CDPAP Registry Form-2024 - w HIPAA DD (2.0)

Full Name 姓名(必填)

First Name 名 Last Name 姓

Date of Birth 出生日期(必填)

mm/dd/yyyy

Aide Code 護理員號碼

SSN 工卡號碼(必填)

Cell # 手機號碼(必填)

Address 地址(必填)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County(必填)

Authorization for Direct Deposit – Employee Form 員工直接存款授權

Name of Financial Institution 金融機構名稱

Account Number 賬號號碼:

ABA Transit Routing Number ABA 轉賬路由號碼:

Deposit Amount 金額:

Entire Check 全數

Flat Amount per Check 指定金額(每張支票)

% Percentage of Net 百分比率

Flat Amount per Check 指定金額(每張支票)

Please enter a number greater than or equal to 0.

Percentage of Net 百分比率%

Please enter a number from 0 to 100.

Account Type 賬戶類型

Checking 支票

Savings 儲蓄

EMPLOYMENT APPLICATION FORM 工作申請表 CDPAP

Application Date 申請日期(必填)

Maiden Name 母姓(必填)

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Height 身高

Please enter a number greater than or equal to 0.

Height 身高

feet' inches

Weight 體重

Sex 性別(必填)

Male 男

Female 女

Rehired? 重新入職？(必填)

Yes 是

No 否

Marital Status 婚姻狀況(必填)

Single 單身

Married 已婚

Head of Household 申報戶主

If "Yes", Date of Rehire? 如果選"是”, 重新入職的時間：

緊急聯絡人信息

Name 緊急聯繫人姓名(必填)

Relationship 關係(必填)

Cell # 手機號碼(必填)

General Questions 請答回以下問題

1. Have you previously been employed at Golden Touch? 你是否曾經受僱於萬有護理公司？(必填)

Yes 是

No 不是

If Yes 如果選擇是

Date of employment: 僱用日期

Position 職位

Supervisor 主管人

2. Are you over the age of 18 你是否18 滿歲？(必填)

Yes 是

No 不是

3. If hired, can you provide proof of citizenship or legal right to work in the United States? 如果受雇，你是否能提供在美國合法工作的證明？(必填)

Yes 是

No 不是

4. Have you been convicted of a felony other than a traffic violation? 是否犯過除交通違規以外的重罪(必填)

Yes 是

No 不是

If Yes, please provide the conviction date and nature of the offense 如有，請註明重罪的日期和性質

PLEASE NOTE: a conviction record does not necessarily disqualify you for employment.
請注意：定罪記錄並不一定會取消您的就業資格

Language 語言

If other, please specify. 如選擇其他，請說明。

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Availability 可工作時間

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Availability Time Range 具體時間

Monday 週一 Time

Tuesday 週二 Time

Wednesday 週三 Time

Thursday 週四 Time

Friday 週五 Time

Saturday 週六 Time

Sunday 週日 Time

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When can you start working? 開始工作日期

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Work Area 工作區域(必填)

Work Related Questions 工作相關問題

1. Do you drive? 你是否會開車？(必填)

Yes 是

No 不是

2. Do you smoke 你是否抽煙？(必填)

Yes 是

No 不是

3. Are you ok with working in an environment where there's smoking? 你是否能在有人抽煙的環境中工作？(必填)

Yes 是

No 不是

4. Are you ok with working in an environment where there are pets? 你是否能接受在有寵物的環境中工作？(必填)

Yes 是

No 不是

If no, please specify what animals 如果不能，請列舉出不能相處的動物:

