Employment Application

Thank you for your interest in applying to CityCARE Home Health.

The entire application can be completed online using a computer or cell phone and will take approximately 20 minutes.

Please, fill out the forms below

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IN ORDER TO SECURE EMPLOYMENT WE WILL NEED YOUR IDENTIFICATION AND SOCIAL SECURITY CARD. PLEASE UPLOAD THEM HERE.

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Frequently Asked Questions

WHAT ARE THE AGENCIES HOURS?

The Agency Office’s days and hours of operation are Monday to Sunday from 8:00 AM to 4:00 PM. We are on call 24 hours a day and 7 days a week. Unless it is an emergency please call us only during regular office hours.

WHERE ARE YOUR CLIENTS?

CityCARE Home Health services clients in all seven Connecticut counties. Fairfield, New Haven, Middlesex, New London, Windham, Hartford, Litchfield.

WHEN WILL I BE PAID?

City CARE Home Health has a standard 40-hour work week, which is Monday through Sunday, beginning on Monday at 12:01 am and ending on Sunday at 12:00 midnight. The Agency's pay period covers a 7-day timeframe, which starts at 12:01 am on the Monday and ends at 12 Midnight Sunday. Payday is every Friday and occurs 52 times a year. In order to make sure payroll is processed properly and to comply with Connecticut State Laws you must use the telephone clock in/out system. Pay checks will be ready for pickup at the Agency Office by appointment during office hours on Friday. This paycheck will include all hours worked the previous week.

HOW DO I GET A WORK ASSIGMENT?

  • Work assignments for in-home employees are scheduled by the Office Manager. They are offered on the basis of services required, qualifications/expertise needed and availability of employee(s).
  • Keep your contact information current with the Agency office. We must be able to reach you easily and often on short notice.
  • When you receive and accept an assignment, you agree to the hours that the job requires. Should the requirements of that job change, you will be given first option of keeping that assignment, if you are willing to work within the changes. On the other hand, if you are not able to work within the new changes, another employee will be assigned.
  • You may refuse an assignment but doing so does not mean a replacement assignment will become available; or, if one does, it doesn't mean that the replacement assignment will be given to you. There is no guarantee of work assignments, as requests for service are unpredictable and can be sporadic.
  • Sometimes assignments come up on very short-notice. Being willing to accept these last-minute assignments and/or being available to cover for sick employees, will increase your chances of receiving assignments.

DO YOU OFFER DIRECT DEPOSIT?

Direct deposit is offered to all City Care Home Health employees. If you do not wish to receive a direct deposit, Wisely cards are available free of charge and can be funded electronically. Finally, you have the option of picking up a paper check from our office.

WHAT IS THE CLOCK IN SYSTEM?

In accordance with City CARE Home Health Policy # 6.60 - Payroll, employees shall accurately record all hours worked by clocking in/out from the clients home phone. Be sure you clock in and out accurately at the beginning and end of your work shift. Your Supervisor will review your clock in/out time before it is forwarded to payroll for processing. While we make an effort to correct any clock in/out errors which we notice, your payroll hours may not include the times you failed to punch in/out. In such cases payroll correction will be made the following week. Falsifying clock in/out times are grounds for immediate Termination of Employment.

MAY I USE MY CELL PHONE WHEN I AM WITH A CLIENT?

You are not permitted to make or accept telephone calls or texts while you are on duty at clients’ homes, unless they are from Managerial Staff, or an emergency/urgent situation develops. If you carry a cell phone with you, when you are on duty, be sure to either turn it off or put it on "vibrate" to ensure clients are not disturbed. Advise others to phone the Agency Office and leave a message, should they need to reach you, while you are on duty. The Agency Office will contact you with the message. Personal phone calls and/or texting may be done on your breaks or between assignments. Long distance calls may not be made using Agency phones, unless the call is business-related. Neither may Long distance calls be made using a client's phone.

WHAT IF I CANNOT MAKE MY ASSIGMENT?

When you are not able to work because of short-term illness or other reasons, you must contact your Supervisor, as soon as you are aware that you cannot report for duty, in order that a substitute can be arranged, if necessary. As a minimum, you are required to give at least 48-hours’ notice. If you become aware, during non-office hours, that you cannot cover your assignment(s), you must contact the Supervisor on call. If you do not contact a Supervisor and fail to report for your assignment, you will be considered a "no-show" and may be subject to disciplinary action.

