Employee Information

Name: ___________ Physical Address: Mailing Address (if different): City/State/Zip: ______________ Phone Number: _______ Employer: ____________

Social Security Number:

County: Email (optional): Client:

There are some tax exemptions given to certain domestic employer/employee relationships. Please mark any of the below boxes if the relationship exists. Is the employee the: o Parent, o Spouse, or o Child, under the age of 21 of the employer? This is the relationship between the employee and the employer not the employee and the client.
The fine print - under IRS guidelines, Publication 15 (Circular E) Section 3, employees are not subject to Social Security, Medicare and federal unemployment tax (FUTA) if these relationships exist. The exemptions are as follows: A. Parent employed by child - Payments for the services of a parent employed by his or her child in other than a trade or business, such as domestic services, are not subject to Social Security, Medicare and FUTA tax. (IRS Pub. 15, Section 3, Paragraph 4) B. One spouse employed by another - Payments for services of one spouse employed by another in

other than a trade or business, such as domestic service in a private home, are not subject to Social
Security, Medicare, and FUTA tax. (IRS Pub. 15, Section 3, Paragraph 2) C. Child employed by parents - Payments for work other than in a trade or business, such as domestic work in the parent's private home, are not subject to Social Security, Medicare, and FUTA tax until the child reaches age 21. (IRS Pub.15, Section 3, Paragraph I)

The state of Georgia follows the federal guidelines in applying liability for state unemployment tax (SUTA). If the employee falls into any of the three categories outlined above, Social Security and Medicare tax will not be withheld from the employee's checks. The employer will not be charged for their portion of Social Security and Medicare or FUTA and SUTA withholdings.

Employee Signature: _______________


Authorization Form to be Fully Completed & Signed

Human Resource ProFile, Inc.
8506 Beechmont Ave. Cincinnati,OH 45255-4708 800-969-4300 / 513-388-4300

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***** Please
First City/State City/State

Print Clearly


Last Address Previous Social Security # MI County County Driver's License Number
Age is not a criterion in any decision. but

Maiden Zip Zip

Date of Birth Professional


Day Year


is used for identification

purposes ONLY. License #

Driver's License State of Issuance

License: Type


High School: If GED received, College: Major area of study: list state and district or military facility, and year received: Name as it appears From To on high school diploma or GED certificate: City / State CamDUS / Phone Number


I Frnrn


Graduate? Y/N

Degree Type Earned




Degree Type Earned

Name used at time of graduation

or final attendance:

Grad./Tech./Other: Major area of study:






Degree Type Earned

Name used at time of graduation entered a plea of no contest, withheld had prosecution for any crime? deferred,

or final attendance:

Have you ever pled guilty, been convicted, had prosecution diverted

(diversion program),

or adjudication




If Yes, list All Offenses, including Traffic and/or Criminal Offense


City, County, and State of Offense County


I have been informed in writing that a consumer report or investigative consumer report may be obtained on me for employment purposes. I hereby authorize the procurement of the report and authorize and direct the release to Human Resource ProRle, Inc., an independent contract agency, information held by any parties regarding my previous employment, my criminal history record and/or record of convictions in federal, state and local files for violations of any federal. state. local statutes or ordinances. my credit history. workers' compensation history. driving record. government agency lists. and scholastic records and hereby release said persons. schools, companies. courts. agencies. and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I further understand this information may be reviewed periodically by Human Resource Profile, Inc. and reported to my prospective/current employer. I hereby acknowledge that Human Resource ProFile, Inc. cannot vouch for or guarantee the accuracy of information provided by third parties. Accordingly, I release Human Resource ProFile, lnc., its agents and/or my prospective/current employer from any and all liabilities arising out of any errors or omissions regarding my background information and authorize Human Resource ProFileto release any and all information to my prospective/current employer.

Signature TO BE COMPLETED BY: Acumen

Date Fiscal Agents - Georgia

Date Sent: Time Sent:

_ _


Acumen Customer Service

Acct #


Phone: 866-522-8636



I]] Conviction

Employment History Federal District

0 Workers' Compensation 0 Federal Exclusion 0 Professional Licensure 0 Special Request,

0 Credit



Fax: 877-522-8636
Education Verification Violent Sex Offender _
with the

When requesting a report for employment purposes from HRP.you must also certify to HRPthat you have provided the applicant/employee

isclosure form and obtained the applicant/employee's

consent to procure the report. HRP'stwo page authorization profile forms complies with these requirement

I HAVE BEEN INFORMED IN WRITING AND ACKNOWLEDGE THAT A "CONSUMER REPORT" AND/OR AN "INVESTIGATIVE CONSUMER REPORT" MAY BE OBTAINED ON ME FOR EMPLOYMENT PURPOSES. Inc. OH 45255-4708 * 800-969-4300 * 513/388-4300 * Fax 513/388-4320 09101 . 8506 Beechmont Avenue * Cincinnati. Signature _ Date ----------------- *This form needs to be signed and dated by the employee.FlIlploymrll! "\l'l'Cl'lIill!! IMPORTANT DISCLOSURE Please read before completing and signing the Applicant ProFile. Human Resource ProFile. I ALSO ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS STATEMENT. I FURTHER UNDERSTAND THAT THIS "CONSUMER REPORT" AND/OR "INVESTIGATIVE CONSUMER REPORT" WILL BE PERFORMED BY HUMAN RESOURCE PROFILE AND PROVIDED TO MY PROSPECTIVE EMPLOYER.