5. Are you able to do light cleaning? 你是否能進行日常打掃工作？(必填)

Yes 能

No 不能

6. Are you able to cook for patients? 是否能為客戶提供烹飪服務？(必填)

Yes 能

No 不能

If yes, what kind of cuisine can you cook? 請問你會燒哪種菜式？

7. How did you hear about this position or Golden Touch? 你從哪裡得知這個工作機會以及萬有護理公司？

EMPLOYMENT HISTORY 過往工作經驗

1. Name of Company 公司

1. Address of Company 公司地址

1. Tel. # 電話

1. Fax # 傳真

1. Name of Supervisor 主管

1. Position 職位

1. From 從

1. To 到

1. Weekly Starting 第一週

1. Weekly Final 最後一週

1. Reason for Leaving 離職原因

May we contact your employer？是否可以聯繫？

Yes 是

No 否

2. Name of Company 公司

2. Address of Company 公司地址

2. Tel. # 電話

2. Fax # 傳真

2. Position 職位

2. Name of Supervisor 主管

2. From 從

2. To 到

2. Weekly Starting 第一週

2. Weekly Final 最後一週

2. Reason for Leaving 離職原因

2. May we contact your employer？是否可以聯繫？

Yes 是

No 否

EDUCATION & TRAINING 培訓

1. Name and Address of School 培訓機構

1. Major/ Program 培訓項目

1. Diploma / Degree 學位

1. Graduated 是否畢業

Yes 是

No 否

1. From 從 (mm/dd/yy)

1. To 到 (mm/dd/yy)

2. Name and Address of School 培訓機構

2. Major/ Program 培訓項目

2. Diploma / Degree 學位

2. Graduated 是否畢業

Yes 是

No 否

2. From 從 (mm/dd/yy)

2. To 到 (mm/dd/yy)

3. Name and Address of School 培訓機構

3. Major/ Program 培訓項目

3. Diploma / Degree 學位

3. Graduated 是否畢業

Yes 是

No 否

3. From 從 (mm/dd/yy)

3. To 到 (mm/dd/yy)

REFERENCES 推薦人

List people other than relatives or friends, who have knowledge of your work experience and/or education 請提供親戚或朋友以外熟悉您工作和/ 或培訓的推薦人

PLEASE READ
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I also understand that any false statement on this application may result in my application not being considered. I further understand that this application is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that my employment is at-will and can be terminated by either party with or without notice, at any time, for any reason or no reason. No one other than the Golden Touch Home Health LLC has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in writing signed by the Administrator.
我在求職申請中所陳述的事實真實且完整。我了解，如果受僱，對此有任何虛假陳述申請可能會導致我被解僱。我也明白，此申請中的任何虛假陳述都可能導致我的申請無法通過正在考慮。我進一步了解，本申請表無意成為僱傭合同，本申請表也不構成僱傭合約。如果雇主決定僱用我，則以任何方式對雇主承擔義務。我理解並同意我的就業是隨意的並且任何一方均可在通知或不通知的情況下隨時以任何理由或無理由終止。除了金手指之外沒有人 Home Health LLC 有權簽訂任何指定期限的僱用協議或做出任何與前述規定相反的協議只能由管理員以書面簽署。

1. NAME / TITLE 姓名/ 職稱

1. ADDRESS 地址

1. PHONE 電話

2. NAME / TITLE 姓名/ 職稱

2. ADDRESS 地址

2. PHONE 電話

3. NAME / TITLE 姓名/ 職稱

3. ADDRESS 地址

3. PHONE 電話

Influenza Vaccination Employee Statement 已打針或同意打針簽字表

Consent 已打針或同意打針簽字表 Vaccine to Golden Touch Home Health LLC Employees. I am aware of the influenza policy and have had a chance to have my questions answered about influenza vaccination. I understand the benefits and risks of the vaccine, and:為 Golden Touch Home Health LLC 員工接種疫苗。我了解流感政策，並且有機會得到有關流感疫苗接種的問題的解答。我了解疫苗的益處和風險，並且：

I agree to have the influenza vaccine for the influenza season.我同意在流感季節接種流感疫苗。

*If you have already received the influenza vaccine for this influenza season, please specify the vaccinated date: 如果您已接種本流感季節的流感疫苗，請註明接種日期：

Declination of Influenza Vaccination for Health Care Personnel 不打針戴口罩簽字表

I have been advised that I should receive the influenza vaccine to protect myself and patients I serve I have read the Center for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have read had the opportunity to discuss the statement and have my questions answered by a HR officer. I am aware of the following facts:
我被建議應該接種流感疫苗以保護自己和我所服務的病人我已閱讀疾病中心的內容控制與預防 (CDC) 的疫苗資訊聲明解釋了疫苗及其預防的疾病。我讀過有機會討論該聲明並讓人力資源官員回答我的問題。我了解以下事實：