    JOB/EMPLOYMENT APPLICATION

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    JOB/EMPLOYMENT APPLICATION

    Personal Information

    Name
    Address

    Please list all addresses where you have resided in the past seven years

    Phone
    Electronic
    Date of Birth
    SSN
    Gender

    Language

    Education

    Formal


    Informal

    Do you currently have a CNA/PCA/HHA license?

    Other

    Restrictions

    Work Limitations

    List any work limitations that you may have and briefly describe:

    Availability for Work

    Hours & Days Available for Work


    Indicate Days and List Hours Available for Work:

    Client Types and Work Duties

    Type of Position(s) Preferred

    Live-in care usually requires that you to in a client’s home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:

    Clients Not Willing/Able to Work With
    Duties Not Willing/Able to Perform
    Experience
    Assignment Location

    Transportation

    Type
    Type
    Transporting Clients

    Investigations

    Have you ever been convicted of a crime in a state court or federal court in any state. If “yes”, please explain
    Have you ever been investigated for abuse, neglect or domestic violence? If “yes”, explain:
    Were you subject to any decision imposing disciplinary action by a licensing agency in any state, or the District of Columbia. If “yes” please explain.

    Reference Information

    Work Related #1 (Last Position)
    Work Related #2 (2 nd Last Position)
    Personal #1

    JOB/EMPLOYMENT APPLICATION

    I certify that I have read and understand this application. The answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. Additionally, any prospective employee who makes a false written statement regarding prior criminal convictions or disciplinary action can be guilty of a class A misdemeanor.

    I authorize former employers, references and any other individual/organizations to provide information to CityCARE Home Health and I hereby release and discharge any of the above and CityCARE Home Health from any liability of any kind or nature. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and completion of a background check. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

    PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    Pre-Employment Background Check Authorization

    Understand that as part of the employment process, CityCARE Home Health needs to complete a background check on me regarding:

    1. Criminal record;
    2. Sex and violent offenders record;
    3. Employment verification;
    4. Education verification;
    5. License verification;
    6. Motor vehicle Records;
    7. Personal/professional reference verification;
    8. Medical suitability;
    9. Social security verification;
    10. Drugs/alcohol.
    • I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to CityCARE Home Health or its authorized agent(s).
    • I understand that this authorization is to be part of the written and signed employment application.
    • I also understand that i do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
    • I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
    • I further authorize that a photocopy of this authorization may be considered as valid as the original.
    • I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with CityCARE Home Health is contingent upon successful complection of a background check.
    Name
    Phone Number
    Former Name(s)
    Date(s) Used
    Current Address *
    Date of Birth
    Social Security Number *
    Current driver’s license number
    State
    List any other cities, states and dates of residency during last 10 years

    CityCARE Home Health complies with state and federal regulations for conducting criminal background checks and sexual offender investigations: Our background check will include a review of any application materials prepared or requessted by the agency and completed by the prospective employee; an in-person interview of the registry established and maintained pursuant to section 54-257 a review of criminal conviction information obtained through a search of current criminal matters of public record in this state based on the prospective employee’s name and date of birth; If the prospective employee has esided in this state less than three years prior to the date of the application with the agency, a review of criminal conviction information from the state or states where such prospective employee resided during such three-year period; a review of any other information that the agency deems necessary in order to evaluate the suitability of the prospective employee for the position.

    ACKNOWLEDGMENT OF HANDBOOK

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    Acknowledgment of Handbook

    I have been oriented to CityCARE Home Health Employee Handbook. I understand the Agency’s policies and procedures and hereby agree to abide by them. I also understand that all jobs are “Per Diem” positions and, being such, are not permanent.

