EFTA00525136.pdf

Form W-4 (2017) Purpose. Complete Form W.4 so that your employer can withhold the correct federal Income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. II you are exempt, complete only ines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expkes February 15, 2018. See Pub. 505. Tax Withholding and Estimated Tax. Note: if another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding oven if the employee is a dependent, if the employee: • Is ago 65 or older, • Is blind, or • Wall claim adjustments to income; tax credits; or lionized deductions, on his or her tax return. The exceptions don't apply to supplemental wages greater than $1,000,000. Saab instructions. If you aren't exempt, con te the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding alowances based on itemized deductions, certain credits, arkustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For tegutar wages, withholding must bo based on allowances you clamed and may not be a fiat amount or percentage of wages. Head of household. Generally' , you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the Costs of keeping up a home for yourself and your depending') or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and F8ng Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowance. Credits for chid or dependent care expenses and the ct•ld tax creed may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nomvago income. If you have a bre. amount of nonwage income, such as Interest ccdividends. consider making estimated tax nts using Form 1040-ES. Estimated Tax for widuais. Otherwise, you may Owe additional tax. If you have pension or annuity Income, see Pub. 50510 Ind out if you should adjust your withholding on Form V4.4 or W-4P. Two earners or multiple jobs. II you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on el jobs using worksheets from only one Form W-4. Your withholding ustiVy cos be most accurate when all allowances are ctirned on the Form W-4 for the highest paying pb and zero allowances are claimed on the others. Soo Pub. 505 for derails. Nonresident alien. If you a:e a norrosidonl alien. see Notice 1392, Supplemental Fcim W-4 Instructions for Nonresident Aliens, before completing lHa form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505. especially !flour earnings exceed $130,000 (Single) or $180,000 (Manisa Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at wrnv.ksgovfre4. Personal Allowances Worksheet (Keep for your records.) A Enter "1" for yourself if no ono else can claim you as a dependent A • You're single and have only one Job; or B Enter "1" if: • You're married, have only one Job, and your spouse doesn't work; or { - • Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. / B C Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-" may help you avoid having too little tax withheld ) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter "1" If you will file as head of household on your tax return (see conditions under Head of household above) . E F Enter "1" If you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . F (Note: Do not include child support payments. See Pub. 50G, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. • If your total income will be less than $70,000 ($100,000 If married), enter "2" for each eligible child; then less "1" If you have two to four eligible children or less "2" if you have five or more eligible children. • if your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. G H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) so H • if you plan to Itemize or claim adjustments to Income and went to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all • if you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 that apply. to avoid having too little tax withheld. • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. -------------------------- Separate here and give Form W-4 to your employer. Keep the top part for your records. Form W-4 Department of the Treastry !Memel Revenue Service Employee's Withholding Allowance Certificate If- Whether you are entitled to claim a certain number of allowances or exemption from withholding Is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. I OMB No. 1545-0074 20 1 7 1 Your first name and middle initial Last name 2 Your social security number Home address (number and street or nerd route) 3 0 Single • Married 0 Married, but withhold at Ngher Single rate. Note: If maniac:, but legally scented, or spouse's a nowesilent alen.chKS the 'Snit' box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call 1.800.772.1213 for a replacement card. 1:- 0 5 6 7 Total number of allowances you are claiming (from line H above or from the applicable worksheet on Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, • This year I expect