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Personal Information
Address Information
Background History PA
Other Information
Emergency Contacts
Health Assessment

Personal Information

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First Name*

Middle Name

Last Name*

Email 2

Email 3

SSN*

Gender*

Female Male

Phone 1*

Phone 2

Phone 3

Date of Birth*

Age

Country of Birth*

Maiden Name

Mother's Maiden Name

Relationship to Consumer

Language*

Other Languages

Ethnicity*

Personal Information

Address Information

Background History PA

Have you ever been excluded or terminated in any federal health care program or new york medicaid?

Yes No

Do you reside at the same address as the consumer?

Yes No

Background History PA

Other Information

Have you used an Alias?

Yes No

Alias*

Are you a citizen of the United States?

Yes No

If no, are you legally authorized to work in the US?

Yes No

How did you hear about us?

Please specify other information (Hear about us)

Position applied for

Please specify other information (Position applied for)

Available Start Date

Driving License Information

Do you have a valid driver license?

Other Information

Emergency Contacts

Health Assessment

Government Forms 0 / 5

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New York Taxes
Federal Taxes
I-9
Dept. of Labor Statistics
Direct Deposit

New York Taxes

How will you File New York Taxes?

Married

Married but withhold at higher single rate

Single or Head of household

Are you a resident of New York City?

Yes No

Are you a resident of Yonkers?

Yes No

Please use the NYS worksheet HERE to find out your allowances

Total number of allowances you are claiming for New York State and Yonkers, if applicable*

Total number of allowances for New York City

Use the fields below to have additional withholding per pay period under special agreement with your employer.

New York State amount*

New York City amount*

Yonkers amount*

New York Taxes

Federal Taxes

Step 1: Personal Information

How will you file your Federal Taxes?

Single or Married filing separately

Married filing jointly or Qualifying surviving spouse

Head of household

Step 2: Multiple Jobs or Spouse Works

If you (and your spouse) have a total of only two jobs held at the same time, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate for jobs with similar pay.

Step 3: Claim Dependent and Other Credits

How many Children under 17 years old will you be claiming?

Child Dependent amount

How many Other dependents will you be claiming?

Other Dependent amount

Total

Step 4: Other Adjustments (optional)

Other income (not from jobs).

If you want tax withheld for other income (not from jobs) you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income.*

Deductions.

{If you expect to claim deductions other than the standard decution and want to reduce your withholding, use the Deductions Worksheet on page 3 (Form W-4 Instructions) and enter the result here}*

Extra withholding.

Enter any additional tax you want withheld each pay period*

Federal Taxes

I-9

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States

2. A noncitizen national of the United States (An individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.)

3. A lawful permanent resident (Enter USCIS or A-Number.)

4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

Alien Registration Number

USCIS Number*

Form I-94 Admission Number

Foreign Passport Number

Country of Issuance

I-9

Dept. of Labor Statistics

Form 8850

If you are under age 40, enter your date of birth

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

Check here if any of the following statements apply to you:

I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months; or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
During the past year, I was convicted of a felony or released from prison for a felony.
I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if any of the following statements apply to you:

I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months; or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
During the past year, I was convicted of a felony or released from prison for a felony.
I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a member of a family that:

Received TANF payments for at least the past 18 months; or
Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

Check here if you are a member of a family that:

Received TANF payments for at least the past 18 months; or
Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Dept. of Labor Statistics

Direct Deposit

Form of Payment

Paycard Direct Deposit

Enter your account information to get paid with direct deposit.

First Name

Last Name

Bank Name

Type of Account

Checking Routing Number

Confirm Checking Routing Number

Checking Account Number

Confirm Checking Account Number

Saving Routing Number

Confirm Saving Routing Number

Saving Account Number

Confirm Saving Account Number

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Direct Deposit

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Personal Information

Personal Information

Address Information

Address Information

Background History PA

Background History PA

Other Information

Driving License Information

Other Information

Emergency Contacts

Emergency Contacts

Health Assessment

Health Assessment

New York Taxes

Use the fields below to have additional withholding per pay period under special agreement with your employer.

New York Taxes

Federal Taxes

Federal Taxes

I-9

I-9

Dept. of Labor Statistics

Dept. of Labor Statistics

Direct Deposit

Direct Deposit

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