不打針戴口罩簽字表

Influenza is a serious respiratory disease kills thousands in the US each year. 流感是一種嚴重的呼吸道疾病，每年在美國奪走數千人的生命。

Influenza vaccination is recommended for me and all other health care personnel to protect this facility’s patients from influenza, its complication, and death. 建議我和所有其他醫護人員接種流感疫苗，以保護該機構的患者免受流感及其併發症和死亡的影響。

If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility. 如果我感染流感，我可以在出現流感症狀之前 24 小時內排出病毒。我排出的病毒會傳播流感

If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existed. 如果我感染了流感，即使我的症狀很輕微或根本不存在，我也可能會將嚴重的疾病傳播給其他人。

I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t, my immunitydeclines over time. This is why vaccination against influenza is recommended each year. 我知道引起流感感染的病毒株幾乎每年都會發生變化，即使沒有變化，我的免疫力也會隨著時間的推移而下降。這就是為什麼建議每年接種流感疫苗。

I understand that I cannot get influenza from the influenza vaccine. 我了解我不會透過流感疫苗感染流感。

The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contract, including all patients in this health care facility, coworkers, my family and my community. 我拒絕接種疫苗的後果可能會對我的健康以及與我有合約的人的健康產生危及生命的後果，包括該醫療機構中的所有患者、同事、我的家人和社區。

Because I have refused vaccination against influenza, I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza season. 由於我拒絕接種流感疫苗，因此在流感季節期間，在患者或居民可能出現的區域，我將被要求佩戴外科或手術口罩。

Consent 不打針戴口罩簽字表

I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future. 我承認我已完整閱讀並完全理解本文件。儘管有這些事實，我還是決定透過下面的簽名拒絕接種流感疫苗。我意識到我將來可能隨時重新解決這個問題並接受疫苗接種。

HEPATITIS B VACCINATION ACCEPT / DECLINE FORM 乙型肝炎疫苗接種接受/拒絕表

I am an employee of Golden Touch Home Health LLC and I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B at this time. I under-stand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. 我是 Golden Touch Home Health LLC 的員工，我了解，由於我在職業上接觸血液或其他潛在傳染性物質，我可能面臨感染乙型肝炎 (HBV) 的風險。此時我有機會接種B型肝炎疫苗。我了解，如果拒絕接種該疫苗，我將繼續面臨感染B型肝炎（一種嚴重疾病）的風險。如果將來我想接種B型肝炎疫苗，我可以免費接種該系列疫苗。

I 本人(必填)

Accept Hepatitis B Vaccine. 同意接種Hepatitis B疫苗

Decline Hepatitis B Vaccine. 拒絕接種Hepatitis B疫苗

EMPLOYEE TRAINING ACKNOWLEDGEMENT: ELECTRONIC VISIT VERIFCATION

員工培訓確認：電子訪問驗證

I acknowledge that I have received and thoroughly reviewed Golden Touch Home Health’s Electronic Visit Verification (EVV) Education Handouts and attended the EVV training session on the date signed below. This session included training on the federal and state laws and regulations regarding EVV. I received training on EVV and understand the policies and procedures specific to my job functions. I agree to follow the policies and procedures on EVV.
我承認我已經收到並徹底閱讀了 Golden Touch Home Health 的電子就診驗證 (EVV) 教育講義，並參加了下面簽署的日期的 EVV 培訓課程。本課程包括有關 EVV 的聯邦和州法律法規的培訓。我接受了 EVV 培訓，並了解針對我的工作職能的政策和程序。我同意遵守 EVV 的政策和程序。

RECEIPT OF EQUIPMENT 設備接收

ACKNOWLEDGMENT TO THE CAREGIVER HANDBOOK (Golden Touch Copy for Employee File)對看護者手冊的確認（萬有護理公司的員工檔案副本）