the document(s) ) have examined appear to be genuine and to relate to the individual. Date of Rehire (monthldaylyear) (ifapplicable) C. The instructions must be available during completion of this form.OMB No. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals.) Middle Initial Maiden Name Apt. Document Title: Document #: Expiration Date (if any): employee presented I attest. Section 1. State. under penalty of perjury. that I am (check one of the following): A citizen of the United States A noncitizen national of the United o o mployec's Signature Preparer penalty and/or Translator that I have assisted Certification in the completion of perjury. Employee Information Print Name: Last and Verification First (To be completed and signed by employee at the time employment begins. Citizenship and Immigration Services Form 1-9. and iftbe document(s). 1615·0047. # Date of Birth (month/day/year) 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 etion ofthis form. o o I attest. that the employee began employment on (month/day/year) st of m knowledge the employee is authorized to work in the United States. Employers CANNOT specify which document(s) they will accept from an employee. (State 10 ment agencies may omit the date the employee began emp oymen • Signature ofEmp oyer ntative Print Name Title Domestic Employer BUSiness or Organization Name and Address (Street Name and Number. Print Name Preparcr's/Translator's Signature Date (monthldaylyear) ListB ListC Issuing authority: Expiration Date (if any): Document#: Expiration Date (if any): CERTIFICATION: I attest. Updating and Reverification A. If employee's previous grant of work authorization has expired. Signature of Employer or Authorized Representative Date (monthldaylyear) Employer write the date here . (To be completed and signed if Section I is prepared by a person other than the employee. Zip Code) Date (monthldaylyear) Employer write your address here Section 3. Employment Eligibility Verification Read instructions carefully before completing tbis form. New Name (ifapplicable) (To be completed and signed by employer. provide the information below for the document that establishes current employment authorization. uuder penalty of perjury. that I have examined the document(s) presented by the above-named employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. that to the best of my knowledge.) I attest. City. under 0/ this form and that to the best of my knowledge the in/onnation is true and correct. under penalty of perjury. Expires 08/31/12 Department of Homeland Security U. this employee is authorized to work in the United States.S.) B. that the above-listed document(s) appear to be genuine and to relate to the employee named.

School ID card with a photograph 4. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States 2. School record or report card 11. eye color. Passport or U. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551) 1. doctor. provided it contains a photograph or information such as name. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Coast Guard Merchant Mariner Card 8.S. height.S. U. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10.LISTS OF ACCEPTABLE LIST A Documents that Establish Both Identity and Employment Authorization 1. gender. gender. state or 3. a foreign passport with Form 1-94 or Form 1-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status. and address issued by the Department of State (Form FS-545) 3. or territory of the United States bearing an official seal 5. Native American tribal document 9. Employment Authorization Document that contains a photograph (Form 1-766) 3. Passport Card LlSTB DOCUMENTS LlSTC Documents that Establish Employment Authorization AND All documents must be unexpired Documents that Establish Identity OR 1. county. Day-care or nursery school record 6. Military card or draft record 6. Native American tribal document 5.S. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machinereadable immigrant visa local government agencies or entities. as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form 7. Voter's registration card 5. U. and address 2. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form 1-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM orRMI 7. height. Citizen ID Card (Form 1-197) 6.S. U. date of birth. date of birth. eye color. municipal authority. Military dependent's ID card 4. Certification of Birth Abroad 2.S. U. ID card issued by federal. Original or certified copy of birth certificate issued by a State. or hospital record 12. Identification Card for Use of Resident Citizen in the United States (Form 1-179) 8. Employment authorization document issued by the Department of Homeland Security Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) . Clinic.

AZ 85206 Phone: Fax: 866-522-8636 877-522-8636 I hereby authorize Acumen Fiscal Agent. to initiate credit entries and.lnvemess Ave. debit entries for the purpose of correcting an erroneous credit previously initiated to my account indicated below. Suite 210 Mesa. o New Account o checking (attach a voided check) o Change of Account o Cancellation o savings (Please contact your bank for the routing number. LLC. please be aware the next 1-2 paychecks will not be direct deposited to your old account . if necessary. Any changes to your account(s) must be submitted immediately! When you submit a change.AUTHORIZATION FOR DIRECT DEPOSIT Payroll Agent: Acumen Fiscal Agent. Please note: When depositing to multiple accounts.Paper checks will mailed to your address of record until the new account is authorized.. Do not use a deposit slip) Financial Institution Name Branch Name and Phone Number Address City State Zip Account Routing Number Account Number % of check to be deposited This authority is to remain in full force and effect until Company and Financial Institution have received written notification from me of its termination in such time and manner as to afford Company and Financiallnstitution a reasonable opportunity to act upon it. I further authorize the Financiallnstitution named below to accept such entries and to credit or debit the amount thereof to such account. Please be sure to indicate the percentage of your check you want deposited to each account. Attach a voided check for checking account(s) or contact your bank for the routing number on savings accounts. LLC 4542 E. You can have your check deposited into more than one account. Do not use a deposit slip) Financiallnstitution Name Branch Name and Phone Number Address City State Zip Account Routing Number Account Number % of check to be deposited o New Account o Change of Account o Cancellation o checking (attach a voided check) o savings (Please contact your bank for the routing number. the percentage total must be 100%. COMP April 2012 . hereinafter called Company. Print Name Social Security Number Signature Date Phone Number Authorization will take effect not less than 10 days after acceptance by Financial Institution.

This authorization is to remain in full force and effect until Company receives written notice from me of its termination in such time and in such a manner as to afford a reasonable opportunity to act on it. ************************************************************************ I hereby authorize Acumen Fiscal Agent. Employee Signature Name Address City Social Security Number Birth date State _ . To take advantage of the safety. direct deposit or check. I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit. Date _ _ _ _ _1 __1 _ _ Cell Phone # HomeFax# _ _ Home Phone # ALWAYS CHECK YOUR PAY STUB OR YOUR ACCOUNT TO VERlFY THAT YOUR DEPOSIT HAS POSTED. check the pay card option below and sign the authorization statement. I understand that I am responsible for notifying Acumen when my pay card is activated. I authorize Bank to accept and credit any credit entries indicated by Company to my account. dependability and convenience of pay cards.PAY SELECTION OPTION FOR EMPLOYEE Acumen Fiscal Agent offers three pay receipt options. Pay cards are available to every employee and are a convenient way to access your pay and ensure that your pay will be available each payday morning without waiting for the mail to receive a paper check. My net pay will be deposited onto the pay card each payday. My pay card is not valid until this notification is complete. __ Direct Deposit Option __ I choose to have my paycheck deposited directly into my checking/savings account. My Money Network Visa pay card and information kit will be mailed to my home address. You may choose a pay card.Zip. Pay Card Option I choose to have my pay deposited directly to my pay card. (here in after "Company") to deposit any amount owed to me for wages by initiation of credit entries to my account at the financial institution (hereinafter ''Bank'') handling my choice indicated above. Paper Check Option __ I choose to have my pay sent to me by the US Postal Service in the form of a paper check. I will complete the Authorization for Direct Deposit and return to payroll along with this Pay Selection Agreement. LLC. Further. In the event that Company deposits funds erroneously into my account. ++++++++++++++++++++++For Paycard ABA # 084003997 Payroll Use Only ++++++++++++++++++++++++++ _ Paycard # .