    Employee’ Name
    Todays Date

    CITYCARE HOME CARE

    PCA LIVE-IN RESPONSIBILITIES

    CITYCARE HOME CARE

    Meals: The client is responsible for providing meals for you while you provide live-in services. You are to eat what the client eats, whether you prepare it for them or it is prepared by the family. If you have a special diet, you are excused from the general rule requiring you eat what the client eats, however, you are responsible for bringing this food with you and taking the time to prepare it during the time that you prepare the client’s food. Neither the client nor their family is required to provide food for your special diet

    Time off: There is no extended period of time required for you to maintain a caregiver relationship with a client. If you would like time off, you must make a written request at least 2 weeks in advance. If you do not request time off with at least a 2 week notice, the time off may not be approved. If there is an emergency, we ask that you call immediately and allow us to find someone to fill the case before you leave. You cannot walk out on a Client under any circumstances until your replacement Caregiver arrives. All changes in shifts of Caregivers will only take place at 9:00 AM on the day you arrive and on the day you leave without pre-approval from City Care Home Care. You are not, under any circumstance, allowed to schedule your own fill-in for a time off request. All scheduling changes are to be conducted through and by a scheduling coordinator only, any violation will result in immediate disciplinary action.

    Hospitals: If the client goes into the hospital, you must immediately notify the office by telephone. You are not, under any circumstance, allowed to go to the Hospital with the client. After the client leaves for the hospital you are to immediately clock out, inform City Care Home Care of the hospitalization and you are to then follow the directions they provide to you. Make sure that the client has their ID and keys before they leave for a hospital stay.

    Ambulance: If the Client falls or otherwise experiences a medical emergency, you must first call 911 immediately and then call City Care Home Care to report the incident. If the client is placed in an ambulance, you are to stay behind, immediately clock out, inform City Care Home Care of the ambulance trip, and you are to then following the direction they provide to you. Make sure that the client has their ID and keys before they leave on an ambulance.

    Sleep: You are expected to receive 8 hours of sleep during each 24-hour period. This 8 hour period of sleep will be from 12a.m. to 8a.m. each day and will be unpaid. You do not need to clock out at 12a.m. nor back in at 8a.m., this will be done administratively for your overnight periods. However, if you do not experience at least 5 hours of uninterrupted sleep (if the client wakes up during your sleep time and requires your assistance), you must record the time that you use taking care of the client when you should be sleeping. To record this time you must first re-set the call in system by calling to “clock out,” and then call back immediately to “clock in” again, complete what is required of you, call again to “clock out” and then one final time to “clock in” again for the remainder of the day prior to going back to sleep. This is to document the amount of time that you spent taking care of the client during the night. This must be done for each time the client wakes up during the night if you are unable to obtain 5 hours of uninterrupted sleep.

    Meals Time: You are expected to receive three separate 1 hour meal time breaks during each 24-hour period. Each of these three 1-hour meal periods will be unpaid. You do not need to clock out nor back in for these periods, this will be done administratively for your meal periods. However, if you do not experience the full hour of uninterrupted meal time (if the client requires your assistance during such period of time), you must notify City Care Home Care that you were unable to take one or more of your one-hour meal breaks during any 24-hour period.

    Personal Time: You are expected to receive four1-hour personal breaks during each 24-hour period. Each of these two personal break periods will be unpaid. You do not need to clock out nor back in for these periods, this will be done administratively for your personal break periods. However, if you do not experience the full period of uninterrupted personal time (if the client requires your assistance during such period of time), you must notify City Care Home Care that you were unable to take one or more of your personal breaks during any 24 hour period.

    Clocking In and Out: You must clock in immediately upon your arrival at the clients home. You must clock out at 8 a.m. every day. If you are staying after 8 a.m. on any day, immediately after you have clocked out, you are to clock back in to begin the shift for the next day. If you are taking time off or your shift with the client has ended, you must then clock out when the replacement aide arrives at the client’s home. You may not leave the client until your replacement arrives.

    Should you have any questions about the above, or anything at all, please be sure to contact City Care Home Care. We will be glad to answer any questions you may have in reference to company policy and procedure. You must always speak with City Care Home Care in reference to time off, leaving a client, and anything that has to do with a schedule.

    By signing this memorandum, you confirm that you have received the information as it pertains to meals, time-off, hospitalizations and ambulance needs of the clients, sleep and mealtime, and calling in and out. You further confirm that you understand and agree with all of the information provided in the memorandum and that if you have any questions about any of the topics here presented it is your responsibility to call the office and speak with [*] in order to better understand this information. You also understand that by signing this memorandum you are liable for fulfilling the policies and complying with the policies as described in this memorandum.

