Instructions for completing New Hire Paperwork-REVISED 07 2016 · 5/2/2013 · about you for employment purposes. These purposes may include hiring, contract, assignment, promotion,

Instructions for completing New Hire Paperwork

HIGHLIGHTED fields on each form are REQUIRED

Forms 1 & 2 Consumer Reports Notification/Criminal Check Disclosure Form

Please read, and sign that you understand that reference checks and criminal background checks have been or will be completed in conjunction with your job offer.

Form 3 Email Request Form, Acceptable Use Policy

Please complete highlighted portions of this form

Once complete and printed, please sign the form before submitting to Human Resources

A copy of the Email Acceptable Use Policy is also included for your reference.

Form 4 Confidentiality & Security Agreement

Please review, print and sign the Confidentiality & Security Agreement

Form 5 Federal I‐9 form

Please complete highlighted portions at the top of the form

Instructions for completing the form can be found in the packet, following the form.

When printing please be sure to print section 1/page 1 (employee form) and section 2/page 2 (employer form).


Forms 6 & 7 Address and Direct Deposit Form

Please complete highlighted portions of form

Your voided check or deposit slip will be attached to the Direct Deposit form


Form 8 Team Member Data Sheet

Please complete highlighted portions of form, other fields not highlighted may be completed as appropriate

Once printed, please complete the RECORD OF SIGNATURE AUTHENTICITY section on the form before submitting to Human Resources

Form 9 Federal W4 Tax Form



Form 10 Indiana State Tax Form (only complete this form if you live in INDIANA)



Forms 11 & 12 Kentucky State Tax Form & Indiana Non‐Residence Form (only complete these forms if you live in KENTUCKY)



There will be a Notary available in Human Resources when you turn in your paperwork to complete the non‐residence form.

Form 13 Conditional Letter of Employment

Please read the conditional letter of employment which states that your employment is contingent on the satisfactory completion of the pre‐employment screenings (criminal background check and drug‐screen results).

Once read and printed, please sign the letter before submitting to Human Resources

Form 14 WOTC Forms

Review the instructions

Complete the forms and return to Human Resources

ALL NEW HIRES must complete this paperwork, even if, from the description on the forms, I may appear that you will not qualify for the Tax Credit

Please bring your completed new hire paperwork to Human Resources

after you have completed your Pre‐Employment Physical.

CONSUMER REPORTS NOTIFICATION

You are hereby notified that a consumer report or an investigative consumer report may be obtained from a consumer-reporting agency, other agency or directly by this employer for the purpose of evaluating you for employment, promotion, reassignment or retention as a team member. The report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living from public or private record sources or through personal interviews with your neighbors, friends, associates or educational facility.

Disclosure

Clark Memorial Hospital will obtain one or more consumer reports or investigative consumer reports (or both) about you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living. We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General Information Services, Inc. GIS’s address is P.O. Box 353, Chapin, SC 29036. GIS’s telephone number is (866) 265-4917. GIS’s website is at www.geninfo.com. To prepare the reports, GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You may inspect GIS’s files about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification. If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed. The Federal Trade Commission provides a summary statement of your rights on its website at www.ftc.gov/credit. Please sign below to acknowledge your receipt of this disclosure.

Signature Date

Printed name

CMH Network and E-Mail Request Form

for New Team Members

General Information

Team Member Name: Last 4 Digits of SS#:

Preferred Name: Department

Title/Position: Supervisor:

Security Questions

TM Birthday: Mother’s Maiden Name:

TM City of Birth: Mother’s City of Birth:

By signing this form you are agreeing to the following statements:

1) I have read and signed the CMH HIPAA Privacy and Security Agreement and understandmy responsibilities in handling patients’ protected health information (PHI).

2) I have read the Email Acceptable Use policy document provided during orientation andunderstand my responsibilities and use of this account.

3) I understand that I shall use the computer systems in an efficient, ethical, and legalmanner. Failure to do so could result in termination of employment.

4) I understand that all transactions on any portion of the computer system and emailcommunications may be logged an monitored for inappropriate use.

5) I understand that my email messages are not private and can be made available for reviewat the request of Human Resources leadership.

6) I understand that my email account is fixed in size and that I am responsible for routinelydeleting or archiving emails to keep the account size within this limit.