These forms can be found in the blue "Paying for Your Supports" folder. Employee Name (please print): Employee Social Security Number (last 4 digits): _ _ (please use the 3 letter code found in the 'Service Code' column of the "Georgia COMP Program Code Descriptions" located in the blue "Paying for Your Supports" folder of the start up packet) Service Code: --Service Code: Service Code: --Service Code: Effective Month: Participant Name (please print): _ _ Employee Rate: $. Please consult the "Show Me the Money" sheet for rate information and the "Georgia COMP Program Code Descriptions" for service code information. please provide Acumen with the following information so your employee is paid the correct rate for the service(s) provided. Employee Rate: $ Employee Rate: $ Employee Rate: $ Please Circle: _ _ _ _ 15t Half or e= Half _ Participant or Representative Signature Date Support Coordinator/Broker Signature • • • Date • Please complete this form for each new employee Consult with your Support Coordinator as there are Maximum rates that can not be exceeded Should you choose to change these rates in the future. Suite 210 Mesa. you must consult with your Support Coordinator and complete a new form for any employee that you wish to have the payroll rate changed This form must be received by Acumen prior to the effective date FAX: 877-522-8636 or MAIL: Acumen Fiscal Agent.GEORGIA COMP Program Employee Rate Form In efforts to ensure proper payment. Arizona 85206 ~ I GACOMP April 2012 . LLC 4542 East Inverness Ave.

7. enter "0" in the brackets beside your marital status. 9. Box 49432.300 $. If the remainder is over $1 . Married Filing Joint. ADDITIONAL ALLOWANCES Enter 0 or 1 or 2 [ (worksheetbelow must be completed) D. P. GA 30359. A. DEPENDENT ALLOWANCES B. Add the Amounts on Lines 1. My state of residence is __ :---. Estimate of Taxable Income not Subject to Withholding G. 2C. Allowable Deductions to Federal Adjusted Gross Income E. STATE AND ZIP CODE LINES 3 . B. 12/09) STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE 1a. a) I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year.500 $2. Divide the Amount on Line G by $3. _ _ _ $-----$ $ _ _ (This is the maximum number of additional allowances you can claim. D. If necessary. and 2D F. O.8 PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING 3. HOME ADDRESS (Number. LETTER USED (Marital Status A.500 round up) 7. Also. Subtract Line B from Line A D. Single: Enter 0 or 1 [ ] 4. I authorize my employer to deduct per pay period the additional amount listed above. _ _ _ ADDITIONAL ALLOWANCES FOR DEDUCTIONS: Federal Estimated Itemized Deductions Georgia Standard Deduction (enter one): Each Spouse Single/Head of Household $1. treet. CITY. stop here) H. [ 1 [ 1 _ 1. Do not accept forms claiming exempt if numbers are written on Lines 3 . Employee's Signature Date Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding. Check here 0 I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemptionfrom withholding status claimed on this Form G-4. C. Married Filing Separate: Enter 0 or 1 or 2 [ E. or E) TOTAL ALLOWANCES (Employer:The letter indicates the tax tables in the Employer'sTax Guide) (Total of Lines 3 . both spouses working: Enter 0 or 1 or 2 [ C. mail form to: Georgia Department of Revenue. EXEMPT: (Do not complete Lines 3 .) A. ADDITIONAL WITHHOLDING $ Enter 0 or 1 or 2 [ WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES (Must be completed only if step 5 is greater than zero) COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION: Yourself: 0 Age 65 or over Spouse: 2.000. YOUR FULL NAME 2a. B. 0 Age 65 or over 0 Blind 0 Blind Number of boxes checked x 1300 $ $. _ _ . Head of Household: 6.or RuralRoute) S CERTIFICATE 1b.Form G-4 (Rev. EMPLOYER'S NAME AND ADDRESS: EMPLOYER'S FEIN: EMPLOYER'S WH#: Do not accept forms claiming additional allowances unless the worksheet has been completed.7 if claiming exempt) Readthe Line 8 instructions on page2 beforecompletingthis section.-My spouse's (servicemember) state of residence is The states of residence must be the same to be exempt.5) _ 8. Check here 0 b) I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act as provided on page 2. MARITAL STATUS (If you do not wish to claim an allowance. Married Filing Joint. one spouse working: 5. Subtract Line F from Line E (if zero or less. C. Atlanta. YOUR SOCIAL SECURITY NUMBER 2b. Enter total here and on Line 5 above $ $. Withholding Tax Unit.