    Agreed and Accepted By
    Printed Name
    Todays Date

    EMPLOYEE NON-SOLICITATION

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    Employee non-solicitation

    During the term of employment of the person signing below (“Employee”) with CityCare Home Health Corp. (“CityCare”) and for 120 days thereafter, whether for compensation or not, Employee (directly or indirectly, either as an employee, employer, consultant, agent, principal, partner, stockholder, corporate officer, director, or in any other individual or representative capacity):

    1. Shall not lure away or hire, or encourage any other person or entity to lure away or hire, any employee of CityCare to perform services for any other person or entity, or attempt to lure away any such employee to leave their job with City Care; or
    2. Shall not try to take or actually take, or help any other person or entity to try to take or actually take any client of CityCare to do business with or seek to do business with any other person or entity; and shall not seek or attempt to cause any client of CityCare to reduce, terminate, or otherwise modify its relationship with CityCare.

    Employee hereby agrees to account for and pay over, the compensation, earnings, profits, monies, accruals, or other benefits derived or received by Employee as a result of any transaction constituting a breach of any of the covenants provided in this agreement.

    mployee understands that it is impossible to measure in money the damages that will accrue to CityCare in the event that Employee breaches these covenants, thus CityCare shall also be entitled to such equitable relief (including specific performance) without the requirement to post bond in order to restrain the Employee from violating such covenant.

    The remedies provided for in this agreement are cumulative and in addition to any other rights and remedies CityCare may have under law or in equity.

    This agreement is binding on and is for the benefit of the parties and their respective successors and assigns. The obligations of Employee under this agreement may not be assigned without CityCare’s written consent. This agreement may only be changed or modified by an instrument in writing signed by all of the parties to this agreement. A failure of either party to insist upon strict compliance of any term of this agreement shall not be deemed a waiver of such provision or any other provisions of this agreement. This agreement may be executed on separate pages by each person and reproductions of signatures (e.g., .pdf, .jpg) shall be as enforceable as an original.



    CITYCARE:
    CITYCARE HOME HEALTH CORP.

    EMPLOYEE:
    Name/Title:
    Todays Date:

      Department of Homeland Security

      U.S. Citizenship and Immigration Services

      OMB No. 1615-0047; Expires 08/31/12

      Form I-9, Employment

      Eligibility Verification

      Instructions
      Read all instructions carefully before completing this form.

      Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.

      What Is the Purpose of This Form?

      The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.

      When Should Form I-9 Be

      When Should Form I-9 Be Used?

      All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9

      Filling Out Form I-9

      Section 1, Employee

      This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

      Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

      Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an mployment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present

      in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).

      Preparer/Translator Certification

      The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally.

      Section 2, Employer

      For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.

      If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.

      Employers must record in Section 2:

      1. Document title;
      2. Issuing authority;
      3. Document number;
      4. Expiration date, if any; and
      5. The date employment begins.

      Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9.

      Form I-9 (Rev. 08/07/09) Y

      For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."

      Section 3, Updating and Reverification

      Employers must complete Section 3 when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section1 (if any). Employers CANNOT specify which document(s) they will accept from an employee.

      A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

      B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

      C. If an employee is rehired within three years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B; and:

      1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C);

      2. Record the document title, document number, and expiration date (if any) in Block C; and

      3. Complete the signature block.

      Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3.

      What Is the Filing Fee?

      There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.

      USCIS Forms and Information

      To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.

      Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218.General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.

      Photocopying and Retaining Form I-9

      A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.Photocopying and Retaining Form I-9Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.

      Privacy Act Notice

      The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

      This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

      This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

      Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

      Form I-9 (Rev. 08/07/09) Y Page 2

      EMPLOYERS MUST RETAIN COMPLETED FORM I-9M
      DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

      Paperwork Reduction Act

      An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

      Form I-9 (Rev. 08/07/09) Y Page 3

      Department of Homeland Security

      U.S. Citizenship and Immigration Services

      OMB No. 1615-0047; Expires 08/31/12

      Form I-9, Employment

      Eligibility Verification

      Read instructions carefully before completing this form. The instructions must be available during completion of this form.
      ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.

      Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)

      Print Name:

      Last *

      First *

      Middle Initial

      Maiden Name

      Address (Street Name and Number) *

      Apt. #

      Date of Birth (month/day/year) *

      City *

      State *

      Zip Code *

      Social Security # *

      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): *

      until (expiration date, if applicable - month/day/year)

      Employee's Signature *

      Date (month/day/year) *

      Preparer and/or Translator Certification(To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

      Preparer's/Translator's Signature

       

      Print Name

       

      Address (Street Name and Number, City, State, Zip Code)

       

      Date (month/day/year)

       

      CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

      (month/day/year)

       

      and that to the best of my knowledge themarried employee is authorized to work in the United States. (State

      employment agencies may omit the date the employee began employment.)

      Signature of Employer or Authorized Representative

       

      Print Name

       

      Title

       

      Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

       

      Date (month/day/year)

       

      Form I-9 (Rev. 08/07/09) Y Page 4

      Form W-4
      (Rev. December 2020) Department of the Treasury Internal Revenue Service

      Employee’s Withholding Certificate

      ► Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
      ► Give Form W-4 to your employer.
      ► Your withholding is subject to review by the IRS.
      		 OMB No. 1545-0074 2023

      Step 1:
      Enter
      Personal
      Information

      (a) First name and middle initial *

      Last name *

      (b) Social security number *

      Address *

      		 ► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

      City or town, state, and ZIP code
      (c)

      Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

      Step 2:
      Multiple Jobs
      or Spouse Works
      Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.
      Do only one of the following.
      (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
      (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
      (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This
      option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld
      TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

      Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

      Step 3:
      Claim Dependents
      If your income will be $200,000 or less ($400,000 or less if married filing jointly):
      Multiply the number of qualifying children under age 17 by $2,000
      Multiply the number of other dependents by $500
      Add the amounts above and enter the total here
      		 3

      Step 4 (optional):
      Other Adjustments
      (a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here.
      This may include interest, dividends, and retirement income
      		 4(a)
      (b) Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter
      the result here
      		 4(b)
      (c) Extra withholding. Enter any additional tax you want withheld each pay period.
      		 4(c)

      Step 5:
      Sign Here

      		 Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
      Employee’s signature * (This form is not valid unless you sign it.) Date *

      Employers Only

      		 Employer’s name and address

      		 First date of employment

      		 Employer identification number (EIN)
      For Privacy Act and Paperwork Reduction Act Notice, see page 3.
      Cat. No. 10220Q
      Form W-4 (2023)
      Form W-4 (2023)
      Page 2

      General Instructions

      Future Developments

      For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

      Purpose of Form

      Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505.

      Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.

      Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

      As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).

      When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:

      1. Expect to work only part of the year;
      2. Have dividend or capital gain income, or are subject to additional taxes, such as the
        3. additional Medicare tax;
      3. Have self-employment income (see below); or
      4. Prefer the most accurate withholding for multiple job situations.

      Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

      Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

      Specific Instructions

      Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

      Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.

      Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

      If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

      Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

      Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

      Step 4 (optional).

      Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

      Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

      Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

      Form W-4 (2023)
      Page 3

      Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

      If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

      Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

      1 Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have onejob, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that
      value on line 1. Then, skip to line 3
      		 1
      2 Three jobs.. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
      a) Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying jobin the “Lower Paying Job” column. Find the value at the intersection of
      the two household salaries and enter that value on line 2a
      		 2a
      b) Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying
      Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b
      		 2b

      c) Add the amounts from lines 2a and 2b and enter the result on line 2c
      		2c
      3 Enter the number of pay periods per year for the highest paying job. For example, if that job
      paysweekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc.
      		 3
      4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter thisamount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additionalamount
      you want withheld)
      		 4

      Step 4(b)—Deductions Worksheet (Keep for your records.)

      1 Enter an estimate of your 2023 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local
      taxes (up to $10,000), and medical expenses in excess of 7.5% of your income
      		1
      2
      Enter:
      • $27,700 if you’re married filing jointly or qualifying widow(er)
      • $20,800 if you’re head of household
      • $13,850 if you’re single or married filing separately
       
      		 2
      3
      If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-”
      		 3
      4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
      adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information
      		 4
      5
      Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4
      		5

      Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

      You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

      The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

      If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

      Form W-4 (2023)
      Page 4

      Married Filing Jointly or Qualifying Widow(er)