TM Signature: _________________________________ Date: ________________

----------------------------------------------------------------------------------------------------------------------------------------------------------------

I.S. Use Only: Track-It #:_________ Account Size: 50 Mb 250 500 1 Gb

Date Created: ____/____/____ Initials _____

Revised: May 2, 2013

ELECTRONIC MAIL (EMAIL) ACCEPTABLE USE

Policy #: IS-002 RVS RVW

ORIGINAL DATE: May 1, 2004 EFFECTIVE DATE:June 20,2004

WRITTEN BY: Larry Reverman

9.2009 4.2013

10.2011

DEPARTMENT: Hospital Wide APPROVED BY: Larry Reverman, Director

PURPOSE: E-Mail has become a necessary and vital business tool for communication in

the organization. This policy establishes guidelines for acceptable use and

proper utilization of the organization's electronic mail systems. It requires

that electronic mail use be solely for the organization's business purposes, and

prohibits its use for transmitting protected health information unless specific

security restrictions are met and authorized. This policy also defines

appropriate content guidelines.

POLICY: Workflow and Behavior

a. The electronic mail system is to be used for business purposes only.

b. All messages sent by electronic mail are considered to be organizational

records, and the organization reserves the right to access and disclose all

messages sent over its electronic mail system for any purpose. Management

may review the electronic mail communications of Team Members they

supervise to determine whether they have breached security, violated policy, or

taken other unauthorized actions. Electronic mail messages may be disclosed

to law enforcement officials without prior notice to the Team Members who

may have sent or received such messages.

c. Any personal use of email shall not interfere with normal business activities,

will not involve solicitation, will not be associated with any for-profit outside

business activity and will not potentially embarrass the organization.

d. Initiating or continuing non-business email chain letters or multi-person

distributions is strictly prohibited.

e. During the course of normal business operations, email may only be sent or

received through an email account by the owner of that account. If there is a

legitimate business reason to read another's mail, the account owner may use

message forwarding.

f. Individuals may not use broadcast facilities found in electronic mail systems

and voice mail systems without management approval.

g. Automatic forwarding of electronic mail messages to any outside mail service

(i.e. Hotmail, Yahoo, Gmail) address is prohibited.

h. PHI contained in electronic mail that will be carried by the public Internet will

be encrypted by approved methods. Information Systems will define approved

methods.

i. Only approved e-mail software is to be used on hospital-owned computers. The

approved software is Microsoft Outlook and Exchange Server. No instant

messaging software is allowed on the CMH network.

j. Team Members must receive approval from their department director to have

personal devices such as iPhones, smartphones or iPads configured to send and

retrieve emails to the Hospital email system.

ELECTRONIC MAIL (EMAIL) ACCEPTABLE USE

Policy #: IS-002 RVS

RVW

ORIGINAL DATE: May 1, 2004 EFFECTIVE DATE:June 20,2004

WRITTEN BY: Larry Reverman

9.2009 4.2013

10.2011

DEPARTMENT: Hospital Wide

APPROVED BY: Larry Reverman, Director

Content Issues and Guidelines

a. All electronic mail sent through the mail server can be archived by a user on the

local workstation and is subject to management review. Electronic mail

messages may be monitored for internal policy compliance, suspected criminal

activity, and other systems management reasons. In addition, the organization

routinely employs automatic electronic mail content scanning tools to identify

selected keywords, file types, and other information.

b. “All User” e-mails unrelated to essential business operations are discouraged.

Solicitation for non-Hospital approved functions is prohibited.

c. Team members will treat electronic mail as a private and direct communication

between a sender and a recipient.

d. The transmission of PHI, passwords and other sensitive data by electronic mail

is permitted within the internal network. This information is prohibited from

being sent via the Internet unless the email is encrypted.

e. Email users should only download and open file attachments from known

individuals and trusted sources.

f. Electronic mail sent by Team Members to Internet discussion groups, electronic

bulletin boards, or other public forums will be consistent with the

organization’s business interests and policy. Disclosures of PHI and other

sensitive information via these channels are prohibited.

g. Team Members will not create or forward electronic mail messages that are

defamatory, harassing or explicitly sexual. Messages will not contain profanity,

obscenities, or derogatory remarks related to employees, patients, or others.