Legal Consent(必填)

I agree to the terms and conditions. 我同意以下對看護者手冊的條款和條件。

I acknowledge that I have received the Golden Touch Caregiver Employee Handbook ("Handbook") and understand that violations of the policies contained in the Handbook, including the anti-harassment policy, could result in corrective action, up to and including termination. I further understand that the information contained in the Handbook represents guidelines for Golden Touch and that Golden Touch reserves the right to modify the Handbook or amend or terminate any policy, procedure, or Employee benefit program at any time. I further understand that the contents of the Handbook do not form a written employment contract. Either Golden Touch or I have the right to terminate my employment at any time. I further understand that no manager, supervisor or representative of Golden Touch, other than the Human Resources Manager, has any authority to enter into any agreement guaranteeing employment for any specific period of time. I also understand that any such agreement, if made, will not be enforceable unless it is in writing and signed by both parties. I also understand that an agreement made by the Human Resources Manager of Golden Touch is not binding on unless it is agreed to in writing by the Human Resources Manager of Golden Touch. I further understand that if I have any questions about the interpretation or application of any policies contained in the Handbook, I should direct these questions to my immediate supervisor.
我確認我已收到《Golden Touch Caregiver 員工手冊》（「手冊」），並了解違反手冊中包含的政策（包括反騷擾政策）可能會導致糾正措施，甚至包括解僱。我進一步了解，本手冊中包含的資訊代表了 Golden Touch 的指導方針，而 Golden Touch 保留隨時修改本手冊或修改或終止任何政策、程序或員工福利計劃的權利。我進一步了解，本手冊的內容不構成書面僱傭合約。 Golden Touch 或我都有權利隨時終止我的僱傭關係。我進一步了解，除人力資源經理外，Golden Touch 的任何經理、主管或代表均無權簽署任何保證在任何特定期限內就業的協議。我還了解，任何此類協議一旦達成，除非以書面形式並由雙方簽署，否則將不可強制執行。我還了解，除非經 Golden Touch 人力資源經理書面同意，否則 Golden Touch 人力資源經理制定的協議不具約束力。我進一步了解，如果我對本手冊中包含的任何政策的解釋或應用有任何疑問，我應該將這些問題直接向我的直接主管提出。

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Consent for Employee Handbook

I acknowledge that I have received the Golden Touch Caregiver Employee Handbook ("Handbook") and understand that violations of the policies contained in the Handbook, including the anti-harassment policy, could result in corrective action, up to and including termination. I further understand that the information contained in the Handbook represents guidelines for Golden Touch and that Golden Touch reserves the right to modify the Handbook or amend or terminate any policy, procedure, or Employee benefit program at any time. I further understand that the contents of the Handbook do not form a written employment contract. Either Golden Touch or I have the right to terminate my employment at any time. I further understand that no manager, supervisor or representative of Golden Touch, other than the Human Resources Manager, has any authority to enter into any agreement guaranteeing employment for any specific period of time. I also understand that any such agreement, if made, will not be enforceable unless it is in writing and signed by both parties. I also understand that an agreement made by the Human Resources Manager of Golden Touch is not binding on unless it is agreed to in writing by the Human Resources Manager of Golden Touch. I further understand that if I have any questions about the interpretation or application of any policies contained in the Handbook, I should direct these questions to my immediate supervisor. 我確認我已收到《Golden Touch Caregiver 員工手冊》（「手冊」），並了解違反手冊中包含的政策（包括反騷擾政策）可能會導致糾正措施，甚至包括解僱。我進一步了解，本手冊中包含的資訊代表了 Golden Touch 的指導方針，而 Golden Touch 保留隨時修改本手冊或修改或終止任何政策、程序或員工福利計劃的權利。我進一步了解，本手冊的內容不構成書面僱傭合約。 Golden Touch 或我都有權利隨時終止我的僱傭關係。我進一步了解，除人力資源經理外，Golden Touch 的任何經理、主管或代表均無權簽署任何保證在任何特定期限內就業的協議。我還了解，任何此類協議一旦達成，除非以書面形式並由雙方簽署，否則將不可強制執行。我還了解，除非經 Golden Touch 人力資源經理書面同意，否則 Golden Touch 人力資源經理制定的協議不具約束力。我進一步了解，如果我對本手冊中包含的任何政策的解釋或應用有任何疑問，我應該將這些問題直接向我的直接主管提出。

