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: _______________

Date:
GA4-2012

EMPLOYMENT PROFILE
Authorization Form to be Fully Completed & Signed

Human Resource ProFile, Inc.

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

r n !I
Name

,I', 11Il'''

~ ~. l r

L'

nil!.

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

Print Clearly

*****

INDIVIDUAL INFORMATION
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

__
Month

1----.-1__
Day Year

is used for identification

purposes ONLY. License #

Driver's License State of Issuance

License: Type

State

SCHOOLS ATTENDED School Name

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

Dates

I Frnrn

Tn

Graduate? Y/N

Degree Type Earned

City/State/Campus/Phone

Number

Graduate?

Degree Type Earned

Name used at time of graduation

or final attendance:

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

City/State/Campus/Phone

Number

From

To

Graduate?

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

Yes

No

Year

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

City

City, County, and State of Offense County

State

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:

_ _
History

From:

Acumen Customer Service

Acct #

ACUFA-OOl

Phone: 866-522-8636

I]] Conviction

Employment History Federal District

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

0 Credit

0 MVR

o
o

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

FlIlploymrll!

"\l'l'Cl'lIill!!

IMPORTANT DISCLOSURE

Please read before completing and signing the Applicant ProFile.

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. 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. I ALSO ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS STATEMENT.

Signature

Date -----------------

*This form needs to be signed and dated by the employee.

Human Resource ProFile, Inc.

8506 Beechmont Avenue * Cincinnati, OH 45255-4708 * 800-969-4300 * 513/388-4300 * Fax 513/388-4320

09101

OMB No. 16150047; Expires 08/31/12 Department of Homeland Security U.S. Citizenship and Immigration Services

Form 1-9, Employment Eligibility Verification

Read instructions carefully before completing tbis form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. Section 1. Employee Information
Print Name: Last

and Verification
First

(To be completed and signed by employee at the time employment begins.)

Middle Initial Maiden Name

Apt. #

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, 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
mployec's Signature

Preparer
penalty

and/or Translator
that I have assisted

Certification
in the completion

of perjury,

(To be completed and signed if Section I is prepared by a person other than the employee.) I attest. under 0/ this form and that to the best of my knowledge the in/onnation is true and correct. 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, uuder penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) st of m knowledge the employee is authorized to work in the United States. (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. City, State, Zip Code) Date (monthldaylyear)

Employer write your address here

Section 3. Updating and Reverification

A. New Name (ifapplicable)

(To be completed and signed by employer.)

B. Date of Rehire (monthldaylyear) (ifapplicable)

C. If employee's

previous

grant of work authorization

has expired.

provide

the information

below for the document

that establishes

current employment

authorization.

Document Title:

Document #:

Expiration Date (if any):

employee presented

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and iftbe document(s), the document(s) ) have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date

(monthldaylyear)

Employer write the date here

LISTS OF ACCEPTABLE
LIST A Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card LlSTB

DOCUMENTS
LlSTC Documents that Establish Employment Authorization AND

All documents must be unexpired

Documents that Establish Identity OR 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2. Permanent Resident Card or Alien

Registration Receipt Card (Form 1-551)

1. 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. Certification of Birth Abroad 2. ID card issued by federal, state or 3. 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, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address issued by the Department of State (Form FS-545)

3. Certification of Report of Birth

issued by the Department of State (Form DS-1350)

4. Employment Authorization Document

that contains a photograph (Form 1-766)

3. School ID card with a photograph 4. Voter's registration card

5. U.S. Military card or draft record
6. Military dependent's ID card

4. Original or certified copy of birth

certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. In the case of a nonimmigrant alien

authorized to work for a specific employer incident to status, 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, 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. U.S. Coast Guard Merchant Mariner

Card 8. Native American tribal document

5. Native American tribal document

9. Driver's license issued by a Canadian

government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record

6. U.S. Citizen ID Card (Form 1-197)

6. 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. 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)

AUTHORIZATION FOR DIRECT DEPOSIT

Payroll Agent: Acumen Fiscal Agent, LLC 4542 E.lnvemess Ave., Suite 210 Mesa, AZ 85206 Phone: Fax: 866-522-8636 877-522-8636