Remarks of this nature, even if made in jest, are prohibited. Team Members are

also prohibited from sending or forwarding messages or images via systems

that would offend on the basis of race, gender, national origin, religion, political

beliefs, or disability.

h. Should Team Members receive an offensive or harassing communication, they

are to immediately bring the occurrence to the attention of their immediate

supervisor and/or the Human Resources Manager. (See the CMH Personnel

Policies and Procedures Non-Harassment Policy for further direction.)

i. When Team Members receive unwanted and unsolicited email, they are

encouraged to respond directly to the originator of the electronic mail messages

requesting discontinuation of the communications. If the originator continues

to send the messages, the worker should report the communications to their

manager. Information Systems should be contacted by management to assess if

technical options are available to block further transmissions.

REFERENCES Health Insurance Portability and Accountability Act of 1996, Public Law 104-

191; the Code of Federal Regulations, 45 C.F.R. Part 164 Subpart C and all

amendments thereof.

Confidentiality and Security Agreement I understand that the facility or business entity named below (the “Company”) in which or for whom I work, volunteer or provide services, or with whom the entity (e.g., physician practice) for which I work has a relationship (contractual or otherwise) involving the exchange of health information (the “Company”), has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information. Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning, communications, computer systems and management information (collectively, with individually identifiable health information and protected health information, “Confidential Information”).

In the course of my employment / assignment at the Company, I understand that I may come into the possession of this type of Confidential Information. I will not use company systems to access patient information if it is not necessary to perform my job related duties. This includes NOT accessing my own health information or that of my child or person’s for which I am personal representative via the company systems. The Company’s Privacy and Security Policies available on the Company intranet (on the Security Page) and the internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtain authorization for access to Confidential Information.

Signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above.

Employee/Consultant/Vendor/Office Staff/Physician Signature Facility Name and COID 16365

Date

Employee/Consultant/Vendor/Office Staff/Physician Printed Name Business Entity Name Clark Memorial Hospital

June 8, 2010 Attachment to LPNT.IS.SEC.005

1. I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a need to know it.

2. I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information except as properly authorized.

3. I will not discuss confidential information where others can overhear the conversation, even if the patient’s name is not used. I will make every reasonable attempt to refrain from practices that might lend itself to unintended breach of patient confidentiality.

4. I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information.

5. I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my contract, or my relationship ceases with the Company.

6. Upon termination, I will immediately return any documents or media containing Confidential Information to the Company.

7. I understand that I have no right to any ownership interest in any information accessed or created by me during my relationship with the Company.

8. I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during my relationship with the Company.

9. I understand that violation of this Agreement may result in disciplinary action, up to and including termination of employment, suspension and loss of privileges, and/or termination of authorization to work within the Company, in accordance with the Company’s policies.

10. I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals.

11. I understand that I should have no expectation of privacy when using Company information systems. The Company may log, access, review, and otherwise utilize information stored on or passing through its systems, including e-mail, in order to manage systems and enforce security.

12. I will practice good workstation security measures such as locking up electronic media devices when not in use, using screen savers with activated passwords appropriately, and position screens away from public view.

13. I will practice secure electronic communications by transmitting Confidential Information only to authorized entities, in accordance with approved security standards.

14. I will:

a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).

b. Use only approved licensed software.

c. Use a device with virus protection software.

15. I will never:

d. Share/disclose user-IDs, passwords or tokens.

e. Use tools or techniques to break/exploit security measures.

f. Connect to unauthorized networks through the systems or devices.

16. I will notify my manager, Local Security Coordinator (LSC), or appropriate Information Services person if my password has been seen, disclosed, or otherwise compromised, and will report activity that violates this agreement, privacy and security policies, or any other incident that could have any adverse impact on Confidential Information.

The following statements apply to physicians using any Company systems containing patient identifiable health information (e.g. HMS, Meditech, eCW):

17. I will only access software systems to review patient records or Company information when I have a business need to know, as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmatively representing to the Company at the time of each access that I have the requisite business need to know and appropriate consent, and the Company may rely on that representation in granting such access to me.

18. I will accept full responsibility for the actions of my employees who may access the Company software systems and Confidential Information.

19. I have no intention of varying the volume or value of referrals I make to the Company in exchange for Internet access service or for access to any other Company information.

20. I have not agreed, in writing or otherwise, to accept Internet access in exchange for the referral to the Company of any patients or other business.

