line 1 and line 2 (if applicable) on the certificate you file with your higher-paying job employer. If you arrive at negative allowances (less than zero), see Withholding allowances above.

If you are a single or a head of household taxpayer, and your combined wages from all of your jobs are between $107,650 and $2,263,265, use the chart(s) in Part 6 and enter the additional withholding dollar amount from the chart on line 3.

If you are a married taxpayer, and your combined wages from all of your jobs are $107,650 or more, use the chart(s) in Part 5 and enter the additional withholding dollar amount from the chart on line 3 (Substitute the words Higher-paying job for Higher earner's wages within the chart).

Dependents - If you are a dependent of another taxpayer and expect your income to exceed $3,100, you should reduce your withholding allowances by one for each $1,000 of income over $2,500. This will ensure that your employer withholds enough tax.

Following the above instructions will help to ensure that you will not owe additional tax when you file your return.

Heads of households with only one job - If you will use the head-of-household filing status on your state income tax return, mark the Single or Head of household box on the front of the certificate. If you have only one job, you may also wish to claim two additional withholding allowances on line 15.

DIRECT DEPOSIT ENROLLMENT FORM

Date:

* Office

Bank Name

Account Number

Tracking / ABA Number

Checking

Saving

A copy of a voided check or copy of deposit slip with your name on it must be attached to this form

Please note: Please allow 2 week of paycheck before the direct deposit takes effect.

Date Entered

By

Applications

Application Form

Document Upload

Previous Work History

Applicant's Authorizations

*This application will be considered for 30 days from the date it is submitted. Should you wish to be considered for employment after that date, you must submit a new application.

Do not write bellow this line

PPD Agreement

Dress Code Agreement

Availability Form

CHRC Demographic Information

DOH CHRC 102 (1/07)

Section 3 - Agency Authorized Person Information

PEOPLE CARE CONSENT FOR INFORMATION TO BE POSTED TO THE HOME CARE REGISTRY

Employment Eligibility Verification Department Of Homeland Security U.S. Citizenship and Immigration Services

LIST OF ACCEPTABLE DOCUMENTS

Translator Certificate

New York Urban Youth Job Program

Categories:

Agreement:

Please Fill In These Forms And Legibly

Where You Reffered to an employer by?

APPLICANT'S AUTHORIZATION - READ CAREFULLY BEFORE SIGNING

ATTESTATION TO COMPLY WITH CDPAP REGULATIONS

Supplement B,Reverification and Rehire (formerly Section 3)Department of Homeland Security U.S. Citizenship for Section 1

CONSUMER DIRECTED PERSONAL ASSITANCE PROGRAM CONSENT TO TRANSFER NECESSARY PERSONAL ASSISTANT MEDICAL DOCUMENTATION

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Signature-All Applicants Must Sign

Employee's Withholding Certificate

2023

Step 2(b)-Multiple Jobs Worksheet (Keep for your records.)

Step 4(b)-Deductions Worksheet (Keep for your records.)

Married Filing Jointly or Qualifying Widow(er)

Single or Married Filing Separately

Head of Household

Department of Taxation and Finance Employee's Withholding Allowance Certificate IT-2104 New York State , New York City , Yonkers

DIRECT DEPOSIT ENROLLMENT FORM

PEOPLE CARE
CONSENT FOR INFORMATION TO BE POSTED TO THE HOME CARE REGISTRY

Employment Eligibility Verification
Department Of Homeland Security

U.S. Citizenship and Immigration Services

Supplement B,
Reverification and Rehire (formerly Section 3)

Department of Homeland Security
U.S. Citizenship for Section 1

CONSUMER DIRECTED PERSONAL ASSITANCE PROGRAM
CONSENT TO TRANSFER NECESSARY PERSONAL ASSISTANT
MEDICAL DOCUMENTATION

Department of Taxation and Finance Employee's Withholding Allowance Certificate IT-2104
New York State , New York City , Yonkers