NOTICE AND ACKNOWLEDGEMENT FOR LIVE-IN CAREGIVER UNDER NEW YORK STATE LABOR LAWS根據紐約州勞動法對住家保母的通知和確認

Medical Benefit Coverage Waiver Request Form 免除醫療福利申請表

On behalf of myself and my eligible dependents (if any), I waive the option to enroll in health insurance offered at this time by or through my employer for the following reasons:

出於以下原因，本人及受撫養人現放棄參加由/ 通過我僱主提供的醫療保險：

Waiving Health Coverage 放棄醫療保險(Please select one of the following 請選擇以下一項)(必填)

I am covered under another group plan as a spouse or dependent 本人作為配偶或受撫養人得到其他團體醫療計劃保障

I am covered by Medicaid, Medicare, or Veterans Program 我現有醫療補助，聯邦醫療保險或退伍軍人計劃的保障

I am covered under a health insurance plan sponsored by second employer 我現有第二雇主所提供的醫療保險計劃的保護

I am covered through a non-group, individual or private health care plan not offered through my employer 我現有非團體, 個人或私人醫療保健計劃

I don’t wish to participate in health care benefits at this time (I am declining health insurance entirely) 我目前不希望參加任何醫療保健福利（我完全拒絕了醫療保險）

HIPAA Privacy Authorization Form 隱私授權表格

This form is used to authorize consent for Golden Touch Home Health LLC and its’ affiliates to communicate PHI to the person or organization below.

此表格用於授權萬有護理公司及其附屬機構同意將客戶健康信息機密與以下人員或組織進行溝通。

Consent HIPAA Privacy Authorization Form(必填)

I agree to the terms and conditions. 我同意以下HIPAA條款和條件。

1. I hereby authorize to use and/or disclose the protected health information described below to Golden Touch Home Health LLC.
我特此授權將以下描述的受保護的健康信息使用和/或揭露給萬有護理。
2. Authorization for Release of Information of my complete health care history including mental health, HIV, health status and medication.
授權發布我的所有醫療保健歷史記錄的信息，包括精神健康，艾滋病健康狀況和藥物。
3. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
我授權的人可以使用此醫學信息來進行醫學治療或諮詢，開票或索償，或我指示的其他目的。
4. I understand that consent expires in 12 months from date of signature unless I cancel before that time. I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.
我理解並且同意隱私授權表格有效期為12個月，除非我在此之前取消。我有權隨時以書面形式撤銷此授權。我理解，如任何人或機構已經按照我的指定執行了授權，使用或揭露受保護的健康信息，事後撤銷是無效的。
5. I understand that information disclosed under this authorization might be redisclosed by the recipient, and this disclosure may no longer be protected by federal or state law.
我理解收件人可能會重新揭露此授權下的信息，而可能不再受聯邦或州法律的保護。
6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
我理解我的待遇，付款，註冊或享受福利的資格將不取決於我是否簽署此授權書。

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Parity and Other Jobs 根據《紐約州勞動法》第 195.1 條關於家庭護理助理工資平等和其他工作的工資率和發薪日的通知和確認

· Employee’s Rate(s) of Pay for Each Type of Work Shift: $18.55 per hour for Regular Rate
每種輪班類型的員工薪資：正常薪資每小時 18.55 美元

· Wage Parity Rates: $2.54 Per hour for supplemental wages*
工資平等率：每小時 2.54 美元的補充工資*

· Overtime Pay Rate(s) for each type of work or shift: Single Pay Rate: $27.825 per hour This must be at least 1½ times the worker’s regular rate with few exceptions.
每種類型的加班費率工作或輪班：單次薪資：每小時 27.825 美元除少數例外情況外，這必須至少是工人正常工資的 1.5 倍。