7 if claiming exempt.INSTRUCTIONS FOR COMPLETING FORM G-4 Enter your full name. Single . The servicemember is present in Georgia in compliance with military orders. therefore. Married Filing Separate . Employers will honor the properly completed form as submitted pending notification from the Withholding Tax Unit.enter 1 if you claim yourself or 2 if you claim yourself and your spouse E. or 2 if you claim yourself and a qualified dependent for whom you maintain a home Do not claim a deduction on Line 4 for a dependent used to qualify you as head of household Line 4: Enter the number of dependent allowances you are entitled to claim. one spouse working . EXAMPLES.C. By correctly completing this form. b) Check the second box if you are not subject to Georgia withholding and meet the conditions set forth under the Servicemembers Civil Relief Act. both spouses working . Failure to complete and submit the worksheet will result in automatic denial of your claim. Failure to submit a properly completed Form G-4 will result in your employer withholding tax as though you are single with zero allowances.enter 1 if you are claiming yourself B. Married Filing Joint. If the spouse does not fill out the form. Employers are required to mail any Form G-4 claiming more than 14 allowances or exempt from withholding to the Georgia Department of Revenue for approval. the spouse is required to submit a Georgia Form G-4 so that withholding will occur as is required by Georgia Law when a Georgia domiciliary works in another state and withholding is not required by such other state. you can adjust the amount of tax withheld to meet your tax liability. the employer should not report any of the wages as Georgia wages on the W-2.enter 1 if you claim yourself but the individual(s) for whom you maintain a home does not qualify as a dependent. Employers who know that a G-4 is erroneous should not honor the form and should withhold as if the employee is single claiming zero allowances until a corrected form has been received.A. A. On the W-2 for 2010 and any year thereafter. you qualify to claim exempt. and 4. such forms remain in effect until changed or until February 15 of the following year. O. The amount on Line 4 of Form 500E2 (or Line 16 of Form 500) was $0 (zero). The spouse is in Georgia solely to be with the servicemember. Your employer withheld $500 of Georgia income tax from your wages. The domicile of the spouse is the same as the domicile of the servicemember. Under the Act.enter 1 if you claim yourself or 2 if you claim yourself and your spouse C. If the spouse of a servicemember is entitled to the protection of the Military Spouses Residency Relief Act in another state and files a withholding exemption form in such other state. § 48-7-102 requires you to complete and submit Form G-4 to your employer in order to have tax withheld from your wages.5. 2. Line 3: Write the number of allowances you are claiming in the brackets beside your marital status. Receiving a refund in the previous tax year does not qualify you to claim exempt. the employer shall withhold Georgia income tax as if the spouse is single with zero allowances. Your tax liability is the amount on Line 4 (or Line 16) and you filed a prior year income tax return. Upon approval. You can not claim exempt if you did not file a Georgia income tax return for the previous tax year. a spouse of a servicemember may be exempt from Georgia income tax on income from services performed in Georgia if: 1. 3.enter I if you claim yourself or 2 if you claim yourself and your spouse D. Your employer withheld $500 of Georgia income tax from your wages. the employer should report all wages earned during the year as Georgia wages. Enter total of the numbers on Lines 3 . you do not qualify to claim exempt. Do not complete Lines 3 . Line 5: Complete the worksheet on Form G-4 if you claim additional allowances. The amount on Line 4 of Form 500E2 (or Line 16 of Form 500) was $100. as amended by the Military Spouses Residency Relief Act. Enter the number on Line H here. The spouse maintains domicile in another state. and you expect to file a Georgia tax return this year and will not have a tax liability. Head of Household . Your tax liability is the amount on Line 4 (or Line 16). Additional information for employers regarding the Military Spouses Residency Relief Act: L On the W-2 for 2009. Line 6: Enter a specific dollar amount that you authorize your employer to withhold in addition to the tax withheld based on your marital status and number of allowances. address and social security number in boxes I a through 2b. therefore. You can claim exempt if you filed a Georgia income tax return last year and the amount on Line 4 of Form 500E2 or Line 16 of Form 500 was zero.G. . Line 8: a) Check the first box if you qualify to claim exempt from withholding. Line 7: Enter the letter of your marital status from Line 3. Married Filing Joint. 2.

These include. _ Position Date you can start Wage Desired _ Employment Eligibility: To be employed with the State of Georgia. Field of Study College? If yes. United States citizenship or authorization to work in this country. you must meet certain State and Federal employment eligibility requirements. but not limited to. Graduate? _ Completed date. Yes_No Date Degree completed: _ _ Former Employers Ir-Fr_o_m __ I_T_O __ --+I_N_am_e +f_d_dr_e_ss --+1_P_OS_it_io_n 1Reason for leaving Name: _ Page 1 of2 . Degree Yes No Yes No # of months.Application for Employment Personal Information Date Name Last Address First Middle _ _ _ Phone Number Social Security No. Please answer the following questions: Are you employed now? _Yes No Are you 18 years of age or older? Yes No Have you ever been convicted of a felony? Yes No Are you a United States citizen? __ Yes __ No Are you an alien authorized to work in the United States __ Yes __ NO Education High School Graduate or equivalent (GED)? Vocational Business School? If yes. and no felony convictions.

expiration date (mo/yr) _ Other professional licenses: _ *You must provide a copy of your current CPR Card and Basic First Aid Card to your employer References IN_am_e -+IP_h_o_n_e_N_u_m_b_e_r_R_el_a_tio_n_s_h_iP I _ Briefly list reasons you should be considered for this job: I certify that the facts contained in this application are true and complete to the best of my knowledge. or conveyed during any interview. at the option of either myself or this employer. I further understand and agree that if I am hired. or misrepresentation on this application is sufficient cause for refusal to hire. with or without cause and without prior notice. and I understand that no such promise or guarantee is binding upon this employer unless made in writing. is intended to create an employment contract. character and general reputation. no matter when discovered by employer.Application for Employment Georgia Licenses and Certifications: Type of License/Certificate Current Valid Drivers License Yes NO *CPR Training Certificate_ Yes _ NO If yes. expiration date ( mo/yr) _ Nurse Aide Certification Yes No If yes. and I authorize my former employers and references to disclose information regarding my former employment. Signature _ Date _ Narne: _ Page 2 of2 . No promises regarding employment have been made to me. I understand that any false statement. I authorize this potential employer to investigate all statements contained in this application. or dismissal if employer has employed me. expiration date ( mo/yr) _ *Basic First Aid Training Certificate _ Yes _ NO If yes. and may be terminated at any time. without giving me prior notice of such disclosure. omission. my employment will be "at will" and without fixed term. I understand and agree that nothing contained in this application.

the Employee acknowledges that even though he/she is the Employee of a Medicaid Recipient or an approved Designee of the Medicaid Recipient in the self-directed services option. Therefore. and WHEREAS.A.ACUMEN STATEMENT OF COMMUNITY SERVICE WORKER (EMPLOYEE) PARTICIPATION THIS STATEMENT OF PARTICIPATION is between Acumen Fiscal Agent. through the Provider is the source of payment to the Employee. LLC (Provider) also known as the Financial Management Services Provider (FMS) and the undersigned Community Services Worker (Employee) and becomes effective on the date of enrollment indicated by Acumen and is contingent upon the processing of all applicable enrollment paperwork in accordance to the rules and regulations governing the self-directed service option for the State of Georgia Department of Community Health. the Employee acknowledges that he/she is an employee of the Medicaid Recipient or an approved Designee (Representative) of the Medicaid Recipient and not the employee of Provider and/or the Department and is not neither entitled to nor will make any claim for any employee benefits from Provider and/or the Department. Division of Medical Assistance (the Department). the Employee will only provide services in accordance to the Recipient's approved Individual Service Plan and in compliance to the rules of the self-directed services option program. WHEREAS. Provider functions as an Organized Health Care Deliver System (OHCDS) solely by virtue of providing the waiver service of "Financial Support Services" in accordance to the rules and regulations of the self-directed services program in the state of Georgia. WHEREAS. and O. Page 1 of6 .C. the Employee agrees to protect the confidentiality of personal and health information relating to the Medicaid Recipient and to release that information only on the request of the Recipient or as otherwise allowed by law. certification and/or licensure requirements and other necessary qualifications have been met as required by law in the State of Georgia to render health care services to Medicaid Recipients involved in the self-directed services option. WHEREAS the Department has contracted with Provider to enroll qualified Community Service Workers (Employees) to render services to eligible Medicaid Recipients. WHEREAS. as amended. will not request payment for any services not performed in accordance to the rules of the program or the Recipient's approved Individual Service Plan. the Employee agrees to accept payment from Provider as payment in full for approved services rendered in accordance to the rules and regulations of the program and on behalf of the Medicaid Recipient. WHEREAS.G. the Employee agrees to comply and correctly complete all required paperwork and be approved prior to providing any services under this self-directed program. WHEREAS. Employee affirms that all prerequisites. WHEREAS. WHEREAS. § 49-4-1 et seq.. the Department is charged with the administration of the Georgia State Plan for Medical Assistance (the "Medicaid program") in accordance with the requirements of Title XIX of the Social Security Act of 1935. the Department.

