EFTA00606119.pdf

09/05/2019 12:27 FAX ka0001/0003 WHITE FLEISCHNER FINO, LLP E-Mail FAX COVER SHEET FAX NUMBER TRANSMITTED TO: TO: Darren Indyke RE: W-4/Medical Insurance Form FROM: Habibe Aydin DATE: August 5, 2014 TOTAL PAGES ( 3 ) INCLUDING COVER SHEET COMMENTS: Please see attached. THIS MATERIAL BEING TRANSMITTED IS CONFIDENTIAL AND SOLELY FOR THE PERSON OR ENTITY NAMED ABOVE AND MAY BE COVERED BY THE ATTORNEY- CLIENT PRIVILEGE. IF YOUR ARE NOT THE INTENDED RECIPIENT, PLEASE DO NOT READ THE COMMUNICATION. IF YOU HAVE RECEIVED THE MATERIAL IN ERROR PLEASE NOTIFY US BY TELEPHONE AND RETURN AT THE ABOVE ADDRESS VIA POSTAL MAIL EFTA00606119  New York Member Enrollment Form - OHI I UnitedHealthcare MAILING ADDRESS: Oxford A. group ktformetfon (To tm competed by the employer) . _ _ . .. _. _. .- ..._. _ _.. Please past neatly using black or blue ballpoint pen • ALL DATES MUST BE: MM/DD/YYYY Group Number Group Name Man CEP Sing Group i Date of lire ' Effective Date ;Occupation% _ . _. / / _ / / _ I .. YVA LZ:ZI PTOZ/S0/90 O On Leave of Absence O Reared .. COBRA/Young AdulUSC Ougiying Event Date Employer illansture dale O Union Employes O Disabled . Event 1 / X / / a Applicant Dela (To be combined by the employes) I Employn/Subscriber I Spouse Chad I Child I Soot Saw Number Last Name: First Name, Middle Initiab \if Vje a ate ol Birth: (MWDD/YYYY) / / / i / / Gender and Disabil --- tietalus. HChedcappmpiste hrs. M err / [' Disabled OM OF / °Disabled . OM OF I ° Diseiled — OM OF / °Disabled Primary Care Physician (PCP) IORurvicer: l PCP Name: (if an aiming pima of PCP. check 'Yost) j Oyes: O Yee: O Yes • yes Check all that apply: j °Domestic Penner i O rutting Student O Pull-time Student f 'O Young Adult O Young Adult Prior Carrier Confer (List coverage pier to this.) Policy Number: From Date / 0 Same for sii Thru date:: I I I I I C. Coordination of Benefits Employea/Subealber i Spouse Chid - ... _ _ — . . ____ _ . Child Check appropriateO Part A I / ,O Part A I / . 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Ser Swiss Oat* WSJ•• taw 41-904•4 Personal Allowances Worksheet (Keep for your records.) A En•.er '1' for yourself if no one else can claim you as a dependent A • You we single and have only one job; cc B Enter '1" 4: { • You are married, have only one job, and your spouse does not woe; or B • Your wages from a second job or your spouse' a wages (or the total of braless $1,500 cc lees. } C Enter -1* for you spouse. But, you may choose to erase -4)-* if you we maned and ham ether a waking spouse or more than one job. (Entering --0-* may help you avoid having too Ma tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you wil claim on your tax ratan D E Enter el- 4 you nil fee as heed of househokl on you tax retain (see conditions under Heed of household above) E F Erne "V d you have at least $2.000 of dad or dependent owe expenses for wrath you plan to claim a Credit . F (Not* Do not include child supine payments. See Pit. 503, Chid ad Dependent Care Expenses, for details.) O Child Tax Credit linclucing *Morel chid tax credit). See Pub. 972. Child Tax Croce, for more inknnatior. • If your total income Mo be Ian than $65.000 ($95,000 If married). clear et for each eligible end; then less el" if you have three to six °table chicken a less '2' it you have seven or more eligible children. • li your total Iroorre ell be between $65,030 ad $14,030 ($95,000 rid $119,000 if matte* aver':' beach eligible chat . . . 0 H Add sire A through 0 ad ea ton hat. Noss This may be efferent torn the number of exemptions you balm on you lac robin.) le H • If you plan to itemize a darn adjustments toilsome and wait to reduce your withholding. see thr Deductions Foe arturacT { endAdjustments Worksheet on page 2. OcerOva a • If you as angle and hew more than one job or we muted end you end your spouse both work and the Comblrel weidtgliesta avtwge from ell jobs exceed $50,000 ($20,000 Unman). see the twieternersiniMple Jobs Worksheet on pipe 2 to list apply. avoid haves) loo alb tax withhold. • I nether of the above situatora applies, stop here and enter the rumba from Ina H on line 6 at Fan W4 below. Separate Sr. and give Form W-4 to your OmplOyer. Keep the top part for your recede. Employee's Withholding Allowance Certificate Form W-4 01.4011b.1546-0074 Orprown home wear name ammo ► Meer you wsatedodarn • oaten cacao.. el .Iowans or autaptioo horn withholding ts mega to none by en RS. Yoe *mayor My to rowed * nod • one of this ton" to **IRS. 2014 I Youea sae and moot nits Last name ACCI i turd 3 iN Singe 0 Monied 0 Na. IImedal, tut Sooty wont re acme a. emotion as dock w lope kw 4 Isar last some tapes bee tot oboe on yew sada soca ewe, dwelt hwy. You mat call 1400-772-1213 fora ►0 a (hem line 11 above or born the amicable worksheet on page 2) 6 Additional amount, 0 any, no want withheld from each paycheck 7 Id:km exemption from vAtaceding for 2014, *odic:artily that I meet boas of the Mowing conditions to exemption. • Last year I had a right to a rasa of an federal income tax withheld because a had no tax liability, and • This year I expect a rotten Wander* Income tax vehhold because I expect to have no tax If you meet both conditions, wits 'Exempt" here Under senates of perjury, I dedare that I of my blow edge and Dallis true, corect, area corals Emplosa's signature (This loon la not win unless you sign it.) oi Date iv Briayers rave ad abyss Employer: IRS) I Mama 6Wkeig 10 Eselwerldowlcutenrurrter(ELO) For Fancy Act and Paperwork Reduction Act None, an pegs 2. Cn No 102203 kern W..4 (sole EFTA00606121