· Wage Parity Pay Rate: $0 per hour This must be at least 1½ times the worker’s regular rate with few exceptions.
工資平等工資率：每小時 0 美元除少數例外情況外，這必須至少是工人正常工資的 1.5 倍。

· Multiple Pay Rates: $0 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.
多種工資率：每小時 0 美元這必須至少是工人多重費率的加權平均值的 1.5 倍支付一周的工資，少數情況例外。

Check one:選擇一項：

I have been given this pay notice in English, because it is my primary language. 我收到了英文版的薪資通知，因為這是我的主要語言。

My primary language is ______. I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language. 我的主要語言是______。我只收到英文版的工資通知，因為勞工部尚未提供我的主要語言的工資通知表。

Primary Language 主要語言

I have been given this notice in my primary language.

Yes 是

No 否

LS 62 Notice to Wage Parity Home Care Aides - (cont’d)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation
LS 62 家庭照顧者同工同酬通知 -（續）
家庭護理員總報酬最低費率的福利部分

	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 plan or agreement that creates the benefit, e.g., Union Local No. 1 Collective Bargaining Agreement or Insurance Company X Benefit Plan

Supplement Number 1

1. Hourly Rate 薪酬

1. Type of Supplement 类型

1. Name & Address of Provider 提供者的名稱和地址

1. Agreement Plan Information 協定/ 計劃資訊

Supplement Number 2

2. Hourly Rate 薪酬

2. Type of Supplement 类型

2. Name & Address of Provider 提供者的名稱和地址

2. Agreement Plan Information 協定/ 計劃資訊

Supplement Number 3

3. Hourly Rate 薪酬

3. Type of Supplement 类型

3. Name & Address of Provider 提供者的名稱和地址

3. Agreement Plan Information 協定/ 計劃資訊

*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.
*如果工資補貼作為單一款項支付給多個 Taft-Hartley 多雇主計劃，僅列出以下內容： (1) 補貼支付總額或福利包；（2）一攬子福利中包含的福利類型，例如退休金、健康和福利或其他； (3) 接收單位的名稱和地址付款已發送； (4) 作為協議的相關 CBA 或同意書。

列出任何其他好處並將清單附加到本文檔中。

Copies of the above listed agreements or summaries may be obtained by: 上述協議或摘要的副本可透過以下方式取得：

8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit 8850 工作機會信用預篩選通知和認證請求

Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

Check if apply. 勾選以下符合您的項目。

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit. 如果您收到了州勞動力機構 (SWA) 或參與工作機會積分的當地機構的有條件認證，請在此處勾選。

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.如果以下任何陳述適用於您，請勾選此處。 • 我所在的家庭在過去18 個月內有9 個月接受過貧困家庭臨時援助(TANF) 的援助。 • 我是一名退伍軍人，並且是在過去15 個月內至少有3 個月領取補充營養援助計劃(SNAP) 福利（食品券）的家庭成員。 • 我是由州批准的康復機構、工作票計劃下的就業網絡或退伍軍人事務部轉介到這裡的。 • 我已年滿 18 歲，但未滿 40 歲或以上，且我是以下家庭的成員：過去 6 個月曾獲 SNAP 福利（食品券）；或 b. 過去 5 個月中至少有 3 個月領取 SNAP 福利（食品券），但不再有資格領取。 • 在過去的一年裡，我被判犯有重罪或因重罪而被釋放。 • 我在過去60 天內的任何一個月內都收到了補充保障收入(SSI) 福利。 • 我是一名退伍軍人，在過去的一年中失業時間總計至少 4 週但少於 6 個月。

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. 如果您是退伍軍人並且在過去一年中失業時間至少為 6 個月，請勾選此處。

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. 如果您是有權獲得與服役有關的殘疾賠償的退伍軍人，並且您在過去一年中從美國武裝部隊退伍或解除現役，請在此處勾選。

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. 如果您是有權獲得與服務相關的殘疾賠償的退伍軍人，並且您在過去一年中失業至少 6 個月，請在此處勾選。