The Provider shall notify Employee of modifications to the provisions contained in the Policies and Procedures manual(s) for the self-directed service program(s) in which the Employee is enrolled. certifying agency. and all of the Department's Policies and Procedures manuals governing the Medicaid program. any federal or state governmental agency. subject to any applicable state or federal laws which may deem such records or parts of such records privileged or confidential. The Provider shall reimburse Employees for claims that are submitted in compliance with the Department's and Provider's requirements. use and share records and other information includes but is not limited to disclosure of ownership or control interests.L. Certification of Employee Information. copy. and any amendments thereto (collectively. and all acts or omissions of such persons or entities shall be attributed to Employee. the "Department's requirements"). including but not limited to completion of all enrollment forms. cooperation with site audits. Employee shall comply with all of the Department's and Provider's requirements applicable to the category(ies) of service in which Employee participates under this Statement of Participation. THE PROVIDER'S OBLIGATIONS A. including but not limited to the Composite State Board of Medical Examiners.. regulatory body. Part n and the applicable Part illmanuals. 2. and in such amounts allowed under the Medicaid program as administered by the Department.NOW THEREFORE. THE EMPLOYEE'S OBLIGATIONS A. or any other person or entity. The Provider shall adhere to all applicable provisions of federal and state laws and regulations. including Part I. access. the parties agree to the terms and conditions named herein as follows: 1. access. C. Legal Compliance. and the following: . Legal Compliance. b. and recognizes that the Department and the Provider will rely on such information to evaluate Employee's participation under the Medicaid program. use and share Employee's records and other information as may be necessary for the Department and Provider to determine the appropriateness of Employee's participation in or termination from the Medicaid program. subject to any applicable state or federal law limiting the distribution of such information Employee's authorization to request. Employee certifies that aU statements and information furnished to the Department and Provider for enrollment and continued participation are true and complete. accreditation agency. Employee shall comply with the Department's and Provider's requirements to enroll and continue participating as a Employee in the Medicaid self-directed program. Rules of the Department. Modifications to Department's Policies and Procedures. copy. B. This disclosure provision shall exclude sanctions against Employee that are protected by private order of the issuing board or agency Page 2of6 . Employee Enrollment and Continued Participation. The term "Employee" shall include those persons or entities performing services under the supervision or other direction of Employee. licensing agency. Disclosure. Employee authorizes the Department and Provider to request. Employee's records and information may be requested from or exchanged with any source. in consideration of the mutual covenants and promises contained herein and for other good and valuable consideration. Employee shall give the Provider written updates to information previously submitted. Reimbursement to Employees. and advance notice of changes when required by the Provider in this Statement of Participation and the Department's or Provider's requirements. and of any criminal offenses related to any federal or state health care program. the receipt and sufficiency of which are hereby acknowledged. B.

Employee shall provide the Department Provider with written copies of licenses and/or certifications upon request.S. records or data. Claims Submission. and shall be responsible for research and correction of all billing discrepancies without cost to the Provider. State Attorney General's Office or office of any Georgia District Attorney and their authorized representatives. facility or other license and/or certification that is necessary for rendering Covered Services in the selected category(ies) of service. and any copies thereof.J. furnish or release information for any acts performed and statements made or released in connection with the evaluation of Employee under the Medicaid program including the services rendered by Employee. Employee shall disclose and provide legible copies to the requestor. or permit the requestor to copy. This provision shall apply to all records regardless of the enrollment status of Employee subject to any applicable state or federal laws that may deem such records or parts of such records privileged or confidential. Department of Health and Human Services. This provision shall survive termination or expiration of this Statement of Participation for any reason. and any and all individuals and entities who. and other matters pertinent to Employee's status and duties in connection with this Statement of Participation. and any authorized agency including but not limited to the U. Provider. This provision shall survive termination or expiration of this Statement of Participation for any reason. Employee shall maintain in an orderly manner and ensure the confidentiality of all original source documents. as may be necessary to fully substantiate the nature and extent of all services provided. recoupment of corresponding payments. the State Auditor. Employee shall possess and maintain in good standing and without restriction valid professional. and/or termination of Employee's participation. or longer as required by state or federal law. Employee shall submit claims for Covered Services rendered to eligible Medicaid recipients in the form and format designated by the Provider. Certification of Claims. medical records. Records shall be retained for a minimum of five (5) years from the date of service. Hold Harmless. Page 3 of6 . Except where disclosure is protected by private order of the issuing board or agency. without cost. their agents.. For each claim submitted by or on behalf of Employee. identifying recipient data. B. accuracy and completeness. License/Certification. all Medicaid-related documents. Upon request by the Department. A. Employee shall give written notification to the Department Provider within 5 days of the effective date of any restriction or adverse action against Provider's license and/or certification. :L. Employee releases from liability and holds harmless the Department. and as required by the Department. their agents. the Comptroller General. in good faith. This provision shall survive termination or expiration of this Statement of Participation for any reason. Recipient Records. Provider. occupational. Employee shall certify each claim for truth. Employee's failure to abide by this provision may constitute grounds for disallowance of all applicable charges.

