Interview questions:

Today Date:

Name: First MiddleBirthday: SS# Male Female Document Title: Issuing: Authority ID number: Expiration Date: Social Security Card issuing Authority: Single Married Dependent #: Tax Exempt or N/A: Are you a citizen? Yes Are you lawful permanent resident: yes No

other: please completed page 5 White: Asian: Black: Non-veteran: Yes No not respond Disabled: Yes No not respond

Address:

Street city State Zip County

Email: Phone:

Are you legally entitled to work in the United States? Yes No Are you at least 18 years of age? Yes No Have you ever been convicted of a crime other than minor traffic violation? Yes No

New Hire: Rehire:

Individual pca training date passed: Certificate number: If previously used for MCO only claims, has this individual maintained continuous employment with your agency? Yes No

Group Affiliation Information: You have the option to affiliate/enroll the individual PCA named above, if 18 years or older, with other agencies you own without completing another application and agreement. Do you want to affiliate the above named individual PCA with any other agency(ies) you own? Yes No

Last

Have you passed Competency Testing? Yes NoDo you have the following:Driver License: Yes No Car: Yes No Certificate nay kind: Yes NoHave you applied for this company before: Yes No

Middle Initial

American Home Health Care LLC APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION Date

Name Social Security # Last First Middle

Other surnames that I have used:

Present Address Street City State Zip

Home Phone #: Alternate Phone #:

How did you hear about this position? Referred By:

Are you legally entitled to work in the United States? YES NO Are you at least 18 years of age? YES NO

In Case of Emergency Notify: Name Phone # Relationship to you

U.S. Military or Naval Service Rank Present Membership in National Guard or Reserves? YES NO

Have you ever been convicted of a crime other than minor traffic violations? YES NOIf yes, describe the nature of the crime and provide the place and date of conviction:

EMPLOYMENT DESIRED

Position: RN LPN/LVN Homemaker Home Health Aide Staffing Clerical Personal Care Attendant Other_________________

Have you passed Competency Testing? YES NO Do you have a Certificate? YES NO

Do you have a current Driver’s License? YES NO Do you currently have a car? YES NO

Have you ever applied to this Company before? YES NO Where? When?

PROFESSIONAL LICENSES, CERTIFICATION, AND REGISTRATIONS Do you have any professional licenses, certifications and/or registrations? YES NO

License/Certificate/ Registration #: Type State Issued Date Expires Status (List Active, Inactive, Restricted,

Conditional or Pending)

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veterans employment. We are an equal opportunity employer.

Date of Birth:_________________ ID: ______________________________ Email:__________________________________________ County

An Equal Opportunity Employer

REFERENCES

Give below the names of three work related references.

NAME ADDRESS COMPANY/POSITION PHONE

EDUCATION

NAME AND LOCATION OF SCHOOL YEARS ATTENDED GRADUATED DEGREE/CERTIFICATION

HIGH SCHOOL Yes

No

COLLEGE Yes

No

COLLEGE Yes

No

ADDITIONAL

TRAINING

FORMER EMPLOYERS

List below your complete employment history for the last five years, starting with the most recent position first. Attach additional pages if necessary.

DATE MONTH AND YEAR

NAME AND ADDRESS OF EMPLOYER SUPERVISOR'S NAME

SALARY POSITION REASON FOR LEAVING

FROM

TO May we contact? YES NO

FROM

TO

FROM

TO

FROM

TO

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without cause, and with or without any prior notice.

I hereby agree that, as a condition of employment by the Agency, I will promptly inform the Agency in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses, of which I am convicted after today.

Date Signature

American Home Health Care LLCCONFIDENTIALITY OF CLIENT INFORMATION

AGENCY POLICY:

By accepting employment with American Home Health Care LLC., you have

obligated yourself to carefully refrain from discussing any client’s condition or personal

affairs with anyone outside the agency, unless expressly authorized to do so. Do not pass

on medical information to clients and visitors unless you have been instructed to do so by

your supervisor. In addition, all information seen or heard regarding clients, directly or

indirectly, is completely confidential and not to be discussed even with your family.

Your job as a American Home Health Care LLC. employee requires that you

govern yourself by high ethical standards. Failure to recognize the importance of

confidentially is not only a breech of agency this, but can also involve an employee in

legal proceedings. Information about clients or the agency is not to be given to media.

This is essential for protection of both the client and the agency. Very strict laws

regarding the release of information concerning clients bind agencies.

I have read and agree to abide by the above policy on confidentiality. I realize that

violating this policy may result in termination of my employment

________________________________________________________________________ Employee Name (print)

_____________________________________________________ __________________ Signature of Employee Date

Revised 3/05 Copyright Mefford, Knutson & Associates, Inc.