21. I understand that the Company may decide at any time without notice to no longer provide access to any systems to physicians on the medical staff unless other contracts or agreements state otherwise. I understand that if I am no longer a member of the facility’s medical staff, I may no longer use the facility’s equipment to access the Internet.

Revised 02/2016

TEAM MEMBER ADDRESS FORM

Current Information (Please do not list a PO Box as your home address)

Name

Street Address

City/State/Zip Code

County Personal Email Address:

Social Security# Phone # with area code

Mailing Address – if different than home address (i.e. PO Box) (If same please note)

Address

City/State/Zip Code

Please list your address that was effective December 31st of the previous year. This information is for county tax calculation purposes only. (if same please note)

Street Address

City/State/Zip Code

County

Signature Date

The terms “LifePoint,” “LifePoint Hospitals,” or the “company” refer to the LifePoint Hospitals, Inc., and its affiliates, unless otherwise stated or indicated by context. The term “facilities” or “hospitals” refer to entities owned or operated by subsidiaries of LifePoint Hospitals, Inc. References to “LifePoint employees” or to “our employees” refer to employees of the subsidiaries

of LifePoint Hospitals, Inc.

© 2014 LifePoint Hospitals, Inc. © 2014 Parallon Business Solutions, LLC

Payroll Service Center

Direct Deposit Form

Facility Name HR Company

Process Level

(Contact HR for Employee ID#, HR Company, & Process Level information)

I elect to receive direct deposit into my existing checking/savings account.

I elect to receive direct deposit into a Skylight Debit Card Account. Do NOT complete the account information if you selected Skylight Debit card account; the PSC will complete. If you want to deposit monies into additional accounts along with a Skylight Debit Card Account, fill out the appropriate boxes below for your other accounts.

Please attach a voided check or document proof of your account number and financial institution’s Transit\ABA routing number for each direct deposit account and forward to your HR Department. DO NOT ATTACH A DEPOSIT SLIP.

***If you need additional accounts (up to a maximum of 5), please attach a separate sheet with the appropriate information.

Employee Name (Please Print) Employee ID# Date

Authorization Agreement I hereby authorize LifePoint and/or its affiliates and/or its service provider (Parallon Payroll Service Center) and the financial institutions listed below to electronically deposit monies to the specific account numbers listed below. If monies which I am not entitled to are deposited to my account I authorize my employer to direct the financial institution to return said funds.

If my financial institution is involved in a successor transaction, the authorization will remain in effect. I will be responsible for notifying the Human Resources by completing this form for cancellation if I do not want funds to go to the successor financial institution.

This agreement will remain in effect until the Parallon Payroll Service Center receives written notification from me (via Human Resources) of its termination in such a manner as to afford Payroll and my financial institution a reasonable opportunity to act on it.

By signing below I acknowledge that I have read the authorization and agree to comply with all of the terms and conditions as stated and that I have read the Direct Deposit information on the front of this sheet.

Account Information for NET PAY DEPOSIT ONLY Name of Financial Institution: Routing Number: Enroll / Change

Cancel

Account Number: Checking / Savings

100.00 %

Account Information for PARTIAL PAY DEPOSIT ONLY*** Name of Financial Institution: Routing Number:

Enroll / Change

Cancel

Account Number:

Skylight Card / Checking / Savings

Amount $

Signature Authorized Signature:

Please complete this form to provide Clark Memorial Hospital with information

for Government Reports and Personnel Records.

Full Name: Today’s Date:

Date of Birth: Social Security #:

Marital Status: Single Married Divorced Widowed

Ethnic Identification: White Black Hispanic

Asian or Pacific Islander American Indian or Alaskan Native LIST PREVIOUS YEARS OF SERVICE AT CLARK MEMORIAL HOSPITAL: MONTH YEAR

FROM

TO

MONTH YEAR

FROM

TO

MONTH YEAR

FROM

TO

RECORD OF SIGNATURE AUTHENTICITY:

Signature (exactly as it would appear in the Medical Record)

Initials (exactly as it would appear in the Medical Record)

Emergency Notification Information: Emergency Contact 1 Emergency Contact 2

Emergency Contact:

Street Address:

City, State, Zip Code:

Phone # with area code:

Relationship:

Revised 02/2016

TEAM MEMBER DATA SHEET

Form W-4 (2016)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 2016 expires February 15, 2017. 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 2016. 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 . . . . . . . . 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

20161 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 2016, 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 (2016)

State of IndianaEmployee’s Withholding Exemption and County Status Certificate

This form is for the employer’s records. Do not send this form to the Department of Revenue.The completed form should be returned to your employer.

