employment packet checklist: acquired brain injury (abi ... · per the ct department of social...

F32 –V 05/01/13

Date: From:

Fax to: 860-627-0230 # of Pages:

Employment Packet CHECKLIST: Acquired Brain Injury (ABI) Waiver

Please refer to this checklist when completing the required paperwork before submitting for processing. All forms must be filled out completely and signed where required. There will be a delay in processing if all necessary forms are not submitted or received completely. If you have any questions or need assistance, please contact the Provider Services department at the number above. Once the application has been received and processed, you will be notified by our staff. Please refer to the following page for an explanation of the forms included in this packet. Please use this page as a cover sheet when mailing or faxing your forms to Allied. 1. DSS Provider Information Manual Acknowledgement Form (must be signed

by employee and employer and returned within 30 days of the hire date)

2. Employment Status Form (must be completed and signed by the employee & employer)

3. I-9 Employment Eligibility Verification (Section 1 must be filled out and signed by the employee. Section 2 must be completed and signed by the employer who must verify the eligibility documents presented and record under the appropriate List in Section 2)

a. Clear and Legible Copies of Eligibility Documents (see the List of Acceptable Documents included in this packet)

4. Form CT-W4 Employee’s Withholding Certificate (must be signed by the employee) - if Box 1 is left empty, the standard deduction will automatically apply

5. W-4 Employee’s Withholding Allowance Certificate (must be signed by the employee) - if Box 3 is not checked, the standard deduction will automatically apply

Optional:

6. Direct Deposit Application (Must be completed and signed by the employee to authorize electronic funds transfer)

(Over for explanation of forms)

FMS-Applications Department P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll-Free: 877-722-8833 www.acrfi.org

F32 –V 05/01/13

Explanation of Forms

Timesheets WILL NOT be processed and payment WILL NOT be authorized before

these forms have been completed, submitted to Allied Community Resources and the employer has received notification from Allied as to the effective date of hire.

Please Note: All potential employees must be approved for services under the ABI

Waiver Program prior to being hired. 1. DSS Provider Information Manual Acknowledgement: After the employee has read the DSS Provider Information Manual, this form must be signed by both the employee and the employer and returned within 30 days of the hire date. Failure to return the signed form by the deadline will result in suspension of employment. 2. Employment Status Form: The top portion is to be completed by the employee. The participant/employer must complete the boxed area. Both the employee and employer are required to sign this form. 3. Employment Eligibility Verification, Form I-9: The employee is to complete Section 1 of the form, sign and date it. The employer or legally authorized representative is to complete Section 2 (list the documents, numbers and expiration dates of IDs presented) and sign and date the form. The list of acceptable documents for identification and employment eligibility are included in this packet. Legible copies of the documents are required.

4. Form CT W-4 Employee’s Withholding Certificate: Required to be completed by any employee to have CT state taxes withheld from their earnings.

5. W-4 Employee’s Withholding Allowance Certificate: Required to be completed by any employee to have Federal taxes withheld from their earnings.

6. Direct Deposit Application (optional)

: Completion of this form by the employee will authorize their earnings to be deposited into their personal bank savings or checking account. Direct Deposit may take up to two pay cycles to be established. **As an option, we offer information regarding Debit Cards. Please call our Customer Service department to request an enrollment form.

NEW EMPLOYERS - your employees MUST complete the forms listed and submit them to Allied Community Resources before a plan START date will be issued. Current EMPLOYERS with NEW HIRES - your employee MUST complete this packet and undergo a criminal history background check prior to working for you. The completed packet must be submitted to Allied Community Resources in order to confirm the date of hire.

FMS-Provider Services P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

F259-04/24/13

Dear Employer, Per the CT Department of Social Services, all employees are required to read the DSS Provider Information Manual that has been provided to you. As an employer on a DSS Waiver Program, you are responsible to ensure that your employees read the manual within 30 days of the date of hire confirmed with you by ACR staff. Once the manual has been read through by your employee, have him/her sign the acknowledgement form below along with your signature and return it to our office so that we may update our records with affirmation that this new progam requirement has been fulfilled. Please note: active employment will be suspended if the signed acknowledgement form is not received by the due date. If your employee states that they have previously read the manual, please indicate as such, sign and return the entire form.

Name of Employee:

Please enter the hire date confirmed with you by ACR:

The due date is: (Please return to Allied before this date.)