a refund of all federal Income tax withheld because I expect to have no tax liability if you meet both conditions, write "Exempt" here * I page 2) for exemption. and 5 6 $ 7 I Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee's signature (This font is not valid unless you sign it) p. 8 Employees name and address (Employer: Complete fines 8 and 10 only if sending to the IRS.) 9 0lke code (optioned, Date w 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, sea page 2. Cat. No. 102200 Form W-4 (2017) EFTA00525136 Form W-4 (2017) Page 2 Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain 1 Enter an estivate of you 2017 dented deductions. These include qualifying home and kcal taxes, medical expenses in excess of 10%d your Income, and miscellaneous your itemized deductions if your income is over $313,800 and you're married filing jollity d you're head of household; $261,500 II you're single, not head of househdd and married filing separately. See Pub. 505 for dais $12,700 if married filing jointly or qualifying widow(er) 2 Enter: i $9,350 If head of household $6,350 if single or monied filing separately 3 Subtract line 2 from line 1. If zero or less, enter "-0-• 4 Enter an estimate of your 2017 adjustments to income and any additional 5 Add lines 3 and 4 and enter the total. (Include any amount for credits Withholding Allowances for 2017 Foam W-4 worksheet in Pub. 505.) 6 Enter an estimate of your 2017 nonwage Income (such as dividends 7 Subtract line 6 from line 5. If zero or less, enter '-O-" 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop 9 Enter the number from the Personal Allowances Worksheet, line 10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Eamers/Multiple also enter this total on line 1 below. Otherwise, stop here and enter credits or adjustments mortgage Interest, charitable contributions, deductions. For 2017, you may have or you're a quail** "*lowiht not a qualifying widow*); or $156,900 standard deduction (see from the Conceding or Interest) any fraction H, page 1 Jobs Worksheet, this total on Form W-4, line to income. state to reduce $287,650 if you're 1 $ 2 $ 3 $ Pub. 505) 4 $ Credits to 6 $ 6 S 7 $ 8 9 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two eamers or multiple lobs on page 11 Note: Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and 2 Find the number in Table 1 below that applies to the LOWEST paying Job and enter you are married filing jointly and wages from the highest paying job are $65,000 or than "3" 3 If line 1 is more than or equal to fine 2, subtract fine 2 from line 1. Enter the result '-0--) and on Form W-4, fine 5, page 1. Do not use the rest of this worksheet Note: If line 1 is less than fine 2, enter --0-11 on Form W-4, line 5, page 1. Complete lines figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet 5 Enter the number from line 1 of this worksheet 6 Subtract line 5 from line 4 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter 8 Multiply line 7 by line 6 and enter the result here. This Is the additional annual withholding 9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 weeks and you complete this form on a date in January when there are 25 pay periods the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld Adjustments Worksheet) it here. However, less, do not enter here (if zero, 4 through 9 below 4 1 if more 2 enter 3 to 5 it here . needed if you are paid remaining in 2017. from each 6 . . . 7 $ . . 8 $ every two Enter paycheck 9 $ Table 1 Table 2 Married FIlingJointly All Others Married Filing Jointly All Others If wages from LOWEST PlY69 Job am— Enter on Ina 2 above if wages from LOWEST paying Job am— Enter on he 2 above If wages from HIGHEST paying Job are— Enter on line 7 above If wages from HIGHEST paying Job are— Enter on Me 7 than $0 - S7,030 7,001 • 14,000 14,001 • 22,000 22,001 - 27,000 27,001 - 35,000 35,001 - 44,000 44,001 - 55,000 55,001 - 65.000 65,031 • 75,003 75,001 • 80.000 80,001 - 95.000 50,001 • 115,000 116,001 - 130,000 130,001 - 140,000 140,001 • 150,003 150,001 and over 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SO - Se.