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $0 $0 $850 $850 $1,000 $1,020 $1,020 $1,020 $1,020 $1,020 $1,020 $1,870
      $10,000 - 19,999 0 930 1,850 2,000 2,200 2,220 2,220 2,220 2,220 2,220 3,200 4,070
      $20,000 - 29,999 850 1,850 2,920 3,120 3,320 3,340 3,340 3,340 3,340 4,320 5,320 6,190
      $30,000 - 39,999 850 2,000 3,120 3,320 3,520 3,540 3,540 3,540 4,520 5,520 6,520 7,390
      $40,000 - 49,999 1,000 2,200 3,320 3,520 3,720 3,740 3,740 4,720 5,720 6,720 7,720 8,590
      $50,000 - 59,999 1,020 2,220 3,340 3,540 3,740 3,760 4,750 5,750 6,750 7,750 8,750 9,610
      $60,000 - 69,999 1,020 2,220 3,430 3,540 3,740 4,750 5,750 6,750 7,750 8,750 9,750 10,610
      $70,000 - 79,999 1,020 2,220 3,340 3,540 4,720 5,750 6,750 7,750 8,750 9,750 10,750 11,610
      $80,000 - 99,999 1,020 2,220 4,170 5,370 6,570 7,600 8,600 9,600 10,600 11,600 12,600 13,460
      $100,000 - 149,999 1,870 4,070 6,190 7,390 8,590 9,610 10,610 11,660 12,860 14,060 15,260 16,330
      $150,000 - 239,999 2,040 4,440 6,760 8,160 9,560 10,780 11,980 13,180 14,380 15,580 16,780 17,850
      $240,000 - 259,999 2,040 4,440 6,760 8,160 9,560 10,780 11,980 13,180 14,380 15,580 16,780 17,850
      $260,000 - 279,999 2,040 4,440 6,760 8,160 9,560 10,780 11,980 13,180 14,380 15,580 16,780 18,140
      $280,000 - 299,999 2,040 4,440 6,760 8,160 9,560 10,780 11,980 13,180 14,380 15,870 17,870 19,740
      $300,000 - 319,999 2,040 4,440 6,760 8,160 9,560 10,780 11,980 13,470 15,470 17,470 19,470 21,340
      $320,000 - 364,999 2,040 4,440 6,760 8,550 10,750 12,770 1 14,770 16,770 18,770 20,770 22,770 24,640
      $365,000 - 524,999 2,970 6,470 9,890 12,390 14,890 17,220 19,520 21,820 24,120 26,420 28,720 30,880
      $525,000 and over 3,140 6,840 10,460 13,160 15,860 18,390 20,890 23,390 25,890 28,390 30,890 33,250

      Single or Married Filing Separately

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $310 $890 $1,020 $1,020 $1,020 $1,860 $1,870 $1,870 $1,870 $1,870 $2,030 $2,040
      $10,000 - 19,999 890 1,630 1,750 1,750 2,600 3,600 3,600 3,600 3,600 3,760 3,960 3,970
      $20,000 - 29,999 1,020 1,750 1,880 2,720 3,720 4,720 4,730 4,730 4,890 5,090 5,290 5,300
      $30,000 - 39,999 1,020 1,750 2,720 3,720 4,720 5,720 5,730 5,890 6,090 6,290 6,490 6,500
      $40,000 - 59,999 1,710 3,450 4,570 5,570 6,570 7,700 7,910 8,110 8,310 8,510 8,710 8,720
      $60,000 - 79,999 1,870 3,600 4,730 5,860 7,060 8,260 8,460 8,660 8,860 9,060 9,260 9,280
      $80,000 - 99,999 1,870 3,730 5,060 6,260 7,460 8,660 8,860 9,060 9,260 9,460 10,430 11,240
      $100,000 - 124,999 2,040 3,970 5,300 6,500 7,700 8,900 9,110 9,610 10,610 11,610 12,610 13,430
      $125,000 - 149,999 2,040 3,970 5,300 6,500 7,700 9,610 10,610 11,610 12,610 13,610 14,900 16,020
      $150,000 - 174,999 2,040 3,970 5,610 7,610 9,610 11,610 12,610 13,750 15,050 16,350 17,650 18,770
      $175,000 - 199,999 2,720 5,450 7,580 9,580 11,580 13,870 15,180 16,480 17,780 19,080 20,380 21,490
      $200,000 - 249,999 2,900 5,930 8,360 10,660 12,960 15,260 16,570 17,870 19,170 20,470 21,770 22,880
      $250,000 - 399,999 2,970 6,010 8,440 10,740 13,040 15,340 16,640 17,940 19,240 20,540 21,840 22,960
      $400,000 - 449,999 2,970 6,010 8,440 10,740 13,040 15,340 16,640 17,940 19,240 20,540 21,840 22,960
      $450,000 and over 3,140 6,380 9,010 11,510 14,010 16,510 18,010 19,510 21,010 22,510 24,010 25,330