Acknowledgement form on file

DSS PROVIDER INFORMATION MANUAL - Acknowledgement Employee Printed Name: Date: I have read and understand the content contained within the DSS Provider Information Manual. I understand the importance of this information and will perform to the best of my ability, the standards expected of a provider of this type of care under the CT Department of Social Services State Waiver Programs, ABI (Acquired Brain Injury), PCA (Personal Care Assistance) and CHCPE (Connecticut Home Care Program for Elders) or Money Follows the Person (MFP).

Employee Signature:

Employer Name (Please Print):

Employer Signature:

This form is not valid unless signed by both the employee and the employer.

F57-V 06/04/15

EMPLOYMENT STATUS FORM

Use this form to establish a rate of pay for the service to be performed, request a change in the hourly rate of pay or process a termination of employment. Please clearly print or type the requested information. You must complete, sign and return a form for each individual employee.

Section 1: Employee information Program Participant (Employer) Name: Employee Full Name:

Date of Birth: (mm/dd/yyyy) Social Security #: _______-______-_________

Employee Legal Signature Date Signed

*Employee is related to: Employer ____ Conservator ____ Participant ____ No Relation ____ *Check as many as apply.

Relationship Type: Parent ____; Spouse _____; Son/Daughter ____; Other* ____

*Please specify: ____ ____________________ ______


Toll Free: 877-722-8833 www.acrfi.org

Section 2: To be completed and signed by Employer

Check One: New Hire Rehire Rate Change* Termination of employee** Service Description: Hourly Rate:

Service Description: Hourly Rate:

Service Description: Hourly Rate:

*Effective Date of Rate Change will be the first day of the current pay cycle after the form is received. Service Description: New Hourly Rate:

Service Description: New Hourly Rate:

**Date of Termination: Voluntary Involuntary

Program Participant (Employer) or Legal Representative Signature Date Signed

For Office Use Only

PCA ECP ABI ABI II MFP BRS CFC PAY CYCLE: Odd ________ Even ________ *Database Update: Initials: *Payroll Entry Date: Initials:

Employee # *FILE WHEN COMPLETED BY BOTH

For Office Use Only

Allied will call employer to confirm:

Date of Hire: _______________

Processor Initials: ___________

Employees will not be paid for shifts worked before this date.

Employees: See Employee General Instructions on Page 2. Sign and return Form CT-W4 to your employer. Keep a copy for your records.1. Withholding Code: Enter Withholding Code letter chosen from above. ....................... 1.

2. Additional withholding amount per pay period: If any, see Page 3 instructions. . ......... 2. $

3. Reduced withholding amount per pay period: If any, see Page 3 instructions. ............ 3. $

Form CT-W4Employee’s Withholding Certifi cate

Department of Revenue ServicesState of Connecticut(Rev. 12/14)

Effective January 1, 2015

Employee Instructions• Read instructions on Page 2 before completing this form.• Select the fi ling status you expect to report on your Connecticut

income tax return. See instructions.

• Choose the statement that best describes your gross income. • Enter the Withholding Code on Line 1 below.

Check if you are claimingthe MSRRA exemption and enter state of legal residence/domicile:_____________________

Employers: See Employer Instructions on Page 2.

Complete this form in blue or black ink only.

Declaration: I declare under penalty of law that I have examined this certifi cate and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for reporting false information is a fi ne of not more than $5,000, imprisonment for not more than fi ve years, or both.

Is this a new or rehired employee? No Yes Enter date hired:mm/dd/yyyy

( )

* If you are claiming the Military Spouses Residency Relief Act (MSRRA) exemption, see instructions on Page 2.

Our expected combined annual gross income is less than orequal to $24,000 or I am claiming exemption under the Military ESpouses Residency Relief Act (MSRRA)* and no withholding is necessary.

My spouse is employed and our expected combined annual gross income is greater than $24,000 and less than or equal Ato $100,500. See Certain Married Individuals, Page 2.

My spouse is not employed and our expected combined Cannual gross income is greater than $24,000.

My spouse is employed and our expected combined Dannual gross income is greater than $100,500.

I have signifi cant nonwage income and wish to avoid having Dtoo little tax withheld.

I am a nonresident of Connecticut with substantial other income. D

Withholding Code

My expected annual gross income is less than or equal to$24,000 or I am claiming exemption under the MSRRA* and Eno withholding is necessary.

My expected annual gross income is greater than $24,000. CI have signifi cant nonwage income and wish to avoid having too Dlittle tax withheld.