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.如果您的家庭成員符合以下條件，請勾選此處： • 至少在過去 18 個月內收到 TANF 補助；或• 自1997 年8 月5 日之後開始的任何18 個月內以及自1997 年8 月5 日之後開始且在過去2 年內結束的最早18 個月期間收到的貧困家庭臨時援助(TANF) 付款；或 • 由於聯邦或州法律限制了這些付款的最長期限，因此在過去 2 年內不再有資格獲得 TANF 付款。

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.如果您處於至少連續 27 週的失業期，並且您在該期間的全部或部分時間內領取了失業救濟金，請勾選此處。

W4 Employee’s Withholding Certificate W4 員工預扣稅證明

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. 填寫 W-4 表格，以便您的雇主可以從您的薪水中預扣正確的聯邦所得稅。將 W-4 表格交給您的雇主。您的預扣稅款須接受美國國稅局 (IRS) 的審查。

Claim Dependent and Other Credits
索賠受扶養人和其他信用

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如果您的總收入為 200,000 美元或更少（如果已婚聯合報稅則為 400,000 美元或更少）：將 17 歲以下符合資格的子女人數乘以 2,000 美元

Multiply the number of other dependents by $500 將其他受扶養人的人數乘以 500 美元

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. 為符合資格的兒童和其他家屬添加上述金額。您可以在此基礎上添加任何其他積分的金額。在此輸入總計。

(optional選填): Other Adjustments 其他調整

(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.其他收入（不是來自工作的收入）。如果您希望對預計今年不需要預扣的其他收入進行預扣稅，請在此輸入其他收入金額。這可能包括利息、股息和退休收入。

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, enter the result here.扣除額。如果您希望申請標準扣除額以外的扣除額並希望減少預扣稅，請在此輸入結果。

USCIS Form I-9 Employment Eligibility Verification USCIS I-9 表格就業資格驗證

Department of Homeland Security U.S. Citizenship and Immigration Services 國土安全部美國公民及移民服務局

Check one of the following boxes to attest to your citizenship or immigration status: 選中以下複選框之一以證明您的公民身份或移民身份：

1. A citizen of the United States 美國公民

2. A noncitizen national of the United States 美國非公民

3. A lawful permanent resident (Enter USCIS or A-Number.) 合法永久居民（輸入 USCIS 或 A 號碼。）

4. A noncitizen (other than Item Numbers 2. and 3. above)獲授權工作至（到期日，如有）的非公民（除上述第 2 項和第 3 項之外） authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:如果您選擇第4項，請輸入以下內容之一：

USCIS A-Number (USCIS A 號碼)

Form I-94 Admission Number (Form I-94表格號碼)

Foreign Passport Number and Country of Issuance (外國護照號碼及簽發國家)