      Head of Household

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $0 $620 $860 $1,020 $1,020 $1,020 $1,020 $1,650 $1,870 $1,870 $1,890 $2,040
      $10,000 - 19,999 620 1,630 2,060 2,220 2,220 2,220 2,850 3,850 4,070 4,090 4,290 4,440
      $20,000 - 29,999 860 2,060 2,490 2,650 2,650 3,280 4,280 5,280 5,520 5,720 5,920 6,070
      $30,000 - 39,999 1,020 2,220 2,650 2,810 3,440 4,440 5,440 6,460 6,880 7,080 7,280 7,430
      $40,000 - 59,999 1,020 2,220 3,130 4,290 5,290 6,290 7,480 8,680 9,100 9,300 9,500 9,650
      $60,000 - 79,999 1,500 3,700 5,130 6,290 7,480 8,680 9,880 11,080 11,500 11,700 11,900 12,050
      $80,000 - 99,999 1,870 4,070 5,690 7,050 8,250 9,450 10,650 11,850 12,260 12,460 12,870 13,820
      $100,000 - 124,999 2,040 4,440 6,070 7,430 8,630 9,830 11,030 12,230 13,190 14,190 15,190 16,150
      $125,000 - 149,999 2,040 4,440 6,070 7,430 8,630 9,980 11,980 13,980 15,190 16,190 17,270 18,530
      $150,000 - 174,999 2,040 4,440 6,070 7,980 9,980 11,980 13,980 15,980 17,420 18,720 20,020 21,280
      $175,000 - 199,999 2,190 5,390 7,820 9,980 11,980 14,060 16,360 18,660 20,170 21,470 22,770 24,030
      $200,000 - 249,999 2,720 6,190 8,920 11,380 13,680 15,980 18,280 20,580 22,090 23,390 24,690 25,950
      $250,000 - 449,999 2,970 6,470 9,200 11,660 13,960 16,260 18,560 20,860 22,380 23,680 24,980 26,230
      $450,000 and over 3,140 6,840 9,770 12,430 14,930 17,430 19,930 22,430 24,150 25,650 27,150 28,600

      Connecticut Health Benefits Waiver of Coverage

      Mailing Address: Enrollment Dept. ■ 14 Central Park Drive ■ Hookset, NH 03106 ■ 1-888-201-4216 ■ www.oxfordhealth.com

      Group Name: *

      Group Policy Number (if known):

      Employee Name: *

      Marital Status: *

      Date of Employment: *

      Date of Birth: *

      I am employed by and working at least 30 hours per week for the group shown above. I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Oxford Health Plans (CT), Inc and/or Oxford Health Insurance, Inc and I refuse coverage.

      Reason for Refusal (please check all appropriate boxes)*

      INFORMATION:

      Name of carrier

      Policy number

      I certify that all information provided in this form is true and complete. By refusing group health benefits, I acknowledge that I and/or my dependents may have to wait until the plan’s next anniversary date to be enrolled for group coverage.

      Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Any material misrepresentation within this waiver may subject the group to termination.

      Signature of Employee*

      Date*

      Signature of Benefits Administrator

      Date

      Acknowledgment of Employee Guidelines

      CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

      Acknowledgment of Employee Guidelines

      I have been oriented to CityCARE Home Health Employee Guidelines. I understand the Agency’s policies and procedures and hereby agree to abide by them. I also understand that all jobs are “Per Diem” positions and, being such, are not permanent.

      Employee’ Name
      Todays Date

      ACKNOWLEDGEMENT OF HIPPA AND UNIVERSAL PRECAUTIONS TRAINING

      CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

      ACKNOWLEDGEMENT OF HIPPA AND UNIVERSAL PRECAUTIONS TRAINING

      Employee’ Name
      Todays Date
      PCA Certification Test
      Clocking in and out.
      Instruction video
      PCA Training
      Employee Handbook

      Titled Universal Precautions

      Hippa Rules And Compliance