Withholding CodeQualifying Widow(er) With Dependent Child

Married Filing Jointly My expected annual gross income is less than or equal to $12,000 or I am claiming exemption under the MSRRA* and Eno withholding is necessary.

My expected annual gross income is greater than $12,000. AI have signifi cant nonwage income and wish to avoid having Dtoo little tax withheld.


Withholding Code

My expected annual gross income is less than or equal to E$15,000 and no withholding is necessary.

My expected annual gross income is greater than $15,000. FI have signifi cant nonwage income and wish to avoid having Dtoo little tax withheld.


Withholding Code

My expected annual gross income is less than or equal to E$19,000 and no withholding is necessary.

My expected annual gross income is greater than $19,000. BI have signifi cant nonwage income and wish to avoid having Dtoo little tax withheld.


Withholding Code

Married Filing Separately

Single

Head of Household

First name Ml Last name Social Security Number

Home address (number and street, apartment number, suite number, PO Box)

City/town State ZIP code

Employee’s signature

Employer’s business name Federal Employer Identifi cation Number

Employer’s business address

City/town State ZIP code

Contact person Telephone number

Employee General InstructionsForm CT-W4, Employee’s Withholding Certifi cate, provides your employer with the necessary information to withhold the correct amount of Connecticut income tax from your wages to ensure that you will not be underwithheld or overwithheld.You are required to pay Connecticut income tax as income is earned or received during the year. You should complete a new Form CT-W4 at least once a year or if your tax situation changes.If your circumstances change, such as you receive a bonus or your fi ling status changes, you must furnish your employer with a new Form CT-W4 within ten days of the change.Gross IncomeFor Form CT-W4 purposes, gross income means all income from all sources, whether received in the form of money, goods, property, or services, not exempt from federal income tax, and includes any additions to income from Schedule 1 of Form CT-1040, Connecticut Resident Income Tax Return or Form CT-1040NR/PY, Connecticut Nonresident and Part-Year Resident Return.Filing StatusGenerally, the fi ling status you expect to report on your Connecticut income tax return is the same as the fi ling status you expect to report on your federal income tax return. However, special rules apply to married individuals who fi le a joint federal return but have a different residency status. Nonresidents and part-year residents should see the instructions to Form CT-1040NR/PY. Check Your WithholdingYou may be underwithheld if any of the following apply:• You have more than one job;• You qualify under Certain Married Individuals and do not use the

Supplemental Table on Page 3 and Page 4; or• You have substantial nonwage income.If you are underwithheld, you should consider adjusting your withholding or making estimated payments using Form CT-1040ES, Estimated Connecticut Income Tax Payment Coupon for Individuals. You may also select Withholding Code “D” to elect the highest level of withholding.If you owe $1,000 or more in Connecticut income tax over and above what has been withheld from your income for the prior taxable year, you may be subject to interest on the underpayment at the rate of 1% per month or fraction of a month. You may be overwithheld if your combined annual income is more than $200,000 but less than $700,000 and your Connecticut fi ling status is fi ling jointly. To help determine if your withholding is correct, see Informational Publication 2015(7), Is My Connecticut Withholding Correct?

Nonresident Employees Working Partly Within and Partly Outside of ConnecticutIf you work partly within and partly outside of Connecticut for the same employer, you should also complete Form CT-W4NA, Employee’s Withholding or Exemption Certifi cate - Nonresident Apportionment, and provide it to your employer. The information on Form CT-W4NA and Form CT-W4 will help your employer determine how much to withhold from your wages for services performed within Connecticut. To obtain Form CT-W4NA, visit the Department of Revenue Services (DRS) website at www.ct.gov/DRS or request the form from your employer. Any nonresident who expects to have no Connecticut income tax liability should choose Withholding Code “E.”Certain Married IndividualsIf you are a married individual fi ling jointly and you and your spouse both select Withholding Code “A,” you may have too much or too little Connecticut income tax withheld from your pay. This is because the phase-out of the personal exemption and credit is based on your combined incomes. The withholding tables cannot refl ect your exact withholding requirement without considering the income of your spouse.

Form CT-W4 (Rev. 12/14)

To minimize this problem, use the Supplemental Table on Page 3 and Page 4 to adjust your withholding. You are not required to use this table. Do not use the supplemental table to adjust your withholding if you use the worksheet in IP 2015(7).Armed Forces Personnel and VeteransIf you are a Connecticut resident, your armed forces pay is subject to Connecticut income tax withholding unless you qualify as a nonresident for Connecticut income tax purposes. If you qualify as a nonresident, you may request that no Connecticut income tax be withheld from your armed forces pay by entering Withholding Code “E” on Line 1.