American Home Health Care LLC VOLUNTARY SELF-IDENTIFICATION INFORMATION

American Home Health Care LLC is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age, handicap, marital status, source of income, class, physical characteristics, sexual orientation or political beliefs.

As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this Voluntary Self-Identification Information form. This data is for analysis and affirmative action only and submission of this information is voluntary. This data will be kept in a confidential file separate from your Application for Employment.

Date_________________________

Position Applied For: PCA ( PERSONAL CARE ASSISTANT)

Gender: Male Female Choose not to respond

Race/Ethnic Background: American Indian / Alaskan

Native Asian Native Hawaiian/ Other Pacific Islander Black / African or African

American Hispanic / Latino White / Caucasian Two or More Races Choose not to respond

Veteran Status: Vietnam era veteran Disabled veteran Other veteran Non-veteran Choose not to respond

Disability Status*: Disabled Not disabled Choose not to respond

* According to the American with Disabilities Act, the term “disability” means, with respect to an individual, a physical or mental impairment that substantially limits

one or more of the major life activities of that individual, a record of such an impairment, or being regarded as having such an impairment.

American Home Health Care LLC 2716 PORTLAND AVE S MINNEAPOLIS MN 55407

PHONE 763-334-6957 | FAX 763-334-6958 | info@ahealthcarehome.com | www.ahealthcarehome.com

Acknowledgment and Required Signatures

After the PCA has documented his/her time and activity, the recipient must draw a line through any dates and times he/she did not receive services from PCA. Review the complete time sheet for accuracy before signing. It is a federal crime to provide false information on PCA billing for Medical Assistance payment. Your signature verifies the time and services entered above are accurate and the services were performed as specified in the PCA Care Plan.

By signing this letter I agree to all the terms and conditions on it.

PCA Signature Date

American Home Health Care LLCPCA AND EMPLOYER PAYMENT AGREEMENT

PERSONAL INFORMATION DATE

NAME______________________________________________________________SS # ____________ LAST FIRST MIDDLE

ADDRESS ______________________________________________________________________________ STREET CITY STATE ZIP COUNTY

DOB: _______________PHONE NO. (H)____________________ (W) __________________ (CELL) ___ PLEASE NOTE: PCAS ARE NOT ALLOWED TO DRIVE THEIR CLIENTS. TO DO SO WILL AUTOMATICALLY TERMINATE YOUR EMPLOYMENT. _______________ THE PCA IS REPONSIBLE TO PAY BACK FOR ALL THE CHECKS THAT AMERICAN HOME HEALTH CARE LLC. MAY ADVANCE TO THEM BEFORE SERVICE AUTHORIZATION FOR THE CLIENT IS RECIEVED. THE PCA MUST PAY BACK THE TOTAL AMOUNT WITHIN 60 DAYS. THE PCA MUST PROVIDE PROOF OF WORK (TIMESHEET) IN ORDER TO CLAIM A PAYMENT. THE TIMESHEET MUST HAVE THE RECIPIENT SIGNATURE OR RESPONSIBLE PARTY, ACCORDING TO THE MINNESOTA ADMINISTRATIVE RULE 9505.2175 SUBPARTS 7. IF THE PCA FAIL TO PRESENT THE TIMESHEET, THE PAYMENT WILL BY DELAY UNTIL THE TIMESHEET IS PROVIDED. AMERICAN HOME HEALTH CARE LLC WILL NOT ACCEPT ANY TYPE OF STAINS (FOOD, BEVERAGES, AND EST.) IN ADDITION, SCREECHES, WHITOUT, EST., OR WRINKLES ON THE TIMESHEETS. IF ANY OF THESE CONDITIONS OCCURS, THE TIMESHHET WILL BE RETURN TO BY RESUBMIT AND A PAYMENT DALEY WILL BE APPLIED. AMERICAN HOME HEALTH CARE LLC. WILL BY NOT RESPONSIBLE FOR ANY TYPE OF CONFLICT BETWEEN THE RECIPIENT AND THE PCA BEYOND THE RESPONSIBILITIES AS A HOME HEALTH AGENCY. IF THE RECIPIENTS DENY THE WORK DONE BY THE PCA, THIS MUST PROVIDE PROOF OF HIS/HERS WORK IN ORDER TO GET THE PROPER PAYMENT. AN EMPLOYEE CANNOT WORK MORE THAN 96 HOURS BI-WEEKLY. IF YOU DO SO WITHOUT AMERICAN HOME HEALTH CARE LLC AUTHORIZATION WE MAY NOT PAY. AMERICAN HOME HEALTH CARE LLC DOES NO GUARANTEE MORE THAN 30 DAYS OF EMPLOYMENT. EVERY EMPLOYEE MUST PASS A BACKGROUND STUDY IN ORDER TO WORK. AMERICAN HOME HEALTH CARE LLC IS NOT RESPONSIBLE OF RECEIVING A DISQUALIFICATION NOTICE AFTER EMPLOMENT. YOU POSSITION WILL BE ON HOLD UNTIL WE RECEIVE A NOTICE THAT THE CHARGES HAS BEEN SET ASIDE. WE ARE NOT RESPONSIBLE FOR YOUR CRIMINAL RECORD. DIRECT DEPOSIT IS AVAILABLE ONLY IF WE RECEIVE THAT TIMESHEET BY THE DUE DATE. FAIL TO DO SO WILL INMEDIATLY STOPS YOUR DEPOSIT.

AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE.

I HEREBY AGREE THAT, AS A CONDITION OF EMPLOYMENT BY THE AGENCY, I WILL PROMPTLY INFORM THE AGENCY IN WRITING OF ANY CRIMINAL CONVICTIONS, IN ANY JURISDICTION (INCLUDING ALL PLEAS OF GUILTY), OTHER THAN MINOR TRAFFIC OFFENSES, OF WHICH I AM CONVICTED AFTER TODAY

SIGNATURE___________________________________________________________ DATE

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veterans' employment. We are an equal opportunity employer.

Page 1 of 2

DHS-4469-ENG 11-16

Minnesota Health Care Programs (MHCP)

Individual PCA Enrollment ApplicationComplete this form online, print and then fax to MHCP. Complete at least all bolded fields to enroll an individual PCA. We will return incomplete forms to you.

New hire (requires new background study and completion of PCA training)

Rehire (requires new background study and completion of PCA training)

Previously used for managed care organization (MCO) claims only (new background study not required)

Individual PCA InformationPROVIDER TYPE

38 – INDIVIDUALLEGAL NAME (FIRST) FULL MIDDLE NAME LAST NAME SOCIAL SECURITY NUMBER

ADDRESS (RESIDENTIAL ADDRESS ONLY – DO NOT ENTER A PO BOX) CITY STATE ZIP CODE

COUNTY OF RESIDENCE PHONE NUMBER DATE OF BIRTH UMPI (if requesting reinstatement)

INDIVIDUAL PCA TRAINING

DATE PASSED: CERTIFICATION NUMBER:

Is the individual 18 years old or older?

Yes No* *May affiliate with only one agency

If previously used for MCO only claims, has this individual maintained continuous employment

with your agency? Yes No

BGS NUMBER or APPLICATION ID

Individual PCA Provider StatementI have reviewed and certify the information provided above is true and correct to the best of my knowledge. I will notify the Minnesota Department of Human Services Provider Enrollment of any additions or changes to the information. By signing this form, I acknowledge I have read and understand the Application and Background Study Privacy Notice. I also authorize the Minnesota Department of Human Services to use the information collected about me according with the Privacy Notice.NAME OF PCA (print or type) SIGNATURE OF PCA DATE SIGNED

Group Affiliation InformationYou have the option to affiliate or enroll the individual PCA named above, if 18 years old or older, with other agencies you directly own without completing another application and agreement. Do you want to affiliate the above named individual PCA with any other agencies you own? Yes No

Agency InformationAGENCY NAME

AMERICAN HOME HEALTH CARE LLCAGENCY NPI OR UMPI

A964487000AGENCY FAX NUMBER

763-334-6958AGENCY PERSONNEL COMPLETING FORM AGENCY SIGNATURE

Page 2 of 2 DHS-4469-ENG 11-16

Next StepsRead, sign and date the MHCP Provider Agreement - Support Worker (PCA, CDCS and CSG) (DHS-4611), and return it with this application.

Fax the application and agreement to 651-431-7465. Only faxed requests will be processed.

*DHS-4611-ENG*DHS-4611-ENG 4-15

Page 1 of 3

Minnesota Health Care Programs

Provider Agreement – Individual Support Worker (CDCS, CSG, PCA)

DIRECT SUPPORT WORKER INITIALS

NAME OF SUPPORT WORKER UMPI

As a participating provider in health service programs administered by the Minnesota Department of Human Services (the Department), the Provider agrees to:

A. Submit documentation to your affiliated agency that fully discloses the extent of services provided to individuals under these programs. The documentation must be legible and meet the requirements of Minnesota Statutes Section 256B.0659, subdivision 12 for all individual support workers in CDCS, CSG, and PCA.

B. Furnish the Department, the Secretary of the U.S. Department of Health and Human Services (DHHS), or the Minnesota Medicaid Fraud Control Unit with such information as it may request regarding payments claimed for services provided under these programs.

C. Comply with all federal and state statutes and rules relating to the delivery of services to individuals and to the submission of claims for such services.