Prohibition on Reassignment. payment to the payee or billing service for services rendered shall be related to the cost of processing. Without cost to the Department. Department of Health and Human Services and the State of Georgia. This provision shall survive termination or expiration of this Statement of Participation for any reason. or portion thereof. within the parameters permitted by Employee's license or certification. Employee shall render Covered Services. Provider. Employee certifies that Covered Services were in accordance with Individual Service Plan and rendered in the amount. and the Department or Provider may withhold. Employee acknowledges and agrees that the payee or billing service designated by Employee to receive payments or to process claims is not an individual or organization. for services rendered prior to the effective date of enrollment indicated by the Provider or for which federal financial participation is not available. judgments. and the Department's Policies and Procedures manuals in effect on the date the service was rendered. recoup or recover payments as a result of Employee's failure to abide by the Department's or Provider's requirements. applicable federal and state laws. Provider. to eligible Medicaid recipients that are medically necessary as defined by the Department. age. Reimbursement for Covered Services performed shall be made in a form and format designated by the Provider. sex. duration. and their agents from all causes of action. and within the category(ies) of service indicated in the Employee Enrollment documents. Covered Services. that advances money based on future Medicaid payments (accounts receivable) due to Employee after agreeing to sell. arising out of the misconduct. Employee agrees to cooperate with refund and recoupment efforts of the Department Employee agrees that the Provider shall not reimburse any claim. By submitting claims for reimbursement. Page 4 of6 . disability. or damages. including but not limited to the provision of services to an eligible Medicaid recipient or a person believed to be a recipient. in accordance with the Individual Service Plan. such as a collection agency or service bureau. color. as defined in the Department's Policies and Procedures manuals. suits. Reimbursement for Covered Services. claims. marital status. If and to the extent such damage or loss (including costs and expenses) is covered by any funds established and maintained by the State of Georgia. Employee acknowledges that payment of claims submitted by or on behalf of Employee will be from federal and state funds. and shall not be based on the payments due to Employee or based upon the percentage of claims processed. Tills provision shall survive F. E. transfer or assign such rights to payment to the individual or organization for an added fee or a percentage of the accounts receivable. Employee agrees to reimburse the funds for such monies paid out by such funds. rules and regulations promulgated by the U. negligence or omissions of Employee in the course of participating in the Medicaid program. or source of payment. Employee shall indemnify and hold harmless the Department. including court costs and attorneys' fees. Employee shall not discriminate against any recipient on the basis of race. and Employee shall not bill. national origin. Furthermore. scope and frequency indicated on the claims. Such reimbursement shall constitute payment in full for Covered Services rendered.C. Indemnification. accept or seek payment from eligible Medicaid recipients.S. religion. D. health status. Payment shall be made in conformity with the provisions of the Medicaid program. or their agents.

e. Waiver of Breach. The Medicaid Recipient is the employer of record of Employee. Termination for Unavailability of Funds. then this Statement of Participation shall terminate immediately without further obligation to or by the Department or Provider. including other plans or programs within the Department. B. D. Termination by Employee.e. C. The Department or Provider may terminate and take other action against Employee under the Medicaid program when adverse action is taken against Employee under any other plan or program. GENERAL PROVISIONS A. Page 5 of6 .termination or expiration of this Statement of Participation for any reason 3. The parties certify that the provisions of O. TERMINATION A.. Waiver of breach of any provision of this Statement of Participation shall not be deemed a waiver of any other breach of the same or different provision of this Statement of Participation. The headings of sections and provisions contained herein are for reference purposes only and shall not affect in any way the meaning or interpretation of this Statement of Participation. Conflict of Interest. Medicaid Recipient may terminate Employee with or without cause in accordance with the State of Georgia's employment laws and regulations. as amended.00). The Provider will attempt to provide Employee with ten (10) days notice of the possible occurrence of events described in this provision. The Provider also may notify other state and federal authorities. Headings. The Provider has the right to terminate this Agreement at any time with or without cause under applicable laws.s. All mailed notices shall be issued to the Employee's address on record with the Provider as of the date of such notice. The Provider shall issue written notice of termination to Employee to be effective on the date indicated therein. D.A. Division of Medical Assistance by the General Assembly of the State of Georgia or from the Congress of the United States of America. E. Notice. § 45-10-20 et seq. Employee shall inform Medicaid Recipient and give ten (10) days prior written notice to the Provider of voluntary termination.G. Termination under Other Programs. Notwithstanding any other provision hereof. TERM. § 423 regarding conflicts of interest have not and will not be violated in any respect. rules or regulations B. plans or programs of Employee's enrollment status in the Medicaid self-directed program. and 41 U. including but not limited to exclusions from or licensure restrictions or conditions by other federal or state authorities. in the event that funds are no longer appropriated for the Department.e. This Statement of Participation shall remain in effect so long as the Medicaid Recipient and Provider continue to meet program eligibility requirements and have not been terminated for any reason. Unless otherwise authorized by the Provider or by law. Termination by Medicaid Recipient. or in the event that the sum of all obligations of the Department incurred pursuant to the Medicaid program equals or exceeds the balance of such sources available to the Department for "Medical Assistance Benefits" for the fiscal year in which this Statement of Participation is effective less one hundred dollars ($100. plans or programs. The certification by the Commissioner of the Department of the occurrence of either of the events stated above shall be conclusive. Termination under the Medicaid program may result in Employee's termination under other federal and state plans or programs.