Military Spouses Residency Relief Act (MSRRA)If you are claiming an exemption from Connecticut income tax under the MSRRA, you must provide your employer with a copy of your military spouse’s Leave and Earnings Statement (LES) and a copy of your military dependent ID card. See Informational Publication 2012(15), Connecticut Income Tax Information for Armed Forces Personnel and Veterans.Employer InstructionsFor any employee who does not complete Form CT-W4, you are required to withhold at the highest marginal rate of 6.7% without allowance for exemption. You are required to keep Form CT-W4 in your fi les for each employee. See Informational Publication 2015(1), Connecticut Employer’s Tax Guide, Circular CT, for complete instructions.

Report Certain Employees Claiming Exemption From Withholding to DRSEmployers are required to fi le copies of Form CT-W4 with DRS for certain employees claiming “E” (no withholding is necessary). SeeIP 2015(1). Mail copies of Forms CT-W4 meeting the conditions listed in IP 2015(1) under Reporting Certain Employees to: Department of Reveunue Services PO Box 2931 Hartford CT 06104-2931

Report New and Rehired Employees to the Department of Labor New employees are workers not previously employed by your business, or workers rehired after having been separated from your business for more than sixty consecutive days.Employers with offi ces in Connecticut or transacting business in Connecticut are required to report new hires to the Department of Labor (DOL) within 20 days of the date of hire. New hires can be reported by:• Using the Connecticut New Hire Reporting website at

www.ctnewhires.com;• Faxing copies of completed Forms CT-W4 to 800-816-1108; or • Mailing copies of completed Forms CT-W4 to: Department of Labor Offi ce of Research, Form CT-W4 200 Folly Brook Boulevard Wethersfi eld CT 06109For more information on DOL requirements or for alternative reporting options, visit the DOL website at www.ctdol.state.ct.us or call DOL at 860-263-6310.For More InformationCall DRS during business hours, Monday through Friday:• 800-382-9463 (Connecticut calls outside the Greater Hartford

calling area only); or • 860-297-5962 (from anywhere).TTY, TDD, and Text Telephone users only may transmit inquiries anytime by calling 860-297-4911.Forms and PublicationsVisit the DRS website at www.ct.gov/DRS to download and print Connecticut tax forms and publications.

Page 2 of 4

Form W-4 (2015)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, 2016. 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 $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.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-earners/multiple jobs situations.

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 flat 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 unmarried 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 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 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 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, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.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 2015. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . . G

H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 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.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20151 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

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

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)

Form W-4 (2015) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details . . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,250 if head of household . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . 3

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

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2015. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2015. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $6,000 06,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 34,000 434,001 - 44,000 544,001 - 50,000 650,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14

150,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 17,000 117,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $75,000 $60075,001 - 135,000 1,000

135,001 - 205,000 1,120205,001 - 360,000 1,320360,001 - 405,000 1,400405,001 and over 1,580

All Others

If wages from HIGHEST paying job are—


$0 - $38,000 $60038,001 - 83,000 1,00083,001 - 180,000 1,120

180,001 - 395,000 1,320395,001 and over 1,580

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

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.


Toll-Free: 877-722-8833 www.acrfi.org

F8-V 03/20/14

DIRECT DEPOSIT APPLICATION

In order to avoid a delay or a rejection to your direct deposit, please follow these instructions. Incomplete or

forms needing correction will be returned.

Check one: NEW CHANGE CANCEL Please note: It can take up to two pay dates before the direct deposit can be made to your account. Funds will

be available on your scheduled pay date as long as timesheets are received when due. If this is a change to a

direct deposit account, there could be a delay in the processing of the new Direct Deposit which may result in

a check being issued.

It is your responsibility to verify funds deposited to your account. Allied is not responsible for any overdraft fees incurred.

EMPLOYEE INFORMATION:

FULL NAME:

ADDRESS:

PHONE #: SSN#: XXX-XX-

NAME OF EMPLOYER:

(You must fill out a separate form for each employer that you work for if you are seeking direct deposit for multiple paychecks.)

