KF Office Please enable JavaScript in your browser to complete this form. - Step 1 of 17The Company is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of age, sex, gender identity, sexual orientation, domestic partnership, race, color, creed, religion, ethnicity, national origin, alienage or citizenship status, disability, marital status, veteran status, military status, domestic violence victim status, genetic information or any other legal recognized protected basis under federal, state, or local laws, regulations or ordinances. The Company also provides reasonable accommodations to disabled individuals to assist in the hiring process and to qualified individuals with disabilities in the performance of essential job functions without imposing a hardship on the Company, as required by federal, state or local law. The Company also is committed to accommodating religious beliefs. 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.Application for EmploymentChoose your companyAliahHomeCareAtYourSideHCLast nameFirst NameM.I.DateAddressApartment/Unit #CityStateZIP CodePhoneEmailDate of BirthSocial Security #Date AvailablePosition Applied ForAre you available to work overtime and work the days and hours required of this position, which may include potential weekend shifts?YesNoIt is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to a job offer (if any) and consistent with applicable law, we will consider whether a reasonable accommodation can be made.Are you a citizen of the United States?YesNoIf no, are you authorized to work in the U.S.?YesNoHave you ever worked for this Company or a related entity?YesNoIf yes, when?Do any of your family or friends work for this Company or a related entity?YesNoIf yes, please list their namesHow did you find out about the position you are applying for?NextEducationHigh SchoolAddressDid you graduate?YesNoDegreeCollegeAddressDid you graduate?YesNoDegreeOtherAddressDid you graduate?YesNoDegreeNextReferencesPlease list 3 professional referencesNameFirstLastRelationshipCompanyPhoneAddressNameFirstLastRelationshipCompanyPhoneAddressNameFirstLastRelationshipCompanyPhoneAddressNextPrevious EmploymentCompanyPhoneAddressSupervisorJob titleResponsibilitiesFrom:To:Reason for leavingMay we contact your previous supervisor for a reference?YesNoCompanyPhoneAddressSupervisorJob TitleResponsibilitiesFrom:To:Reason for leavingMay we contact your previous supervisor for a reference?YesNoCompanyPhoneAddressSupervisorJob titleResponsibilitiesFrom:To:Reason for leavingMay we contact your previous supervisor for a reference?YesNoNextMilitary ServiceBranchFrom:To:Rank at DischargeOther Skills and QualificationsSummarize any special training, skills, licenses and/or certificates that may assist you in the position for which you are applying:Disclaimer and SignatureThe Company is an equal opportunity employer. The Company does not discriminate in employment on account of age, sex, gender identity, sexual orientation, domestic partnership, race, color, creed, religion, ethnicity, national origin, alienage or citizenship status, disability, marital status, veteran status, military status, domestic violence victim status, genetic information or any other legal recognized protected basis under federal, state, or local laws, regulations or ordinances. I have read and fully understand the questions asked in this application. I certify that all answers given by me are true, accurate and complete and I understand that the omission and/or misrepresentation of any fact from this application or during any interview will be cause for immediate dismissal. I hereby authorize the Company and/or 4 its affiliates to obtain reference information about me and release all persons from liability for providing that information. If hired, I agree to abide by all of the Company rules and regulations and understand that, if employed, my employment may be terminated with or without cause, liability or notice, at any time, at the option of either the Company or me. I also understand that no representation, whether oral or written, by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the Company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by a corporate officer of the Company. I understand any offer of employment is contingent upon my successful completion of the Company's lawful preemployment checks. I agree to execute any consent forms necessary for the Company to conduct its lawful preemployment checks. I understand that employment with the Company is contingent upon my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States. SignatureClear SignatureDateNextHHA/PCA AVAILABILITYPlease select the schedules below that you are available to work: (Check all that apply)Live-InShort hours/cluster cases (2 to 6 hours)Long hours (8 to 12 hours)Please enter your availability below: (Example: 8AM-4PM, “LI” – Live-In, “X” – Unavailable)MondayTuesdayWednesdayThursdayFridaySaturdaySundayDateNext Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 ►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. A NTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.Section 1. Employee Information and Attestation(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Other Last Names Used (if any)Address (Street Number and Name)Apt. NumberCity or TownStateZIP CodeDate of BirthU.S. Social Security NumberEmployee's E-mail AddressEmployee's Telephone NumberI 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:A citizen of the United StatesA noncitizen national of the United States (See instructions)A lawful permanent residentAn alien authorized to work until (expiration date, if applicable)Alien Registration Number/USCIS Number):Expiration DateAliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.Alien Registration Number/USCIS Number:ORForm I-94 Admission Number:ORForeign Passport Number:Country of Issuance:Signature of EmployeeClear SignatureToday's DatePreparer and/or Translator Certification (check one):I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or TranslatorClear SignatureToday's DateLast NameFirst NameAddressCity or TownStateZIP CodeNextEmployer Completes Next PageSection 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")Citizenship/Immigration StatusList A Identity and Employment AuthorizationDocument TitleIssuing AuthorityDocument #Expiration Date (If Any)Document TitleIssuing AuthorityDocument #Expiration Date (If Any)Document TitleIssuing AuthorityDocument #Expiration Date (If Any)List B and List C Identity and Employment AuthorizationDocument TitleIssuing AuthorityDocument #Expiration Date (If Any)Document TitleIssuing AuthorityDocument #Expiration Date (If Any)Additional InformationCertification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.The employee's first day of employmentSignature of Employer or Authorized RepresentativeClear SignatureToday's DateTitle of Employer or Authorized RepresentativeLast Name of Employer or Authorized RepresentativeFirst Name of Employer or Authorized RepresentativeEmployer's Business or Organization NameEmployer's Business or Organization Address (Street Number and Name)City or TownStateZIP CodeNextSection 3.Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last NameFirst NameMiddle InitialB. Date of Rehire (if applicable) (if applicable)DateC. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.Document TitleDocument #Expiration Date (If Any)I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.Signature of Employer or Authorized RepresentativeClear SignatureToday's DateName of Employer or Authorized RepresentativeFirstLastNextLISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI LIST B Documents that Establish Identity 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record LIST C Documents that Establish Employment Authorization 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts.NextEmployee’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. Form W-4 Department of the Treasury Internal Revenue Service OMB No. 1545-0074 2021 Step 1: Enter Personal InformationAddressCity or town, state, and ZIP codeSocial security numberDoes 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.Single or Married filing separatelyMarried filing jointly (or Qualifying widow(er))Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)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 spouse also 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 $2,000Multiply the number of other dependents by $5003. Add the amounts above and enter the total hereStep 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 income4(a)(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here4(b)(c) Extra withholding. Enter any additional tax you want withheld each pay period4(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.)Clear SignatureDateEmployer's nameFirstLastEmployer's addressFirst date of employmentEmployer identification number (EIN)NextDepartment of Taxation and Finance Employee’s Withholding Allowance Certificate New York State • New York City • Yonkers IT-2104Your Social Security numberPermanent home address (number and street or rural route)Apartment numberCity, village, or post officeStateZIP codeSingle or Head of householdMarriedMarried, but withhold at higher single rateNote: If married but legally separated, mark an X in the Single or Head of household box.Are you a resident of New York City?YesNoAre you a resident of Yonkers?YesNoComplete the worksheet on page 4 before making any entries.Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19)Total number of allowances for New York City (from line 31)Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.New York State amountNew York City amountYonkers amountI certify that I am entitled to the number of withholding allowances claimed on this certificate.Employee’s signatureClear SignatureDatePenalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties. Employee: detach this page and give it to your employer; keep a copy for your records. Employer: Keep this certificate with your records. Mark in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):A) Employee claimed more than 14 exemption allowances for NYS✓B) Employee is a new hire or a rehire✓First date employee performed services for payAre dependent health insurance benefits available for this employee?YesNoEnter the date the employee qualifiesEmployer's nameFirstLastEmployer's address(Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)Employer identification numberInstructions Changes effective for 2021 Form IT-2104 has been revised for tax year 2021. The worksheet on page 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2021 Form IT-2104 and give it to your employer. Who should file this form This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld. If the federal Form W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you did not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in federal and New York State tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers. For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, if you submit a federal Form W-4 to your employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers. Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim is different from federal Form W-4 or has changed. Common reasons for completing a new Form IT-2104 each year include the following: • You started a new job. • You are no longer a dependent. • Your individual circumstances may have changed (for example, you were married or have an additional child). • You moved into or out of NYC or Yonkers. • You itemize your deductions on your personal income tax return. • You claim allowances for New York State credits. • You owed tax or received a large refund when you filed your personal income tax return for the past year. • Your wages have increased and you expect to earn $107,650 or more during the tax year. Next SIMPLIFIED SCREENING FORM FOR EMPLOYER HIRING INCENTIVES EMPLOYER:Candidate’s Personal InformationStreet AddressApartment/Unit #CityStateZIP CodeHome phoneAlternate phoneEmailSSNDate of birthHiring Incentive Qualification QuestionsAre you currently employed?YesNoIf no, enter the last date you were employed:Have you or any member of your family received Food Stamps (SNAP) in last 18 months (circle)?YesNoIf yes, provide Name, City/State of Recipient:Have you or any member of your family received Welfare (TANF) at any time during the past 18 months?YesNoIf yes, provide Name, City/State of Recipient:Are you a veteran?YesNoCan you supply a DD-214 if needed?:YesNoNextSmartchart.com 516-855-7263 Email all screening forms to: newhires@smartchartHR.com 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. Form 8850 (Rev. March 2016) Department of the Treasury Internal Revenue Service OMB No. 1545-1500 Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.Social security numberStreet address where you liveCity or townStateZIP codeCountyPhoneIf you are under age 40, enter your date of birthCheck 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 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; 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 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.