I hereby authorize Acumen Fiscal Agent, LLC, hereinafter called Company, to initiate credit entries and, if necessary,

debit entries for the purpose of correcting an erroneous credit previously initiated to my account indicated below. I further authorize the Financiallnstitution named below to accept such entries and to credit or debit the amount thereof to such account. You can have your check deposited into more than one 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. Please note: When depositing to multiple accounts, the percentage total must be 100%. Any changes to
your account(s) must be submitted immediately! When you submit a change, please be aware the next 1-2 paychecks will not be direct deposited to your old account .Paper checks will mailed to your address of record until the new account is authorized. 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. 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. 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.

Print Name

Social Security Number

Signature

Date

Phone Number

Authorization will take effect not less than 10 days after acceptance by Financial Institution.

COMP
April 2012

PAY SELECTION OPTION FOR EMPLOYEE Acumen Fiscal Agent offers three pay receipt options. You may choose a pay card, direct deposit or check.
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. To take advantage of the safety, dependability and convenience of pay cards, check the pay card option below and sign the authorization statement.

Pay Card Option

I choose to have my pay deposited directly to my pay card. My Money Network Visa pay card and information kit will be mailed to my home address. My net pay will be deposited onto the pay card each payday. I understand that I am responsible for notifying Acumen when my pay card is activated. 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. I will complete the Authorization for Direct Deposit and return to payroll along

with this Pay Selection Agreement.

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 hereby authorize Acumen Fiscal Agent, LLC. (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. Further, I authorize Bank to accept and credit any credit entries indicated by Company to my account. In the event that Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit. 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. Employee Signature Name Address City Social Security Number Birth date State _ ,Zip, Date _ _ _ _

_1 __1

_
_

Cell Phone # HomeFax#

_ _

Home Phone #

ALWAYS CHECK YOUR PAY STUB OR YOUR ACCOUNT TO VERlFY THAT YOUR
DEPOSIT HAS POSTED.
++++++++++++++++++++++For
Paycard ABA # 084003997

Payroll

Use Only ++++++++++++++++++++++++++

_

Paycard #

GEORGIA COMP Program Employee Rate Form

In efforts to ensure proper payment, please provide Acumen with the following information so your employee is paid the correct rate for the service(s) provided. Please consult the "Show Me the Money" sheet for rate information and the "Georgia COMP Program Code Descriptions" for service code information. 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: $, 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, 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, LLC 4542 East Inverness Ave, Suite 210 Mesa, Arizona 85206

I
GACOMP April 2012

Form G-4 (Rev. 12/09)

STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE

1a. YOUR FULL NAME 2a. HOME ADDRESS (Number, treet,or RuralRoute) S

CERTIFICATE

1b. YOUR SOCIAL SECURITY NUMBER 2b. CITY, STATE AND ZIP CODE
LINES 3 - 8

PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING

3. MARITAL STATUS (If you do not wish to claim an allowance, enter "0" in the brackets beside your marital status.) A. Single: Enter 0 or 1 [ ] 4. DEPENDENT ALLOWANCES B. Married Filing Joint, both spouses working: Enter 0 or 1 or 2 [ C. Married Filing Joint, one spouse working: 5. ADDITIONAL ALLOWANCES Enter 0 or 1 or 2 [ (worksheetbelow must be completed) D. Married Filing Separate: Enter 0 or 1 or 2 [ E. Head of Household: 6. 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. A. B.

1.

0 Age 65 or over

0 Blind 0 Blind

Number of boxes checked

x 1300 $

$. _ _

ADDITIONAL ALLOWANCES FOR DEDUCTIONS: Federal Estimated Itemized Deductions Georgia Standard Deduction (enter one): Each Spouse Single/Head of Household $1,500 $2,300 $.

C. Subtract Line B from Line A D. Allowable Deductions to Federal Adjusted Gross Income E. Add the Amounts on Lines 1, 2C, and 2D F. Estimate of Taxable Income not Subject to Withholding G. Subtract Line F from Line E (if zero or less, stop here) H. Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above

$
$.

