1 Beach Drive SE Suite 305 St. Pete FL 33701
941-378-8822
Step 1 of 12 - W4 Withholding Certificate
Do only one of the following.
TIP: To be accurate, submit a 2021 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.)
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-DESCRIMINATION 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.
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.
All documents containing an expiration date must be unexpired.* Documents extended by the issuing authority are considered unexpired. Employees may present one selection from List A or a combination of one selection from List B and one from List C.Examples of many of these documents appear in the Handbook for Employers (M-274).
A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
To enroll in Full Service Direct Deposit, simply fill out this form. Provide a voided check for each checking account - not a deposit slip. If depositing to savings account, ask your bank to give you the Routing/Transit Number for your account. It isn't always the same as the number on the savings deposit slip. This will help ensure that you are paid correctly.
Below is a sample check MIRC line, detailing where the information necessary to complete this form can be found.
IMPORTANT! Please read and sign before completing and submitting.I hereby authorize the deposit of any amounts owed me, as instructed by my employer, by initiating credit entries to my account and the financial institution (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated to my account. In the event that funds are deposited erroneously into my account, I authorize my employer to debit my account for an amount not to exceed the original amount of the erroneous credit.
This authorization is to remain in full force and effect until my employer and Bank have received written notice from me of its termination in such time and in such manner as to afford my employer and Bank reasonable opportunity to act on it.
The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form from your employer.Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.
Have you had any of the following:
*IF you choose YES to receive the Hepatitis B Vaccine, you must receive the first of three (3) injections in the series within ten (10) working days of signing this form.
*IF you choose YES, upon completion of the series of 3 injections, Nursing Styles will reimburse you for the cost of vaccines.
I have read the information regarding the Hepatitis B Vaccine, have had the opportunity to ask questions and understand the benefits and the risks of the vaccine.
I understand that my position requires frequent contact with blood, which may be positive for Hepatitis B virus.
IF I decline the vaccine at this time, and change my mind at a later date, I will make the effort to contact the Health Department or my physician to complete the Hepatitis B Vaccine series and complete the Nursing Styles Hepatitis B Vaccine Declaration form.
IF I decline the Hepatitis B vaccine series, I relieve Nursing Styles from any and all liability should I contract Hepatitis B.
In consideration of Nursing Styles (Agency) employment of user (Employee), the undersigned Employee hereby agrees not to directly or indirectly use, manipulate, copy, or disclose to any party, other than authorized employees of the agency while performing their duties as an Employee, any Patient Health Information (PHI), to include any personal health information or personal contact information (name, address, phone, email address, etc.), of any current or former client of the Agency and its successors and assigns. Employee acknowledges that misuse of PHI or personal contact information is a violation of HIPAA and may result in termination of employment and formal reporting to federal authorities. Further, Employee acknowledges that any fines related to these violations are the direct responsibility of Employee.
Employee also acknowledges that the Agency, while relying on this agreement, may provide Employee access to Agency Confidential Information, which may include client information, trade secrets, and Agency policies and documents which are not generally available to anyone not employed by the Agency. Employee agrees not to disclose any Agency Confidential Information to any unauthorized party.
I agree not to do business with or solicit business from any individual or business entity that Nursing Styles has introduced to me during my employment. I further agree not to enter into employment or business agreements with such individuals for at least one year after my last date of work with Nursing Styles. I further understand I may be subject to legal action for doing so.
I hereby acknowledge receipt of the employee handbook of Nursing Styles. I understand and agree that it is my responsibility to read and comply with the policies in the handbook.
I understand that the handbook and all other written and oral materials provided to me are intended for informational purposes only. Neither it, Nursing Styles practices, nor other communications create an employment contract or term. I understand that the policies and benefits, both in the handbook and those communicated to me in any other fashion, are subject to interpretation, review, removal, and change by the Agency at any time without notice.
I further understand that I am an at-will employee and that neither this document nor any other communication shall bind Nursing Styles to employ me now or hereafter and that my employment may be terminated by me or Nursing Styles without reason at any time. I understand that no representative of Nursing Styles has any authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action or to assure any benefits or terms or conditions of employment or make any agreement contrary to the foregoing.
I also understand and agree that this Acknowledgement may not be modified orally and that only the Director/Administrator of Nursing Styles may make a commitment for employment. I also understand that if such an agreement is made, it must be in writing and signed by the Director/Administrator of Nursing Styles.
I have received the required information on Alzheimer’s Disease (AD) and Related Dementias prepared by the Florida Health Care Association with the assistance of the Alzheimer Resource Center to meet the statutory requirement of 400.4785(1) (a) F.S.
Employees are only allowed to drive for Private Pay Clients if they have a valid driver's license and a clean driving record for at least 2 years. A clean record means the employee has not been held at fault or arrested on charges of violating motor vehicle laws. The employee is also required to have liability and PIP coverage as required by Florida state law. Nursing Styles does not allow personal use of Client or Employee vehicles while on Company time. Personal use includes using the vehicle for personal errands and activities unrelated to the employee’s job duties. Transportation of clients and running errands for clients are prohibited for Managed Care and VA clients.
Company Driving Rules
Employees who violate company vehicle rules are subject to actions which may include verbal and/or written warnings, suspension of vehicle privileges, termination, and legal action.
If you are involved in a motor vehicle accident in the course of your job duties, you must report the accident and injuries (if any) to the proper authorities. You should notify Nursing Styles as soon as possible. Nursing Styles is not responsible for any fines, citations, towing costs, or any other cost associated with a violation of traffic laws by a employee while performing job duties.
By signing this Driving Acknowledgement, I agree the above list items have been reviewed. I also agree to abide by all Company Driving Rules.