D. Accept as payment in full, amounts paid in accordance with schedules established by the Department, except where payment by the recipient has been authorized by the Department.

E. Make full disclosure of any convictions(s) of program crimes as required by 42 C.F.R. § 455.106.

F. Comply with all federal statutes, implementing regulations and guidance prohibiting discrimination on the basis of race, color, national origin, sex, age, religion and disability in any program or activity receiving federal financial assistance from DHHS; and to comply with the Minnesota Human Rights Act.

G. Render to recipients services of the same scope and quality as would be provided to the general public, within Minnesota Health Care Programs (MHCP) guidelines.

H. Comply with the provisions of any fully executed agreement and/or addendum required by the Department, which is incorporated herein by reference.

I. Comply with the advance directive requirements as required by 42 C.F.R. §§ 489.100 and 417.436.

J. Properly handle and safeguard protected information collected, created, used, maintained, or disclosed on behalf of the Department. For purposes of this Agreement, “protected information” means data subject to any of the following laws:

1. The Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13, in particular § 13.46 (“welfare data”);

2. The Minnesota Health Records Act § 144.291 and § 144.298;

3. The Health Insurance Portability and Accountability Act (“HIPAA”), including but not limited to the requirements of the Privacy Rule and the Security Regulations, 45 C.F.R. Part 160 and Part 164, subparts A and E.

4. Federal law and regulations that govern the use and disclosure of substance abuse treatment records, 42 U.S.C.S. § 290dd-2 and 42 C.F.R. § 2.1 to § 2.67; and

5. Any other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and dissemination of private or confidential information.

Page 2 of 3 DHS-4611-ENG 4-15

K. Comply with the laws described in section J. This includes the Provider:

1. Not using or further disclosing protected information created, collected, received, stored, used, maintained or disseminated in the course or performance of this Agreement other than as necessary to perform its obligations under this Agreement, or as required by law, either during the period of this Agreement or hereafter. See, respectively, 45 C.F.R. §§ 164.502(b) and 164.514(d), and Minn. Stats. § 13.05 subd. 3.

2. Using appropriate administrative, physical, and technical safeguards to prevent use or disclosure of the protected information other than as provided for by this Agreement and to ensure the confidentiality, integrity, and availability of any electronic protected health information (PHI) that it creates, receives, maintains, or transmits on behalf of the Department. Provider will not transmit PHI over the Internet or any other unsecure or open communications channel unless such information is encrypted or otherwise safeguarded using procedures no less stringent than those described in 45 C.F.R. § 164.312. If the Provider stores or maintains PHI in encrypted form, the provider shall, at the Department’s request, promptly provide the Department with the key or keys to decrypt such information. The Provider shall not forward previously encrypted data to any other party, unless otherwise required by this Agreement.

3. Mitigating, to the extent practicable, any harmful effects known to the Provider of a use, disclosure, or breach of security with respect to protected information by the Provider in violation of this Agreement.

L. Agree that this Agreement may be immediately terminated at the discretion of the Department if it determines that the Provider has violated a material term of the Agreement, including but not limited to, non-compliance by the Provider with the HIPAA Privacy Rule and Security Standards. If termination is not feasible, the Department shall report the breach to the Secretary of DHHS.

Upon termination of this Agreement, all of the protected information provided by the Department to Provider, or created or received by the Provider on behalf of the Department, that the Provider still maintains in any form, including information that is in the hands of subcontractors or agents of the Provider, shall be destroyed or returned to the Department, and the Provider shall retain no copies of such information. If it is infeasible to return or destroy the information, the Provider shall provide the Department notification of the conditions that make return or destruction infeasible, and shall extend the protections of this Agreement to such information and limit further use and disclosure of such information to those purposes that make return or destruction infeasible, for as long as the Provider maintains the information.

M. Agree that any ambiguity in this Agreement shall be resolved to permit the Department to comply with HIPAA, MDGPA, and other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and dissemination of private or confidential information and other state and federal laws and regulations.

Upon signature, this Provider Agreement supersedes and replaces all former Provider Agreements the Provider has with the Department.

An individual applicant must personally sign the Provider Agreement. Please sign and date below, initial page 1, and return both page 1 and page 2 of this agreement. Please retain a copy of the provider agreement for your files, and return the original to the Department of Human Services.

NAME OF SUPPORT WORKER (TYPE OR PRINT) TITLE

SIGNATURE OF SUPPORT WORKER DATE

Please return page 1 and page 2 of this document

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

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

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

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

Social Security Card

Not Applicable

Form W-4 (2017)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 2017 expires February 15, 2018. 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 can’t claim exemption from withholding if your total 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 don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t 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 2017. 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’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t 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 . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F 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 $70,000 ($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 $70,000 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

20171 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) 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, 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 (2017)