_
_ _

$-----$

_
_

(This is the maximum number of additional allowances you can claim. If the remainder is over $1 ,500 round up) 7. LETTER USED (Marital Status A, B, C, D, or E) TOTAL ALLOWANCES (Employer:The letter indicates the tax tables in the Employer'sTax Guide) (Total of Lines 3 - 5) _

8. EXEMPT: (Do not complete Lines 3 - 7 if claiming exempt) Readthe Line 8 instructions on page2 beforecompletingthis section. 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. 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. My state of residence is __ :---,-My spouse's (servicemember) state of residence is The states of residence must be the same to be exempt. 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. Also, I authorize my employer to deduct per pay period the additional amount listed above. Employee's Signature Date

Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding.

If necessary, mail form to: Georgia Department of Revenue, Withholding Tax Unit, P. O. Box 49432, Atlanta, GA 30359. 9. EMPLOYER'S NAME AND ADDRESS: EMPLOYER'S FEIN: EMPLOYER'S WH#: Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not accept forms claiming exempt if numbers are written on Lines 3 - 7.

_ _

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

Application for Employment

Personal Information
Date Name Last Address First Middle _ _ _

Phone Number

Social Security No.

Position

Date you can start

Wage Desired

Employment Eligibility: To be employed with the State of Georgia, you must meet certain State and Federal employment eligibility requirements. These include, but not limited to, United States citizenship or authorization to work in this country, and no felony convictions. 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, Field of Study College? If yes, Degree Yes No Yes No

# of months.
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

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) _ *Basic First Aid Training Certificate _ Yes _ NO If yes, expiration date ( mo/yr) _ Nurse Aide Certification Yes No If yes, 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. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if employer has employed me, no matter when discovered by employer. I authorize this potential employer to investigate all statements contained in this application, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation, without giving me prior notice of such disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or this employer. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon this employer unless made in writing.

Signature

Date

Narne:

Page 2 of2

ACUMEN

STATEMENT OF COMMUNITY SERVICE WORKER (EMPLOYEE) PARTICIPATION

THIS STATEMENT OF PARTICIPATION is between Acumen Fiscal Agent, 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, Division of Medical Assistance (the Department). WHEREAS, 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, as amended, and O.C.G.A. 49-4-1 et seq.; WHEREAS the Department has contracted with Provider to enroll qualified Community Service Workers (Employees) to render services to eligible Medicaid Recipients; 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, 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; WHEREAS, 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, the Department, through the Provider is the source of payment to the Employee. Therefore, 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, 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, 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 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, 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; and WHEREAS, 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.

Page 1 of6

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree to the terms and conditions named herein as follows: 1. THE PROVIDER'S OBLIGATIONS

A. Legal Compliance. The Provider shall adhere to all applicable provisions of federal and state laws and regulations, Rules of the Department, and all of the Department's Policies and Procedures manuals governing the Medicaid program, and any amendments thereto (collectively, the "Department's requirements"). B. Reimbursement to Employees. The Provider shall reimburse Employees for claims that are submitted in compliance with the Department's and Provider's requirements, and in such amounts allowed under the Medicaid program as administered by the Department. C. Modifications to Department's Policies and Procedures. 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. 2. THE EMPLOYEE'S OBLIGATIONS A. Legal Compliance. 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, including Part I, Part n and the applicable Part illmanuals. The term "Employee" shall include those persons or entities performing services under the supervision or other direction of Employee, and all acts or omissions of such persons or entities shall be attributed to Employee. B. Employee Enrollment and Continued Participation. 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, including but not limited to completion of all enrollment forms, cooperation with site audits, and the following:

.L. Certification of Employee Information. Employee certifies that aU statements and

information furnished to the Department and Provider for enrollment and continued participation are true and complete, and recognizes that the Department and the Provider will rely on such information to evaluate Employee's participation under the Medicaid program. Employee shall give the Provider written updates to information previously submitted, and advance notice of changes when required by the Provider in this Statement of Participation and the Department's or Provider's requirements.