Governing Law. Neither the Department. either verbal or written. partner or joint venture of the other. Mesa. Each party acknowledges that it has the full power and authority to enter into and perform this Statement of Participation and the person signing on behalf of each party has been properly authorized and empowered to enter into this Statement of Participation. shall constitute the entire agreement between the parties with respect to the subject matter contained herein. to become effective on the date indicated by the Provider. between the parties. employee. IN WITNESS WHEREOF. This Statement of Participation establishes the means and terms of reimbursement between the Provider and Employee but does not prescribe the conduct of any medical or other professional practice. Binding Authority. or agreements. and shall supersede all previous communications. nor Employee is or shall be considered an employer. This Statement of Participation shall be governed by and construed in accordance with the laws of the State of Georgia. the Provider. I further attest by signing below. Amendments. and agree to abide by its terms and conditions. Independent Relationship.E. Accepted and authorized on this day of . I understand that I must sign and return this last page as a condition of employment in this program and that Ican not begin working in the Self Directed Services Option program until this form is completed and returned to Acumen Fiscal Agent. and any amendments thereto. No provision in this Statement of Participation is intended to create or shall be deemed or construed to create any relationship between the Provider and other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this Statement of Participation. Assignment. agent. Employee executes this Statement of Participation in person. amendments or modifications to this Statement of Participation shall be in writing and signed by each party. G. I attest that I have read this "Statement of Community Service Worker (Employee) participation" agreement in its entirety (6 pages). Ifurther understand and agree that violation of any of the terms and/or conditions of this agreement may result in termination of this agreement and payment for employment to any Medicaid Recipient of this program. or as an authorized party on behalf of an entity. that Iunderstand what is being requested of me. Suite 210. H. This Statement of Participation. in the year _ Employee Name (Printed) Employee's Signature ACUMEN (the ''Provider'') Accepted and authorized on this day of . all enrollment documents. AZ 85206 Page 6 of6 . By signing below. Employee may not assign any right or obligation under this Agreement without the prior written consent of the Provider F. representations. Except as otherwise specifically provided herein. in the year _ Please fax this completed page to 877-522-8636 or mail to Acumen at 4542 E Inverness Ave. together with the Department's and Provider's Policies and Procedures manuals. L L Entire Agreement.

505 to find out if you should adjust your withholding on Form W-4 or W-4P. If another person can claim you as a dependent on his or her tax return. and I certify income income here. • If neither of the above situations applies. Write the number here.. see page 2. Child Tax Credit. loyee's Withholding Allowance Certificate ~ Whether you are titled to claim a certain number of allowances or exemption from withholding is subject to review by S. (including child tax credit). Exemptions. 3. Supplemental Form W-4 Instructions for Nonresident Aliens. figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4.. 503. 1545-0074 arate here and give Form W-4 to your employer. Note. Basic instructions. you may owe additional tax. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below.gov for infomnation about Fomn W-4. complete the Personal Allowances Worksheet below. See Pub. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 Exemption from withholding. I declare that I have examined Employee'S signatur (This form is not valid unless you sign it. Infomnation about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page.or spouseis a nonresidentalien. I meet • Last year I had a right to a refund • This year I expect a refund If you meet both conditions. • If your total income will be between $61. converting your other credits into withholding allowances. 505. use Pub. 2.gOO of child support additional child for which you plan to claim a credit Care Expenses. withholding must be based on allowances you claimed and may not be a Hat amount or percentage of wages. exemption withholdinq for 2012. See Pub.000 and $119. The IRS has created a page on IRS.) ~ 8 this certificate and. Tax credits.checkthe "Single"box. you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example. it is true.. Complete all worksheets that apply.) A } does not work. children . No. You must call 1-800-n2-12t3 for a replacement card. 501. Tax Withholding and Estimated Tax. for more information. Otherwise.000 (Married). for details. Complete Form W·4 so that your employer can withhold the correct federal income tax from your pay. stop here and enter the number from line H on line 5 of Form W-4 below. If you are a nonresident alien. for information. correct. Head of household. For regular wages. consider making estimated tax payments using Form 1040-ES.) 9 Officecode(optional) 10 For Privacy Act and Paperwork Reduction Act Notice. before completing this fomn. Generally. you may choose to enter "-0-" if you are married than one job. 7 _ Ities of perjury.ity"i. complete only lines 1. • ~ of all federal write "Exempt" tax withheld to have no tax liabril. because I expect _ I claim Sign your name here. child. Note. ---------------------------------OMB No.but legallyseparated. at www. After your Form W-4 takes effect. state. If married. February 18. see Notice 1392. 972. B C D for your spouse. of all federal tax withheld because I had no tax liability. G G and enter total here.500 or less.The EMPLOYEE completes this form. but withhold at higher Single rate. City or town. 4. Your first name and middle initial Last name 2 Your social security number Home address (number and street or rural route) 3 0 Single 0 Married 0 Married. Child and Dependent ($90. Standard Deduction. adjustments to income.000 if married). certain credits. and Filing Information. But. Check your withholding. If you are exempt. such as interest or dividends.000 if married). Two earners or multiple jobs. Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS. Nonwage income.) or yourself) C D above) under Head of household of dependents (other than your spouse you will claim on your tax return E F G Enter "1" if you will file as head of household Enter (Note.irs. or two-eamers/rnuhjple jobs situations. to the best of my knowledge and belief. If you have pension or annuity Personal Allowances A B Enter"1" for yourself Worksheet (Keep for your records. However. and have either a working . ( and want to reduce your withholding..000 and $84.000 (Single) or $180. See Pub. then less "1" if you have three to • If your total income seven eligible children will be less than $61. you can claim head of household filing status on your tax return only if you are unmanied and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. Nonresident alien. Future developments. See Pub. 10220Q Form W-4 (2012) . If you are not exempt.000 ($10. see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. Keep the top pari for your records. ~ Total number Additional of allowances you are claiming (from line H above or from the applicable from each paycheck that worksheet on page 2) amount. (Entering" Enter number -0-" may help you avoid having too little tax withheld. and ZIP code 4 If your last name differs from that shown on your social securtly card. 505 for details. 505. and '-and complete. and 7 and sign the form to validate it. • You are single and have only one job. have only one job. If you have a working spouse or more than one job. you want withheld from L6=-+'-both of the following conditions for exemption. especially if your eamings exceed $130. enter "1" for each eligible child Add lines A through . Cat. 505 to see how the amount you are having withheld compares to your projected total tax for 2012. Consider completing a new Form W-4 each year and when your personal or financial situation changes.) ~ H • If you plan to itemize or claim adjustments and Adjustments Worksheet on page 2.) Do not include Tax Credit payments. interest and dividends). (Note. See Pub. See Pub. Your exemption for 2012 expires for the highest paying job and zero allowances are claimed on the others. . If you have a large amount of nonwage income.000 enter "2" for each eligible or less "2" if you have eight or more eligible Add lines A-G. Form W-4 (2012) Purpose. check here. see the Deductions • If you are single and have more than one job or are married and you and your spouse both work and the combined eamings /rom all jobs exceed $40. 505 for information on income.govlw4. Child on your tax return (see conditions or dependent care expenses E F "1" if you have at least $1 .000 ($90. or spouse or more if no one else can claim you as a dependent. if any. Your employer may be required to send a copy of this form to the IRS. or Enter "1" if: Enter"1" { • You are married. 2013. you may claim fewer (or zero) allowances. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions.000 if married). see Pub. and your spouse • Your wages /rom a second job or your spouse's wages (or the total of both) are $1. You can take projected tax credits into account in figuring your allowable number of withholding allowances. See Pub. Estimated Tax for Individuals. This may be different from the number of exemptions to income you claim on your tax retum.