= 8,001 - 16,000 16,001 - 26,000 28,001 • 34,000 34,001 - 44,000 44,001 - 70,000 70,001 - 85,000 85,001 - 110,000 110,001 - 125,000 125,001 - 140,000 140,001 and over 0 1 2 3 4 5 6 7 8 9 10 SO - 675,000 75,001 - 135,000 135,001 - 205,000 205,001 - 380,000 360,001 - 405,000 405.001 and over $610 1,010 1,130 1,340 1,420 1,600 SO - $38,000 38,001 • 85,003 85,001 - 185,000 185.031 - 400,000 400.001 and over 6610 1,010 1,130 1,340 1,600 Pdvacy Act and Paperwork Reduction Act Notice. We ask for the inform ton on Ws form o caw out the Internal Revenue laws of the U fled Slates. Internal Revenue Code sections 34020(2) arid 6209 and their regulations meths you to provide this 'acme on; your employer uses t to determin your federal income tax ivithhdding. Failure to pro de pronely ompteled loon wi ream in year being treated &saltine, person who claims no vahhotelng allowances: providing fraudulent information may subject you to penrCtes. Routine uses of his information include gMng it to the department of Justice for civil and criminal fitigaticc4 to cities, states, the tastrkt of Cando. and U.S. commonwealths and possessions Ice use n admnistoing their tax laws; and to the Department of Heaith and Human Services for use n the National Directory or New Hies. we may also dadose this information to other countries under a lax treaty, to fedenl and state ageri s to enforce federal nontax aferinal laws. or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the Information requested on form that Is subject to the Papenvork Reduction Act unless the form displays a valid 0M8 control number. Books or record; 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 reouired by Code section 6103. The average lime end expenses required to complete and Po 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 heal from you. See the instructions for your income tax return. EFTA00525137 EMPLOYMENT APPLICATION Position Applying fon 0 Full-Time 0 Part-Time 0 Seasonal SMTWTFSat Hours Available and/or its affiliate , is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, sec, national origin, age, veteran status, disability, or any other legally protected status. NAME Pint Middle Last Social Security Number 1 Are you at least IS years of age O Yes O No Present Street Address • City State Zip Previous Street Address • City State Bp Phone Number Alternative Phone Number Are you a US. Citizen or an you provide verifica lion of your legal right to work in the United States 0 Yes O No Position Desired 0 runtime 0 Part Time Date An-lable for Work Have you ever been employed by 0 Yes C No Position: ' ? Dates: - List names of Mends or relatives now employed b) crier/err Its affiliate List °Was machites you on operate andude WPM and Shathand) • Last other equipment you an operate Do you have any special slats or mating related to the position sought? EDUCATION Name of Institution City Jr State Circle Last Year Completed High School 9 30 11 12 College I 2 3 4 Graduate School . ' Degree received O Yes 0 No Other MILITARY SERVICE BRANCH !tank Attained Date Entered Date of Discharge EFTA00525138 EMPLOYMENT: Include all previous jobs starting with the present or most recent. May we contact your present employer? 0 Yes O No 1.. Employer Position Held & Dude Address Than No. Supervisor. --. — Data Employed rfCCL: To: Pay Rale Shrting; Mutiny —Reason for Laving a. Employer Position Held Se Dudes Address Phone No. Supenisor Dales Employed - Fr= To: Pay Rale . Sorting: Ending: Reason for Lowing • 3. Employer • Position Held de Duties Address Phone No. Supervisor Dales Employed Prom: . 7o Pay Rate Startinv Ending Rason for Leaving Have you ever been convicted of a felony or a misdemeanor (other than minor traffic violations)? O Yes 0 No If yes, Please explain: PLEASE READ THIS STATEN-EWE CAREFULLY epee to comply with ell rules of this Company. [understand that any falsification or orrtission of information provided on this application or while i nteniewing will be grounds for dismissal from employment, even if not discovered until after my separation from the Company. !authorize a thorough investigation to be made in conjunction with dais application concerning my character, general ;crab lion, personal chazacteristirs end mode of thing, whichever maybe applicable. I understand this investigation may indudepe-sonal inteniews with third parades, such as family members, business assodates,fmancial sources, Mends, neighbors or others with whom I am acquainted. If lam hired, I agree that my employment and compensation can be terminated with or wi thou' cause and with or without notice at any limeyat the option of the Company or myself. Lunde:stand that noother representadveof theCornpany other than thePresident of N.A. Property, Inc. has the authority to modify this agreement in anyway, and that any such modification must be in a writing signed by both the President and myself. I have read and affirm the above statement as my own. Signature re. 1/5) EFTA00525139 U.S. Department of Justice intmigralion and Normalization Service OW No IIIS.0136 Employment Eligibility Verification Please 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 eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. To be competed and signed by employee et the time employment begins. Print Name Last Fest Middle Initial Malden Name Address ahem Name and Numbed Apt I Date of Birth (month/my/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, 0 A citizen or national of the 0 A Lawful Permanent Resident An alien