b.. Disclosure. Employee authorizes the Department and Provider to request,

copy, access, 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 laws which may deem such records or parts of such records privileged or confidential. Employee's records and information may be requested from or exchanged with any source, including but not limited to the Composite State Board of Medical Examiners, any federal or state governmental agency, accreditation agency, licensing agency, regulatory body, certifying agency, or any other person or entity, subject to any applicable state or federal law limiting the distribution of such information Employee's authorization to request, copy, access, use and share records and other information includes but is not limited to disclosure of ownership or control interests, and of any criminal offenses related to any federal or state health care program. This disclosure provision shall exclude sanctions against Employee that are protected by private order of the issuing board or agency

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J.,

License/Certification. Employee shall possess and maintain in good standing and without restriction valid professional, occupational, facility or other license and/or certification that is necessary for rendering Covered Services in the selected category(ies) of service, and as required by the Department. Employee shall provide the Department Provider with written copies of licenses and/or certifications upon request. Except where disclosure is protected by private order of the issuing board or agency, 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. Hold Harmless. Employee releases from liability and holds harmless the Department,
Provider, their agents, and any and all individuals and entities who, in good faith, 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, and other matters pertinent to Employee's status and duties in connection with this Statement of Participation. This provision shall survive termination or expiration of this Statement of Participation for any reason. A. Claims Submission; Certification of Claims. Employee shall submit claims for Covered Services rendered to eligible Medicaid recipients in the form and format designated by the Provider. For each claim submitted by or on behalf of Employee, Employee shall certify each claim for truth, accuracy and completeness, and shall be responsible for research and correction of all billing discrepancies without cost to the Provider. This provision shall survive termination or expiration of this Statement of Participation for any reason.

B.

Recipient Records. Employee shall maintain in an orderly manner and ensure the confidentiality of all original source documents, medical records, identifying recipient data, and any copies thereof, as may be necessary to fully substantiate the nature and extent of all services provided. Records shall be retained for a minimum of five (5) years from the date of service, or longer as required by state or federal law. Upon request by the Department, Provider, their agents, and any authorized agency including but not limited to the U.S. Department of Health and Human Services, the Comptroller General, the State Auditor, State Attorney General's Office or office of any Georgia District Attorney and their authorized representatives, Employee shall disclose and provide legible copies to the requestor, or permit the requestor to copy, without cost, all Medicaid-related documents, records or data. 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. Employee's failure to abide by this provision may constitute grounds for disallowance of all applicable charges, recoupment of corresponding payments, and/or termination of Employee's participation. This provision shall survive termination or expiration of this Statement of Participation for any reason.

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C.

Covered Services. Employee shall render Covered Services, as defined in the Department's Policies and Procedures manuals, to eligible Medicaid recipients that are medically necessary as defined by the Department, in accordance with the Individual Service Plan, within the parameters permitted by Employee's license or certification, and within the category(ies) of service indicated in the Employee Enrollment documents. By submitting claims for reimbursement, Employee certifies that Covered Services were in accordance with Individual Service Plan and rendered in the amount, duration, scope and frequency indicated on the claims. Employee shall not discriminate against any recipient on the basis of race, color, national origin, religion, sex, marital status, age, disability, health status, or source of payment.

D. Reimbursement for Covered Services. Reimbursement for Covered Services performed shall be made in a form and format designated by the Provider. Payment shall be made in conformity with the provisions of the Medicaid program, applicable federal and state laws, rules and regulations promulgated by the U.S. Department of Health and Human Services and the State of Georgia, and the Department's Policies and Procedures manuals in effect on the date the service was rendered. Such reimbursement shall constitute payment in full for Covered Services rendered, and Employee shall not bill, accept or seek payment from eligible Medicaid recipients, Without cost to the Department, Provider, or their agents, Employee agrees to cooperate with refund and recoupment efforts of the Department Employee agrees that the Provider shall not reimburse any claim, or portion thereof, for services rendered prior to the effective date of enrollment indicated by the Provider or for which federal financial participation is not available. Employee acknowledges that payment of claims submitted by or on behalf of Employee will be from federal and state funds, and the Department or Provider may withhold, recoup or recover payments as a result of Employee's failure to abide by the Department's or Provider's requirements. This provision shall survive termination or expiration of this Statement of Participation for any reason. E. Prohibition on Reassignment. 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, such as a collection agency or service bureau, that advances money based on future Medicaid payments (accounts receivable) due to Employee after agreeing to sell, transfer or assign such rights to payment to the individual or organization for an added fee or a percentage of the accounts receivable. Furthermore, payment to the payee or billing service for services rendered shall be related to the cost of processing, and shall not be based on the payments due to Employee or based upon the percentage of claims processed. Indemnification. Employee shall indemnify and hold harmless the Department, Provider, and their agents from all causes of action, claims, suits, judgments, or damages, including court costs and attorneys' fees, arising out of the misconduct, negligence or omissions of Employee in the course of participating in the Medicaid program, including but not limited to the provision of services to an eligible Medicaid recipient or a person believed to be a recipient. 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 agrees to reimburse the funds for such monies paid out by such funds. Tills provision shall survive