Full Name _______________________________________________________ Social Security Number or ITIN __________________________

Home Address ________________________________ City _______________________ State ______ Zip Code ______________________

Indiana County of Residence as of January 1: ________________________________________ (See instructions)

Indiana County of Principal Employment as of January 1: _______________________________ (See instructions)

___________________________________________________________________________How to Claim Your Withholding Exemptions

1. You are entitled to one exemption. If you wish to claim the exemption, enter “1” .............................................................................. ___________Nonresident aliens must skip lines 2 through 6. See instructions

2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1” ................................................... ___________3. You are allowed one (1) exemption for each dependent. Enter number claimed ............................................................................... ___________4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or

(b) if you and/or your spouse are legally blind.Check box(es) for additional exemptions: You are 65 or older □ or blind □ Spouse is 65 or older □ or blind □Enter the total number of boxes checked ........................................................................................................................................... ___________

5. Add lines 1, 2, 3, and 4. Enter the total here ..................................................................................................................................... ►6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions) .................................................. ►

7. Enter the amount of additional state withholding (if any) you want withheld each pay period ........................................................... $ __________8. Enter the amount of additional county withholding (if any) you want withheld each pay period ......................................................... $ __________

I hereby declare that to the best of my knowledge the above statements are true. Signature: ______________________________________________________________________ Date: __________________________

Form WH-4State Form 48845 (R2 / 8-08)

Instructions for Completing Form WH-4This form should be completed by all resident and nonresident employees having income subject to Indiana state and/or county income tax.

Print or type your full name, Social Security number or ITIN and home address. Enter your Indiana county of residence and county of principal employment as of January 1 of the current year. If you did not live or work in Indiana on January 1 of the current year, enter “not applicable” on the line(s). If you move to (or work in) another county after January 1, your county status will not change until the next calendar tax year.

Nonresident alien limitation. A nonresident alien is allowed to claim only one exemption for withholding tax purposes. If you are a nonresident alien, enter “1” on line 1, then skip to line 7. You are considered to be a nonresident alien if you are not a citizen of the United States and do not meet the green card test and the substantial presence test (get Publication 519 from www.irs.gov for information about these tests).

All other employees should complete lines 1 through 7.

Lines 1 & 2 - You are allowed to claim one exemption for yourself and one for your spouse (if he/she does not claim the exemption for him/herself). If a parent or legal guardian claims you on their federal tax return, you may still claim an exemption for yourself for Indiana purposes. You cannot claim more than the correct number of exemptions; however, you are permitted to claim a lesser number of exemptions if you wish additional withholding to be deducted.

Line 3 - Dependent Exemptions: You are allowed one exemption for each of your dependents based on state and federal guidelines. To qualify as your dependent, a person must receive more than one-half of his/her support from you for the tax year and must have less than $1,000 gross income during the tax year (unless the person is your child and is under age 19 or under age 24 and a full-time student at least during 5 months of the tax year at a qualified educational institution).

Line 4 - Additional Exemptions. You are also allowed one exemption each for you and/or your spouse if either is 65 or older and/or blind.

Line 5 - Add the total of exemptions claimed on lines 1, 2, 3, and 4. Enter the total in the box provided.

Line 6 - Additional Dependent Exemptions. An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a son, stepson, daughter, stepdaughter and/or foster child.

Lines 7 & 8 - If you would like an additional amount to be withheld from your wages each pay period, enter the amount on the line provided. NOTE: An entry on this line does not obligate your employer to withhold the amount. You are still liable for any additional taxes due at the end of the tax year. If the employer does withhold the ad-ditional amount, it should be submitted along with the regular state and county tax withholding.

You may file a new Form WH-4 at any time if the number of exemptions increases. You must file a new Form WH-4 within 10 days if the number of exemptions previously claimed by you decreases for any of the following reasons:(a) you divorce (or are legally separated from) your spouse for whom you have been claiming an exemption or your spouse claims him/herself on a separate Form WH-4; (b) someone else takes over the support of a dependent you claim or you no longer provide more than one-half of the person’s support for the tax year; or(c) the person who you claim as an exemption will receive more than $1,000 of income during the tax year.