ACCOUNT INFORMATION:

***YOU MUST ATTACH A VOIDED CHECK OR A BANK AUTHORIZED FORM WITH THE ACCOUNT INFORMATION. WE CANNOT PROCESS ANY APPLICATIONS WITHOUT THIS TYPE OF ACCOUNT VERIFICATION.

BANK NAME: ACCOUNT TYPE: Checking Savings Pre-paid Debit Card

ACCOUNT #: 9 DIGIT ROUTING #:

(If Any Bank Account Information Changes After Set Up, Please Notify Allied Immediately)

RAPID! PAYCARD - PLEASE SIGN ME UP & SEND CARD TO ME (INFORMATION ON BACK OF THIS FORM)

Your payroll account will be set up immediately. You will receive your card in the mail with instructions on activation and usage.

Your signature authorizes Allied Community Resources and the financial institution listed above to deposit

your pay check directly to your account and reverse incorrect transactions. Your signature also verifies you

have read all instructions on this application and agree to the statements made therein.

Signature: __________________________________________ Date: ________________

PCA ___ ECP ___ ABI ___ DDS ___ MFP ___ BRS ___ APC___ ADD___ AVA___ ALH___

PAYROLL SET UP DATE: Initials: _______

EMPLOYEE NO: __ Pass for filing when complete.

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FAQs about the rapid! PayCard Visa Card

Welcome to the rapid! PayCard® Visa® Payroll Card

With your PIN, you may use your card to obtain cash from any Point-of-Sale (“POS”) device, as permissible by merchant that bears the Visa®, Interlink®, STAR®, Accel/Exchange®, brand. With your PIN, you may use your card to obtain cash from any Automated Teller Machine (“ATM”) that bears the Visa®, STAR®, Accel/Exchange®, or Allpoint® brand. All ATM transactions are treated as cash withdrawal transactions.

The rapid! PayCard® Visa® Payroll Card is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. The Bancorp Bank; Member FDIC.

Obtaining Your Card: The USA PATRIOT Act is a federal law that requires all �nancial institutions to obtain, verify, and record information that identi�es each person who opens a Card Account. What this means for you: When you open a Card Account, we will ask you for your name, address, date of birth, and other information that will allow us to reasonably identify you. We may also ask to see your driver’s license or other identifying document.

What is a rapid! PayCard Visa Card and where can I use it?It is a prepaid card that does not require a credit check; therefore, only an identity check is needed and most people qualify. It allows you to collect and spend your pay without hassle or inconvenience. A rapid! PayCard can be used at millions of ATMs and merchant locations worldwide, wherever Visa debit cards are accepted. This card provides you with added safety and security over carrying cash.

Is this payroll direct deposit different from other types of direct deposit?Not at all. The funds are deposited on your card immediately. The only difference is this is a prepaid card account and not a checking account.

How do I apply for a rapid! PayCard and get started with Direct Deposit?It’s easy to apply for your own rapid! PayCard. Just ask your employer or the Payroll department of your company for a rapid! PayCard direct deposit form.

Can I add additional funds to my rapid! PayCard?The rapid! PayCard is fully portable. This means that you can take the card to any other employer (second or part time job), regardless of who gave the card to you and sign up for a direct deposit payment. In addition, you can direct deposit your income tax refund, social security bene�t, military pension, or any other payment that can be direct deposited. Please login to www.rapidfs.com to access your direct deposit account number or ask one of our Customer Service Representatives.

What is the difference between the personalized rapid! PayCard and the instant issue rapid! PayCard?The �rst card you receive is the instant issue rapid! PayCard. It has a Visa brand mark but it does not have your name embossed on it. When you call Customer Support 1-888-RAPID 14 (1-888-727-4314) to activate this card you may also request a FREE upgrade to a personalized card with your name embossed on it. When the personalized rapid! PayCard arrives in the mail (7-10 business days) the instant issue card remains fully usable until you activate your new personalized card.

When will my payroll funds be available on my rapid! PayCard Visa Card?Your pay will typically be available by 10:00 am EST in the morning on your payday. You can check your balance then or anytime by calling 1-888-RAPID 14 (1-888-727-4314) or by visiting www.rapidfs.com.

What happens if I lose my rapid! PayCard? What should I do?Most importantly, your money is protected with Visa Zero Fraud Liability. Just call 1-888-RAPID 14 (727-4314) to report it lost/stolen and request a new card, or ask your employer for a new card. Call 1-888-RAPID 14 (press 0) and tell the representative this is a replacement card. There will be a charge of $10 for a replacement card.