Form I-9 Acceptable Documents I-9 表格可接受的文件

LIST A	LIST B	LIST C
1. U.S. Passport or U.S. Passport Card 美國護照或美國護照卡	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 美國各州或邊遠領地核發的駕駛執照或身分證只要它包含照片或姓名、出生日期等信息，性別、身高、眼睛顏色和地址	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 社會安全帳號卡，除非該卡包含以下內容之一限制： (1) 不適用於就業 (2) 僅適用於工作 INS授權 (3) 僅適用於工作國土安全部授權
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 永久居民卡或外國人登記收據卡（I-551 表）	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 由聯邦、州或地方政府機構或實體簽發的身份證只要它包含照片或姓名、出生日期等信息，性別、身高、眼睛顏色和地址	2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 由出生證明書籤發的證明國務院（表格 DS-1350， FS-545、FS-240）
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine readable immigrant visa 外國護照在機器可讀移民簽證上包含臨時 I-551 印章或臨時 I-551 印刷註釋	3. School ID card with a photograph 附照片的學校身分證	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 由美國州、縣、市當局或領地簽發並加蓋公章的出生證明正本或核證副本
4. Employment Authorization Document that contains a photograph (Form I-766) 就業授權文件內含照片（I-766 表格）	4. Voter's registration card 選民登記卡	4. Native American tribal document 美洲原住民部落文獻
5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole: 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 individual's status or parole 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. 對於因身分或假釋而暫時被授權為特定雇主工作的個人： a. 外國護照；和 b. I-94 表格或 I-94A 表格包含以下內容： (1）姓名與護照一致；和 (2) 對個人身分或假釋的認可，只要認可期限尚未到期，且擬議的就業不與表格上確定的任何限製或限制相衝突。	5. U.S. Military card or draft record 美國軍人卡或徵兵記錄	5. U.S. Citizen ID Card (Form I-197) 美國公民身分證（I-197表）
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 密克羅尼西亞聯邦(FSM) 或馬紹爾群島共和國(RMI) 的護照，附有I-94 表格或I-94A 表格，表明根據美國與密克羅尼西亞聯邦或馬紹爾群島自由聯繫協定的非移民入境資格	6. Military dependent's ID card 軍人家屬身分證	6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 美國居民公民使用的身份證(I-179 表)
	7. U.S. Coast Guard Merchant Mariner Card 美國海岸防衛隊商船水手卡	7. Employment authorization document issued by the Department of Homeland Security For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central. The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document. 國土安全部簽發的就業授權文件例如，請參閱 M-274 的第 7 節和第 13 節 uscis.gov/i-9-central。 I-766 表（就業授權文件）是清單 A，項目編號 4. 的文件，而不是清單 C 文件。
	8. Native American tribal document 美洲原住民部落文獻
	9. Driver's license issued by a Canadian Citizen in the United States (Form I-179) government authority 由加拿大公民在美國政府機構簽發的駕駛執照（I-179 表）
	For persons under age 18 who are unable to present a document listed above: 對於無法出示上述文件的 18 歲以下人士：
	10. School record or report card 學校記錄或成績單
	11. Clinic, doctor, or hospital record 診所、醫生或醫院記錄
	12. Day-care or nursery school record 日託或託兒所記錄

Employer Review and Verification: Documentation from List A OR a combination of documentation from List B and List C above
雇主審查和驗證：清單 A 中的文件或上述清單 B 和清單 C 中的文件組合

List A 列表 A

Document Title 證件名稱

Issuing Authority 簽發機關

Document Number (if any) 證件號碼

Expiration Date (if any) 過期日期

List B 列表 B

Document Title 證件名稱

Issuing Authority 簽發機關

Document Number (if any) 證件號碼

Expiration Date (if any) 過期日期

List C 列表 C

Document Title 證件名稱

Issuing Authority 簽發機關

Document Number (if any) 證件號碼

Expiration Date (if any) 過期日期

Hidden

NEW YORK STATE DEPARTMENT OF HEALTH 紐約州衛生部

Criminal History Record Check 犯罪記錄檢查

Hidden

Have you been convicted of a crime in New York State or any other jurisdiction? 您是否在紐約州或任何其他司法管轄區被定罪？(必填)

Yes是

No否

Hidden

Do you have a final finding of patient or resident abuse?您是否有虐待患者或居民的最終調查結果？(必填)

Yes是

No否

Hidden

(Optional 選填) If selected "Yes", please provide a brief explanation. 如果選擇“是”，請提供簡要說明。

Initial 申請人姓名縮寫(必填)

Date 日期(必填)

Last 4 digit of SSN 工卡號碼後四位(必填)

Applicant Signature 申請人簽名(必填)

Hidden

If subject individual is under 18 years of age（如果申請人未滿 18 歲）

Hidden

Signature of Parent or Legal Guardian: 家長或法定監護人簽名：

Hidden

(Optional 選填) Preparer and/or Translator Certification 準備者和/或翻譯者認證

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.
我證明，我已盡力協助填寫此表格，如有偽證，願受處罰。知識資訊真實且正確。

Hidden

Preparer or Translator Name

First Name 名 Last Name 姓

Hidden

Preparer or Translator Address 準備者或翻譯者地址

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Initial 翻譯員姓名縮寫(必填)

Hidden

Date 日期

Hidden

Signature of Preparer or Translator 翻譯員簽名