F.

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termination or expiration of this Statement of Participation for any reason

3.

TERM; TERMINATION A. 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. The Provider has the right to terminate this Agreement at any time with or without cause under applicable laws, rules or regulations B. Termination by Employee. Unless otherwise authorized by the Provider or by law,

Employee shall inform Medicaid Recipient and give ten (10) days prior written notice to
the Provider of voluntary termination. C. Termination by Medicaid Recipient. The Medicaid Recipient is the employer of record of Employee. Medicaid Recipient may terminate Employee with or without cause in accordance with the State of Georgia's employment laws and regulations.

D. Termination under Other Programs. 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, including but not limited to exclusions from or licensure restrictions or conditions by other federal or state authorities, plans or programs. The Provider shall issue written notice of termination to Employee to be effective on the date indicated therein. The Provider also may notify other state and federal authorities, plans or programs of Employee's enrollment status in the Medicaid self-directed program, including other plans or programs within the Department. Termination under the Medicaid program may result in Employee's termination under other federal and state plans or programs. E. Termination for Unavailability of Funds. Notwithstanding any other provision hereof, in the event that funds are no longer appropriated for the Department, Division of Medical Assistance by the General Assembly of the State of Georgia or from the Congress of the United States of America, 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 ($100.00), then this Statement of Participation shall terminate immediately without further obligation to or by the Department or Provider. The certification by the Commissioner of the Department of the occurrence of either of the events stated above shall be conclusive. The Provider will attempt to provide Employee with ten (10) days notice of the possible occurrence of events described in this provision.

GENERAL PROVISIONS A. Notice. All mailed notices shall be issued to the Employee's address on record with the Provider as of the date of such notice. Waiver of Breach. 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. Conflict of Interest. The parties certify that the provisions of O.e.G.A. 45-10-20 et seq., as amended, and 41 U.s.e. 423 regarding conflicts of interest have not and will not be violated in any respect.

B.

e.

D. Headings. 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.

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E.

Governing Law. This Statement of Participation shall be governed by and construed in accordance with the laws of the State of Georgia. Assignment. Employee may not assign any right or obligation under this Agreement without the prior written consent of the Provider

F.

G. Amendments. Except as otherwise specifically provided herein, amendments or modifications to this Statement of Participation shall be in writing and signed by each party. H. Independent Relationship. 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. 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. Neither the Department, the Provider, nor Employee is or shall be considered an employer, employee, agent, partner or joint venture of the other. Binding Authority. 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.

L Entire Agreement. This Statement of Participation, together with the Department's and
Provider's Policies and Procedures manuals, all enrollment documents, and any amendments thereto, shall constitute the entire agreement between the parties with respect to the subject matter contained herein, and shall supersede all previous communications, representations, or agreements, either verbal or written, between the parties.

IN WITNESS WHEREOF, Employee executes this Statement of Participation in person, or as an authorized party on behalf of an entity, to become effective on the date indicated by the Provider.
By signing below, I attest that I have read this "Statement of Community Service Worker (Employee) participation" agreement in its entirety (6 pages). 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. I further attest by signing below, that Iunderstand what is being requested of me, and agree to abide by its terms and conditions. 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. Accepted and authorized on this day of , in the year _

Employee Name (Printed)

Employee's Signature

ACUMEN (the ''Provider'') Accepted and authorized on this day of , in the year _

Please fax this completed page to 877-522-8636 or mail to Acumen at 4542 E Inverness Ave, Suite 210, Mesa, AZ 85206

Page 6 of6

The EMPLOYEE completes this form.