Penalties are imposed for willingly supplying false information or information which would reduce the withholding exemption.

http://www.irs.gov

Revenue Form K-442A804 (12-99)

KENTUCKY REVENUE CABINETEMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Payroll No. __________________________

Print Full Name _______________________________________________________________________ Social Security No. __________________________

Print Home Address ___________________________________________________________________________________________________________________EMPLOYEE:

File this form with youremployer. Otherwise, hemust withhold Kentuckyincome tax from yourwages without exemption.

EMPLOYER:

Keep this certificatewith your records. If theemployee is believed tohave claimed too manyexemptions, the RevenueCabinet should be soadvised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If SINGLE, and you claim an exemption, enter “1,” if you do not, enter “0” ................................................... ............. ________2. If MARRIED, one exemption each for you and spouse if not claimed on another certificate.

(a) If you claim both of these exemptions, enter “2”(b) If you claim one of these exemptions, enter “1” .............................................................................................. ________(c) If you claim neither of these exemptions, enter “0”

3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents):(a) If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption,

enter “2”; if both will be 65 or older, and you claim both of these exemptions, enter “4” .................................... ________(b) If you or your spouse are blind, and you claim this exemption, enter “2”; if both are blind, and you claim

both of these exemptions, enter “4” ........................................................................................................................ ________4. If you claim exemptions for one or more dependents, enter the number of such exemptions .................................. ________5. National Guard exemption (see instruction 1) ............................................................................................................... ________6. Exemptions for Excess Itemized Deductions (Form K-4A) ............................................................................................ ________

7. Add the number of exemptions which you have claimed above and enter the total ...................................................8. Additional withholding per pay period under agreement with employer. See instruction 1 ............................. $ ____________

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date _________________________________ Signed___________________________________________________________________________________

}

INSTRUCTIONS

1. NUMBER OF EXEMPTIONS—Do not claim more than the correctnumber of exemptions. However, if you have unusually large amounts ofitemized deductions, you may claim additional exemptions to avoid ex-cess withholding. You may also claim an additional exemption if you willbe a member of the Kentucky National Guard at the end of the year. If youexpect to owe more income tax for the year than will be withheld, youmay increase the withholding by claiming a smaller number of exemp-tions or you may enter into an agreement with your employer to haveadditional amounts withheld.

2. CHANGES IN EXEMPTIONS—You may file a new certificate at anytime if the number of your exemptions INCREASES.

You must file a new certificate within 10 days if the number of exemp-tions previously claimed by you DECREASES for any of the followingreasons.

(a) Your spouse for whom you have been claiming an exemption isdivorced or legally separated, or claims their own exemption on a separatecertificate.

(b) The support of a dependent for whom you claimed exemption istaken over by someone else, so that you no longer expect to furnish morethan half the support for the year.

(c) Your itemized deductions substantially decrease and a Form K-4Ahas previously been filed.

OTHER DECREASES in exemption, such as the death of a spouse or a depen-dent, do not affect your withholding until the next year, but require the filing of anew certificate by December 1 of the year in which they occur.

3. DEPENDENTS—To qualify as your dependent (line 4 on reverse), a person(a) must receive more than one-half of his or her support from you for the year,and (b) must not be claimed as an exemption by such person’s spouse, and (c)must be a citizen of the United States, or a resident of the United States, Canada,or Mexico, or (d) must have lived with you for the entire year as a member of yourhousehold or be related to you as follows:

your child, stepchild, legally adopted child, foster child (if he lived in yourhome as a member of the family for the entire year), grandchild, son-in-law, ordaughter-in-law;

your father, mother, or ancestor of either, stepfather, stepmother, father-in-law, or mother-in-law;

your brother, sister, stepbrother, stepsister, brother-in-law, or sister-in-law;

your uncle, aunt, nephew, or niece (but only if related by blood).

4. PENALTIES—Penalties are imposed for willfully supplying false informa-tion or willful failure to supply information which would reduce the withholdingexemption.