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.Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.✓Signature—All Applicants Must Sign 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.Job applicant’s signatureClear SignatureDateNextFor Employers Use OnlyEmployer's NameFirstLastPhoneEINStreet AddressCity or townStateZIP codeIf, based on the individual’s age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6)Date Applicant...Gave informationWas offered jobWas hiredStarted jobUnder penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.Employer’s signatureClear SignatureTitleDatePrivacy Act and Paperwork Reduction Act Notice Section references are to the Internal Revenue Code. Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer’s federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for administration of the Internal Revenue laws, to the Department of Justice for civil and criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. 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 section 6103. The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping . . 6 hr., 27 min. Learning about the law or the form . . . . . . . 24 min. Preparing and sending this form to the SWA . . . . . . . 31 min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from www.irs.gov/formspubs. Click on “More Information” and then on “Give us feedback.” Or you can send your comments to: Internal Revenue Service Tax Forms and Publications 1111 Constitution Ave. NW, IR-6526 Washington, DC 20224 Do not send this form to this address. Instead, see When and Where To File in the separate instructions.Next U.S. Department Of Labor Employment and Training Administration OMB Control No. 1205-0371 Expiration Date: March 31, 2023 Individual Characteristics Form (ICF) Work Opportunity Tax CreditApplicant Information1. Control No. (For Agency use only)2. Date Received (For Agency Use only)Employer Information3. Employer Name4. Employer Address and Telephone5. Employer Federal ID Number (EIN)Applicant Information7. Social Security Number8. Have you worked for this employer before?YesNoIf YES, enter last date of employment:Applicant Characteristics for WOTC Target Group Certification9. Employment Start Date10. Starting Wage11. Position12. Are you at least age 16, but under age 40?YesNoIf YES, enter your date of birth13. Are you a Veteran of the U.S. Armed Forces?YesNoIf YES, are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired?YesNoIf YES, enter name of primary recipientand the city and state where benefits were receivedOR, are you a veteran entitled to compensation for a service-connected disability?YesNoIf YES, were you discharged or released from active duty within a year before you were hired?YesNoOR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?YesNo14. Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired?YesNoOR, received SNAP benefits for at least a 3-month period within the last 5 months but you are no longer receiving them?YesNoIf YES to either question, enter name of primary recipientand the city and state where benefits were received15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?YesNoOR, by an Employment Network under the Ticket to Work Program?YesNoOR, by the Department of Veterans Affairs?YesNo16. Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?YesNoOR, are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired?YesNoOR, did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made?YesNoIf NO, are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired?YesNoIf YES, to any question, enter name of primary recipientand the city and state where benefits were received17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?YesNoIf YES, enter date of convictionand date of releaseWas this a Federal or a State conviction ?FederalState18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)?YesNo19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?YesNo20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?YesNo21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?YesNo22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired?YesNo23. Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation?YesNoIf YES, what state did you receive unemployment compensation in?24. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made.I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.25(a). Signature: (See instructions in Box 25.(b) for who signs this signature block)Clear Signature25.(b) Indicate who signed this form:EmployerConsultantSWAParticipating AgencyApplicantParent/Guardian (if applicant is a minor)26. DateNextKF Office LLC NEW YORK LEASED EMPLOYEE NOTICE Your worksite employer, Universal Health Care, has entered into a contractual relationship with KF Office, LLC to provide for certain aspects of your employment. Pursuant to the contract between your worksite employer and KF Office, LLC, you are a Leased Employee or Co-Employee of KF Office, LLC as defined by New York state law. KF Office, LLC is a Professional Employer Organization (“PEO”) licensed by the New York Department of Labor. For the term of KF Office, LLC’s contract with your worksite employer, KF Office, LLC assumes certain employer responsibilities such as payroll and other administrative, employer functions as may be agreed to between KF Office, LLC and your worksite employer. If you have questions regarding KF Office, LLC’s employer responsibilities to you as a Leased Employee, your supervisor or manager may provide you with additional information or contact information for KF Office, LLC. In addition, for general information regarding the PEO relationship you may contact the New York Department of Labor, Division of Labor Standards at (518) 457-1942 or (518) 457-0401.Employee SignatureClear SignatureDateWitness SignatureClear SignatureWitness Printed NameDateDUE TO THE LENGTH OF THE FORM, IT WILL TAKE ABOUT 45 SECONDS FOR THE SUBMISSION TO REGISTER. PLEASE DO NOT REFRESH THE PAGE.Submit