Form W-4 (2012)

Purpose. Complete Form W4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial
situation changes.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a Hat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmanied and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information; for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or
dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on

income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the
form to validate it. Your exemption for 2012 expires

for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,

February 18, 2013. See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends). Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-eamers/rnuhjple jobs situations.

see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this fomn. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2012. See Pub. 505, especially if your eamings exceed $130,000 (Single) or $180,000 (Married). Future developments. The IRS has created a page on IRS.gov for infomnation about Fomn W-4, at www.irs.govlw4. Infomnation about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page.

converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity

Personal Allowances
A B
Enter"1" for yourself

Worksheet

(Keep for your records.)

A
} does not work; or spouse or more

if no one else can claim you as a dependent.

You are single and have only one job; or Enter "1" if: Enter"1" { You are married, have only one job, and your spouse Your wages /rom a second job or your spouse's wages (or the total of both) are $1,500 or less. and have either a working . .

C
D

for your spouse.

But, you may choose

to enter "-0-" if you are married

than one job. (Entering" Enter number

-0-" may

help you avoid having too little tax withheld.) 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. Child

on your tax return (see conditions or dependent care expenses

E
F

"1" if

you have at least $1 ,gOO of child support additional

child

for which

you plan to claim a credit Care Expenses, for details.)

Do not include Tax Credit

payments.

See Pub. 503, Child and Dependent ($90,000 if married),

(including

child tax credit).

See Pub. 972, Child Tax Credit, children .

for more information. child; then less "1" if you have three to

If your total income seven eligible children

will be less than $61,000

enter "2" for each eligible

or less "2" if you have eight or more eligible

Add lines A-G. Write the number here.

If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter "1" for each eligible child Add lines A through

G and

enter total here. (Note. This may be different from the number of exemptions to income

you claim on your tax retum.) ~

If you plan to itemize or claim adjustments and Adjustments Worksheet on page 2. (

and want to reduce your withholding,

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 $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Keep the top pari for your records. ---------------------------------OMB No. 1545-0074

arate here and give Form W-4 to your employer.

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. Your employer may be required to send a copy of this form to the IRS. Your first name and middle initial Last name 2

Your social security number

Home address (number and street or rural route)

0 Single

0 Married 0 Married, but withhold

at higher Single rate.

Note. If married,but legallyseparated,or spouseis a nonresidentalien,checkthe "Single"box. City or town, state, and ZIP code
4

If your last name differs from that shown on your social securtly card, check here. You must call 1-800-n2-12t3 for a replacement card. ~

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,

if any, you want withheld from

L6=-+'-both of the following conditions for exemption. and '-and complete. because I expect

I claim Sign your name here.

exemption

withholdinq

for

2012, and I certify

income income here.

I meet

Last year I had a right to a refund This year I expect a refund If you meet both conditions,

of all federal

tax withheld because

I had

no tax liability, ~

of all federal write "Exempt"

tax withheld

to have no tax liabril....;ity"i. 7

Ities of perjury, I declare that I have examined Employee'S signatur (This form is not valid unless you sign it.) ~ 8

this certificate

and, to the best of my knowledge

and belief, it is true, correct,

Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

9 Officecode(optional) 10

For Privacy

Act and Paperwork

Reduction

Act Notice,

see page

2.

Cat. No. 10220Q

Form

W-4 (2012)

Form W-4 (2012)

Page 2

Deductions
Note. Use this worksheet

and Adiustments

Worksheet
to income.

only if you plan to itemize deductions

or claim certain credits or adjustments

Enter an estimate of your 2012 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions . $11,900 if married filing jointly or qualifying widow(er) Enter: Subtract Add $8,700 if head of household $5,950 if single or married filing separately line 2 from line 1. If zero or less, enter "-0-" to income and any additional (Include standard deduction (see Pub. 505) any amount for credits in Pub. 505.) . from the Converting Credits to

$ $ $ $

2
3

2 3
4

4
5

Enter an estimate of your 2012 adjustments lines 3 and 4 and enter the total.