atehonzed to (Alien 1 or Admission 0) that tam (check one of the following): Unite0 States (Allen d A work until / Employee's Signature Date (month/day/year) Preparer and/or Translator Certification. (TO at completed and signed if Seaton l is prepared by a person other then the employee.) arrest. under penalty of perjwy. that !have assisted in the temple ton of this form and that to the best of my know/edge the information is true and collect. Preparees/Transiator's Signature Print Name Address (Strew Name and Number. City. State. Zip Code) Date (monttdday/year) Section 2. Employer Review and Verification. To be completed and stoned by employer. Exam MI one document from List A OR examine one document horn List Et and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s) List A Document title- Issuing authority: Document I Expiration Date fir airy) Document g. Expiration Elate (if any) OR List B AND List C Iii /— ija ,14 CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the obove•listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) _k_f_ and that to the best of my knowledge the employee is eligible 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 Address (Street Name and Number. City. State. Zip Code) Date ImontWaylyead Section 3. Updating and Reverification. To be completed and signed by employer A New Name (if applicable) 8. Date of rehire enondltdaneor) lit applicable) C. If employee's previous grant of work authorization has expired. provide the information below for the document that establishes current employment eligibility. Document Tnie Document e E *ovation Date Of any): f attest, under penalty of perjury. that to the best of my knowledge. this omptoyee it eligible to work in the United States. and if the employee presented document(s), the document(s) f have examined appear to be genuine and to relate to the Individual. Signature of Employer or Authorized Representative Date (month/day/nod Form l•P (Rey II4I•9//ll Poly 2 EFTA00525140 LISTS OF ACCEPTABLE DOCUMENTS LIST A Documents that Establish Both identity and Employment Eligibility 1. U.S. Passport (unexpired or expired) 2. Certificate of U.S. Citizenship (INS Form N-560 or N-5611 3. Certificate of Naturalization (INS Form N-550 or N•570) 4. Unexpired foreign passport, with 1-551 stamp or attached INS Form l•94 indicating unexpired employment authorization 5. Permanent Resident Card or Alien Registration Receipt Card with photograph (INS Form (.151 011-551) 6. Unexpired Temporary Resident Card (INS Form 1-688) 7. Unexpired Employment Authorization Card (INS Form I-688A) 8. Unexpired Reentry Permit (INS Form I-3271 9. Unexpired Refugee Travel Document (INS Form 1-5711 OR 10. Unexpired Employment Authorization Document issued by the INS which contains a photograph (INS Form 1-68881 LIST 8 Documents that Establish Identity AND 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 1. LIST C Documents that Establish Employment Eligibility U.S. social security card issued by the Social Security Administration (other than a card stating it is not valid for employment) 2. Certification of Birth Abroad issued by the Depanment of State (Form FS•545 or Form DS-13501 3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (INS Form 1.7971 6. ID Card for use of Resident Citizen in the United States (INS Form 1-179) 7. Unexpired employment authorization document issued by the INS (other then those listed under List A) Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) Fr::= 1 ritRry :0.14/00)Y Nis 3 EFTA00525141 NOTIFICATION/RELEASE OF INFORMATION FORM The purpose of this form is to notify you that consumer report will be conducted on you in the course of consideration for employment with: Last Name: First Name: Middle Name: Social Security #: State of Issue: Current Address: City: State: Zip: In connection with this request I authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to information about my employment, education, consumer credit history, driving record, criminal record and general public history to the person or company with which this form has been filed, or their agent. This releases the aforesaid parties from any liability and responsibility for collection of the above information. APPLICANT'S SIGNATURE: DATE: EFTA00525142 HBRK Associates Inc. 575 Lexington Avenue, e Floor New York, NY 10022 Phone 212-971-1306 July 26, 2017 Re: Sonam Dema employment via NES LLC Dear Sonam, This letter is to confirm that you were offered Oxford Health Insurance by your employer NES LLC beginning August 1, 2017 however you chose not to enroll in the plan. Please sign below to acknowledge you have declined health insurance. Sirycerely yours, /41 Richard Kahn CPA I, Sonam Dema, have declined enrolling in NES LLC health insurance plan offered by Oxford Health. Sonam Dema EFTA00525143