CDPAP I9 LL W4-IT

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047

Expires 07/31/2026
     

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.
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.)
Last Name (Family Name) * First Name (Given Name) * Middle Initial (if any) Other Last Names Used (if any)
Address (Street Number and Name) * Apt. Number (if any)* City or Town *
State * ZIP Code *
Date of Birth (mm/dd/yyyy) * U.S. Social Security Number *
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 		 Employee's E-mail Address *
Employee's Telephone Number *

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):
 

 

If you check Item Number 4., enter one of these:
OR OR

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If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.
Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.
List A OR List B AND List C
 

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears 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.

 First Day of Employment (mm/dd/yyyy):
Last Name of Employer or Authorized Representative * First Name of Employer or Authorized Representative * Title of Employer or Authorized Representative *

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Employer's Business or Organization Name Employer's Business or Organization Address City or Town State ZIP Code
For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.
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Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Hourly Rate Employees
1. Employer Information:
Name :

Priority Home Care Services INC
Doing Business As (DBA) Name(s) :

Priority Home Care
FEIN (optional): 20-2061755
Physical Address :

2 Corporate Drive, Central Valley, NY, 10917
Mailing Address :

2 Corporate Drive, Central Valley, NY, 10917
Phone :

845-781-7376
2. Notice given:

Note: Live-in employees must be paid at least 13 hours for each 24 hour period, provided they receive 8 hours of sleep, with five hours of uninterrupted sleep and 3 hours off for meals. If an employee does not receive 5 hours of uninterrupted sleep, the employee must be paid for all 8 hours. If the employee does not receive meal periods free from duty, the employee must be paid for all 3 hours designated for meals.
3. Employee’s Rate(s) of Pay for Each Type of Work Shift:
See attached list of rates $per hour for $per hour for $per hour for
3a. Wage Parity Rates:
See attached list of rates $per hour for regular wage $per hour for additional wage $per hour for supplemental wages*
4. Allowances:

5. Regular payday:
6. Pay is:

7. Overtime Pay Rate(s) foreach type of work or shift:
See attached list of rates
Single Pay Rate: $ per hour This must be at least 1½ times the worker's regular rate with few exceptions.
See attached list of rates
Wage Parity Pay Rate: $ per hour This must be at least 1½ times the worker's regular rate with few exceptions.
Varies
Multiple Pay Rates: $ per hour This must be at least 1½ times the worker's Weighted average of the multiple rates of pay for the week, with few exceptions.
8. Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, supplements and designated payday. I told my employer what my primary language is.

Check one:

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The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

Please note: It is unlawful for an employee with protected class status to be paid less than an employee without protected class status, if they are performing substantially equal work. Employers also may not prohibit employees from discussing wages with their co-workers.

*Attach Wage Parity supplement notification

LS 62 Notice to Wage Parity Home Care Aides - (cont'd)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation
     
  Hourly Rate Type of Supplement Name & Address of Provider Agreement/Plan information
Supplement Number $XXX (Pension, Welfare, or Other) Insert Name and Address of Company or Organization Providing Benefit Identify the plan or agreement that creates the benefit, e.g Union Local No. 1 Collective Bargaining Agreement or Insurance Company X benefit Plan
Supplement Number1 See attached list of rates Transit, parking, cell phone,FSA, dependent care Leading Edge 14 WALL ST. STE 5B, NEW YORK, NY 10005 Leading Edge
Supplement Number2   PTO   As per Priority's Employee Handbook Policy
Supplement Number3   Sick   As per Priority's Employee Handbook Policy

*If wage supplements are paid as a single payment owed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

List any additional benefits and attach listing to this document.

Copies of the above listed agreements or summaries may be obtained by:

Human Resources     at 845-425-6555
Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits,
and designated payday provided on this form (LS 62) attached and this addendum on the date given below.
My primary language is *. | have been given this notice in my primary language *   Yes    No.
Employee Name (Print): *
Employee Signature: *

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Step 1: Enter Personal Information
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(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, other details, 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) Reserved for future use.

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; 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 generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate . . . . .

TIP: If you have self-employment income, see page 2.

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 Dependent and Other Credits

If your total 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 for qualifying children and other dependents. You may add to this the amount of any other credits. 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 deduction and 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.

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Employers Only
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2022)
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*

Note: If married but legally separated, mark an X in the Single or Head of household box.
Are you a resident of New York City? *
Are you a resident of Yonkers? *
Before making any entries, see the Note below, and if applicable, complete the worksheet in the instructions.

1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19, if using worksheet)...

2 Total number of allowances for New York City (from line 31, if using worksheet)...

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York State amount... $

4 New York City amount... $

5 Yonkers amount... $

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

Penalty – 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.

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Employee:Give this form to your employer and keep a copy for your records. Remember to review this form once a year and update it if needed.

Note:Single taxpayers with one job and zero dependents, enter 1 on lines 1 and 2 (if applicable). Married taxpayers with or without dependents, heads of household or taxpayers that expect to itemize deductions or claim tax credits, or both, complete the worksheet in the instructions. Visit www.tax.ny.gov (search: IT-2104-I) or scan the QR code below.

Employer: Keep this certificate with your records.
If any of the following apply, mark an X in each corresponding box, complete the additional information requested, and send an additional copy of this form to New York State. See Employer in the instructions. Visit www.tax.nys.gov (search: IT-2104-I) or scan the QR code below.

Employee claimed more than 14 exemption allowances for New York State...A

B Employee is a new hire or a rehire...B

First date employee performed services for pay (mm-dd-yyyy) (see Box B instructions.):

You may report new hire information online instead of mailing the form to New York State. Visit www.nynewhire.com.

Note: Employers must report individuals under an independent contractor arrangement with contracts in excess of $2,500 using the online reporting website above, not Form IT-2104

Are dependent health insurance benefits available for this employee?...

If Yes, enter the date the employee qualifies (mm-dd-yyyy):


 
 

Scan here

https://www.tax.ny.gov/r/it2104i-2023
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