000 and over Table 2 All Others If wages from HIGHEST paying job are$0 .000 10 120.12.000 2 22.000 7 65. This is the additional 6 7 8 $ $ Divide line 8 by the number in 2012. Theaverage timeandexpensesequired complete r to andfilethisformwillvarydepending onindividual circumstances.250 1.001 375. charitable contributions. Forestimated averages.15. seethe instructions yourincome for tax return. page 1 (or from line 10 above if you used the Deductions and Adjustments Find the number 1 below that applies to the LOWEST you are married filing jointly and wages from the highest paying job are $65. Complete 9 below to figure the additional 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract Multiply line 5 from line 4 .190.000 and over Enteron line 7 above $570 950 1.001 . Jobs Worksheet. 8 9 10 stop here and enter this total on Form W-4.000 .30. 4 Note.375.000 7 55. $ $ $ 6 7 8 9 10 Enter an estimate Subtract of your 2012 nonwage income (such as dividends or interest) 6 7 line 6 from line 5. ewouldbehappyto hearfromyou. your employer sesit to determine u yourfederalncome i taxwithholding.states. 505.001 . state and local taxes.40.o cities.000 14 135 001 and over 15 Privacy Act and Paperw( rk Reduction Act Notice.001 and over 10 85.000 than "3" 1 2 paying job and enter it here. Enter the result here and on Form W-4.000 6 50. Otherwise. Weaskfortheinformation onthis formto carryouttheInternal evenue R lawsoftheUnitedStates.000 5 40. Enter the number from line H. providing fraudulentnformation i maysubjectyouto penalties.001 -120.060 1.001 .950 if single or married filing separately line 2 from line 1. ooksor B records relating aformor ttsinstructions ustberetained to m aslongastheircontents may become materialntheadministrationf anyInternal evenue i o R law.commonwealths t t and andpossessions for useinadministering theirtaxlaws. page 1. These include qualifying home mortgage interest. Do not use the rest of this worksheet. For example. or less.65. and miscellaneous deductions .25.001 .000 8 80. page 1 Two-Earners/MultiDle Note. U.80.330 Enter on line 7 above $570 950 1.001 125.001 . in Table 2 below that applies to the HIGHEST of pay periods remaining Find the amount 5 6 7 8 9 5 paying job and enter it here annual withholding needed divide by 26 if you are paid line 7 by line 6 and enter the result here.85. Enter the result here (if zero. 505) any amount for credits in Pub. taxreturnsand returninformation areconfidential.700 if head of household $5.$5. page 1. enter "-0-" on Form W-4.000 6 48.001 .001 .001 -110.000 .000 9 9 72. page 1. enter "-0-" to income and any additional (Include standard deduction (see Pub.900 if married filing jointly or qualifying widow(er) Enter: Subtract Add $8. Use this worksheet and Adiustments Worksheet to income. We may also disclose this information to other t req Youarenotrequiredto providetheinformation uestedona formthatis subject o the Paperwork eduction ctunless R A theformdisplays avalidOMBcontrolnumber.001 190. line 5. heDistrictof Columbia. medical expenses in excess of 7.000 0 $0 .001 .000 8 65.65.Form W-4 (2012) Page 2 Deductions Note. every two weeks and you complete this form in December 2011. Drop any fraction Enter the number from the Personal Add lines 8 and 9 and enter the total here.001 .001 .97. asrequired Codesection by 6103. from the Converting Credits to 1 $ $ $ $ 2 3 { } 2 3 4 4 5 Enter an estimate of your 2012 adjustments lines 3 and 4 and enter the total.001 .S. subtract line 2 from line 1. a t Ifyouhavesuggestions making for thisformsimpler. line 5.330 $0 .000 4 30. Withholding Allowances for 2012 Form W-4 worksheet 5 .170. lines 4 through withholding amount necessary to avoid a year-end tax bill. do not enter more 2 3 3 If line 1 is more than or equal to line 2. Routine usesof thisinformation include givingit to theDepartment ofJusticefor civilandcriminal litigation.$70.125.001 .Generally.000 .250 1.andto theDepartment Health of andHuman Services for use in the National Directory of New Hires.30.001 .001 170. only if you plan to itemize deductions or claim certain credits or adjustments 1 Enter an estimate of your 2012 itemized deductions.5% of your income.001 .000 11 97.000 .000 . countries undera taxtreaty. w Seetheinstructions yourincome return.001 .000 0 5.001 90.800 and enter the result here. Use this worksheet 1 Jobs Worksheet (See Two earners or multiole lobs on oaae 1. line H.48. line 5. If you plan to use the Two-Earners/Multiple also enter this total on line 1 below. enter "-0-") and on Form W-4.55.001 . This is the additional amount to be withheld from each paycheck 9 $ Table 1 Married Filing Jointly Enter on line 2 above All Others If wagesfromLOWEST payingjob areEnter on line 2 above Married Filing Jointly If wagesfromLOWEST payingjob areIf wages from HIGHEST paying job are$0 70.) Worksheet) if only if the instructions in Table under line H on page 1 direct you here.001 .120.) .001 . enter "-0-" Allowances Worksheet.to federal ndstateagencieso enforce a t federal ontax n criminal laws.000 25. nternal evenue ode I R C sections 3402(~(2) nd6109 andtheirregulationsequire a r youto provide thisinformation.000 13 120.orto federalawenforcement l andintelligence gencieso combatterrorism.060 1.000 4 30. for tax .001 .000 2 15.40.90.$8.001 . If zero or less. line 6.001 . If zero or less.001 .95.000 3 3 25.001 .50.72. page 1 . Failure provide to a properly completed formwillresultin yourbeingtreatedasasingleperson whoclaimsno withholding allowances.$35.000 5 40.001 340.000 95. However.000 1 12.000 1 8. If line 1 is less than line 2.000 12 110.135. Divide the amount on line 7 by $3. $11.340.

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