Withholding Allowances for 2012 Form W-4 worksheet

5
.

$
$ $

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. If zero or less, enter "-0-" Allowances Worksheet, line H, page 1 . Jobs Worksheet,

Divide the amount on line 7 by $3,800 and enter the result here. Drop any fraction Enter the number from the Personal Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple also enter this total on line 1 below. Otherwise,

8 9 10

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

Two-Earners/MultiDle
Note. Use this worksheet 1

Jobs Worksheet

(See Two earners or multiole lobs on oaae 1.)

Worksheet) if

only if the instructions

in Table

under line H on page 1 direct you here.

Enter the number from line H, 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 $65,000 than "3"

paying job and enter it here. However,

or less, do not enter more

2 3

If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter "-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet. lines 4 through withholding amount necessary to avoid a year-end tax bill. 4

Note. If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete

9 below to figure the additional

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 . 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. This is the additional

6 7 8

$ $

Divide line 8 by the number

in 2012. For example,

every two weeks and you complete this form in December 2011. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1
Married Filing 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 70,001 125,001 190,001 340,001 - $70.000 - 125,000 - 190,000 - 340,000 and over

Table 2
All Others If wages from HIGHEST paying job are$0 35,001 90,001 170,001 375,001 - $35.000 - 90,000 - 170,000 - 375,000 and over Enteron line 7 above $570 950 1,060 1,250 1,330 Enter on line 7 above $570 950 1,060 1,250 1,330

$0 - $5.000 0 $0 - $8.000 0 5.001 - 12.000 1 8.001 - 15,000 1 12,001 - 22,000 2 15,001 - 25,000 2 22,001 - 25,000 25,001 - 30,000 3 3 25,001 - 30,000 4 30,001 - 40,000 4 30,001 - 40,000 5 40,001 - 50,000 5 40,001 - 48,000 6 50,001 - 65,000 6 48,001 - 55,000 7 65,001 - 80,000 7 55,001 - 65,000 8 80,001 - 95,000 8 65,001 - 72,000 95,001 -120,000 9 9 72,001 - 85,000 10 120,001 and over 10 85,001 - 97,000 11 97,001 -110,000 12 110,001 - 120,000 13 120,001 - 135,000 14 135 001 and over 15 Privacy Act and Paperw( rk Reduction Act Notice. Weaskfortheinformation onthis formto carryouttheInternal evenue R lawsoftheUnitedStates. nternal evenue ode I R C sections 3402(~(2) nd6109 andtheirregulationsequire a r youto provide thisinformation; your employer sesit to determine u yourfederalncome i taxwithholding. Failure provide to a properly completed formwillresultin yourbeingtreatedasasingleperson whoclaimsno withholding allowances; providing fraudulentnformation i maysubjectyouto penalties. Routine usesof thisinformation include givingit to theDepartment ofJusticefor civilandcriminal litigation;o cities,states, heDistrictof Columbia, U.S.commonwealths t t and andpossessions for useinadministering theirtaxlaws;andto theDepartment Health of andHuman Services
for use in the National Directory of New Hires. We may also disclose this information to other

t req Youarenotrequiredto providetheinformation uestedona formthatis subject o the Paperwork eduction ctunless R A theformdisplays avalidOMBcontrolnumber. ooksor B records relating aformor ttsinstructions ustberetained to m aslongastheircontents may become materialntheadministrationf anyInternal evenue i o R law.Generally. taxreturnsand returninformation areconfidential, asrequired Codesection by 6103. Theaverage timeandexpensesequired complete r to andfilethisformwillvarydepending onindividual circumstances. Forestimated averages, seethe instructions yourincome for tax
return.

countries undera taxtreaty,to federal ndstateagencieso enforce a t federal ontax n criminal laws,orto federalawenforcement l andintelligence gencieso combatterrorism. a t

Ifyouhavesuggestions making for thisformsimpler. ewouldbehappyto hearfromyou. w Seetheinstructions yourincome return. for tax