Certificate of Residence

Date , Employee Signature

Subscribed and sworn to before me, a Notary Public in and for said County and State, this day of

, . Notary Public Signature

My Commission Expires My County of Residence

The employee swears to be a legal resident of the State of , does not own personalproperty in Indiana, and understands that income from salaries, wages, tips and commissions received from Indiana sourcesare taxable in their state of residence and not subject to Indiana Adjusted Gross Income Tax as a result of the reciprocal taxagreement with the State of . Employee further states the Indiana employer will be advisedof any change in legal residence. Note: The employee understands that the employer remains responsible for withholdingany applicable Indiana County taxes.

Indiana Employer's Name Employer TID Number

Employee Name Street and City Address Social Security Number

Form WH-47SF# 9686 (R/12-97)

Do not send this form to the Indiana Department of Revenue it is to be filed with and held by the employer.

This form is to be used only by residents of States with a reciprocal tax agreement.*

*States that have reciprocal agreements with Indiana are: Kentucky, Michigan, Ohio, Pennsylvania and Wisconsin.

Employment Contingency – Background and Drug Screen Results Pending

Dear Candidate:

On behalf of Clark Memorial Hospital and LifePoint Health, I wanted to inform you that due to

late processing we have not yet received your final Background and/or Drug Screen Results.

If we do not receive the results of your background and drug screen prior to your scheduled start

date, you will be conditionally hired and allowed to work as scheduled until we receive

notification of those results. Once your background and drug screen results have been received

and approved, you will be notified that you have satisfied this condition of employment.

Individuals whose background and drug screen reports render them unable to satisfy this

condition of employment (whether or not they began employment) will be released from their

conditional employment with Clark Memorial Hospital.

We are very excited to begin working with you and if you have other questions the Human

Resources team will be happy to assist.

Sincerely,

Annette Tallarico Director, Human Resources

Please sign below acknowledging that you have read and fully understand the information stated above.

Candidate Signature Date

Revised 6/2013

Applicant Notification

Work Opportunity Tax Credit Program

This employer is participating in the Work Opportunity Tax Credit program. This program is designed by the

federal government to help companies hire more people into the workforce and to retain employees through

federal incentives.

Your response to the questions below will help us determine if this employer qualifies for this program.

Any information you provide will be kept confidential and will not affect your job, wages, or taxes. Thank you

in advance for your time and participation.

► 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 Veteran 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 supplement 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.

O C i / C ShWOTC Instructions/Fax Cover Sheet

This employer is participating in the Work Opportunity Tax Credit program. All information you provide will be kept confidential and will not affectAll information you provide will be kept confidential and will not affect your job, wages or taxes in any way.

Please follow the instructions outlined below:

1. Complete all applicable questions on the Work Opportunity Tax Credit Questionnaire.

2 Complete sign and date the Questionnaire Form 8850 FormW 42. Complete, sign and date the Questionnaire, Form 8850, Form W‐4 including Date of Birth and provide a copy of your Driver’s License. Ensure all applicable fields are complete.

3. Immediately deliver the completed forms to EY using one of the methods below.

If you have any questions or need instruction on how to complete anyIf you have any questions or need instruction on how to complete any portion of the forms, please call EY, our WOTC Administrator, at+1 866 267 5866. EY will be happy to assist you.

Thank You

EY – WORK OPPORTUNITY TAX CREDIT QUESTIONNAIRECOMPANY NAME

WORK LOCATION ID # WORK LOCATION CITY/STATE SOCIAL SECURITY NUMBER

NAME DATE OF BIRTH (IF UNDER 40) DRIVER’S LICENSE #/STATE

ADDRESS (NO P.O. BOXES) CITY/STATE ZIP CODE

� Check if you have worked for this company before. JOB OFFER DATE START DATE

Gove

rnme

nt As

sistan

ce/V

ocati

onal

Reha

bilita

tion

Chec

kALL

that

appl

y:

Yes No Not sure

� � � 1. Have you OR any member of your family living in your household received Food Stamps (SNAP) in the last year? � � � 2. Have you OR any member of your family living in your household received TANF, AFDC, Welfare or any other government assistance in the

last 2 years? � � � 3. Have you OR any member of your family living in your household received TANF, AFDC, Welfare or any other government assistance

any time in the last 10 years?� � � 4. Are you currently in OR have you ever been in a Vocational Rehabilitation program? � � � 5. Have you received Supplemental Security Income - SSI (not retirement or survivor benefits) at any time in the last 3 months?If any questions above (1-5) were answered “Yes” or “Not sure” complete section A:

Secti

on A

CITY AND COUNTY WHERE BENEFITS WERE RECEIVED STATE NAME/SSN OF PRIMARY RECIPIENT (IF NOT SELF)

AGENCY NAME CASEWORKER’S OR COUNSELOR’S NAME (CIRCLE ONE)

AGENCY ADDRESS, CITY, STATE, ZIP CODE AGENCY PHONE NUMBER

Veter

an

Yes No Not sure

� � � 6. Are you a veteran of the U.S. Military?� � � 7. Are you entitled to compensation due to a service connected disability?� � � 8. Were you discharged in the last year? � � � 9. Have you been unemployed at least 4 weeks (not necessarily consecutive) in the last year? � � � 10. Have you been unemployed at least 6 months (not necessarily consecutive) in the last year? � � � 11. Have you or any member of your family living in your household received Food Stamps (SNAP) in the last 2 years?

Enlistment Date: Discharge Date: Date of Birth:

Branch of Service: � Air Force � Army � Marines � Navy � Coast Guard � National Guard ��Other

Conv

iction

Yes No Not sure

� � � 12. Have you been convicted or released from prison for a felony in the last year OR are you in a work release program? If the answer is “YES” or “Not sure” please complete section B:

Secti

on B

PAROLE OR PROBATION OFFICER’S NAME AND ADDRESS (CIRCLE ONE) PAROLE/PROBATION OFFICER’S PHONE NUMBER

CITY AND COUNTY OF CONVICTION/INCARCERATION STATE DATE CONVICTED DATE RELEASED

Nativ

eAme

rican

Yes No

� � 13. Are you an enrolled member of a Native American tribe? Tribe name: City/State:

� �� 14. Is your spouse an enrolled member of a Native American tribe? Tribe name: City/State:

Spouse’s Full Name: (include maiden name if applicable) Spouse’s SSN: Spouse’s Date of Birth:

If “Yes,” to questions 13 or 14, please include a copy of your or your spouse’s tribal membership identification, CDIB or other documentation.

PLEASE READ, SIGN AND DATEI hereby authorize the Department of Social Services, Social Security Administration for Supplemental Security Income, Military Records, Vocational Rehabilitation, Department of Defense, National Guard, Department of Motor Vehicles, Veterans Administration, Superior Court of California, California Employment Development Department, Tribal Governments, Department of Corrections or Probation and/or Parole to provide the verification of information requested by EY or State Workforce Agencies (SWA) and release of information to those entities asrequested. This information will be used for the sole purpose of determining my eligibility, qualification and participation in Federal and State Tax Credits, including the Work Opportunity Tax Credit Program.

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job,and it is, to the best of my knowledge, true, correct and complete.

APPLICANT SIGNATURE DATE

Mail or Fax all forms to: EY Attn: WOTC Processing Center P.O. Box 226896 Dallas, TX 75222 +1 866 291 3722

Rev. 042412 ��

Form 8850 (Rev. March 2015)

Department of the TreasuryInternal Revenue Service

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

OMB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name Social security number

Street address where you live

City or town, state, and ZIP code

County Telephone number

If you are under age 40, enter your date of birth (month, day, year)

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

2 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 9months 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; orb. 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.

3 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.

4 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.

5 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.

6 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.

Signature—All Applicants Must SignUnder penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

Job applicant’s signature DateFor Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2015)

Mail or Fax to EYWOTC Processing Center P.O. Box 226896 Dallas, TX 75222 Fax: +1 800 929 0989

��

Company Name __________________________________ ��

Mail or Fax to EY WOTC Processing Center P.O. Box 226896 Dallas, TX 75222 Fax: +1 800 929 0989 Revised 1/2015 ��

W-4

The W-4 form below is used for documentation purposes for the Work Opportunity Tax Credit program only. Completing this W-4 will not affect your job, wages or taxes. Thank you for your participation.

Date of Birth: / /

Documents

Instructions for completing New Hire Paperwork-REVISED 07 2016 · 5/2/2013 · about you for employment purposes. These purposes may include hiring, contract, assignment, promotion,