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09/05/2019 12:27 FAX ka0001/0003
E-Mail
FAX COVER SHEET
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.
EFTA00606119
Medicare Coverage
New York Member Enrollment Form - OHI
I UnitedHealthcare
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
/
/
_
/
/ ..
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
Soot Saw
Number
Last Name:
First Name, Middle Initiab
\if Vje
a
ate ol Birth: (MWDD/YYYY)
/
[repeated 3 times]
i
/
/
Gender
and Disabil
--- tietalus.
HChedcappmpiste hrs.
Primary Care Physician (PCP) IORurvicer:
M err
['
/
Disabled
OM OF / °Disabled . OM OF I
° Diseiled
j
— OM
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PCP Name: (if an aiming pima of PCP. check 'Yost)
Oyes:
O Yee:
O Yes • i O rutting Student
O Pull-time Student
Check all that apply:
j °Domestic Penner
'O Young Adult
O Young Adult
f
I
Prior Carrier
Confer
(List coverage pier to this.)
Policy Number:
From Date
0 Same for sii
Thru date::
/
I
[repeated 5 times]
OF / °Disabled yes
C. Coordination of Benefits
Employea/Subealber
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Spouse
-
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,O Part A
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box end list
DPAIE.
/
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effective dialer
O Part D
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/
ia Part D
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Pharmacy
Policy Number:
°Senator ell
Cartier:
Policy Holder:
Effective Date:
Group Number:
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Medical
O Sane for SI
Policy Number:
Carden
Policy Holder:
Effective Date:
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EFTA00606120
08/05/2014
12:28 FAX
410003/0003
Form W-4 (2014)
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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
• Your wages from a second job or your spouse' a wages (or the total of braless $1,500 cc lees. }
B
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.
{
Ocer Ova 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.
Form W-4
Employee's Withholding Allowance Certificate
► Meer you wsatedodarn • oaten cacao.. el .Iowans or autaptioo horn withholding ts
Orprown home wear name ammo mega to none by en RS. Yoe *mayor My to rowed * nod • one of this ton" to **IRS.
01.4011b.1546-0074
2014
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(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
Emplosa's signature
(This loon la not win unless you sign it.) oi
Briayers rave ad abyss Employer:
of my blow edge and Dallis true, corect, area corals
Date iv
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