APD Group Home Aid Application

Step 1 of 6

Sexual Misconduct Policy as per 65G-2 taken from The Sexual Misconduct Law FS 393.135

Sexual activity between an employee and a resident of the group home (to whom he or she is rendering services) is not only unethical but is also a crime, regardless of whether or not consent was first obtained from the victim.

"Sexual misconduct" is defined as any sexual activity between an employee and an individual residing within a group home (to whom that employee renders services)
Makes the crime of sexual misconduct punishable as a second degree felony
Makes failure to report known or suspected cases of sexual misconduct a first degree misdemeanor
Eliminates consent by the consumer as a valid defense against prosecution for this crime
Expands Level 1 and 2 background screening requirements to include the newly-created crime of sexual misconduct as a disqualifying offense for employment

Below is the actual text of the Sexual Misconduct Law as it currently appears in Florida Statutes Section 393.135, complete 393 FS can be found at apdcares.org

Sexual misconduct prohibited; reporting required; penalties.

As used in this section, the term:
1. "Covered person" includes any employee, paid staff member, volunteer, or intern of the group home; any person under contract with the group home; and any person providing care or support to a resident on behalf of the group home or its providers.
2. "Sexual activity" means:
  1. Fondling the genital area, groin, inner thighs, buttocks, or breasts of a person.
  2. The oral, anal, or vaginal penetration by or union with the sexual organ of another or the anal or vaginal penetration of another by any other object.
  3. Intentionally touching in a lewd or lascivious manner the breasts, genitals, the genital area, or buttocks, or the clothing covering them, of a person, or forcing or enticing a person to touch the perpetrator.
  4. Intentionally masturbating in the presence of another person.
  5. Intentionally exposing the genitals in a lewd or lascivious manner in the presence of another person.
  6. Intentionally committing any other sexual act that does not involve actual physical or sexual contact with the victim, including, but not limited to,sadomasochistic abuse, sexual bestiality, or the simulation of any act involving sexual activity in the presence of a victim.

Sexual Misconduct Continued

"Sexual misconduct" means any sexual activity between a covered person and a resident to whom a covered person renders services, care, or support on behalf of the group home or its providers, or between a covered person and another resident who lives in the same home as the resident to whom a covered person is rendering the services, care, or support, regardless of the consent of the resident. The term does not include an act done for a bona fide medical purpose or an internal search conducted in the lawful performance of duty by a covered person.

A covered person who engages in sexual misconduct with an individual with a developmental disability who:
1. Resides in a residential facility, including any comprehensive transitional education program, developmental disabilities institution, foster care facility, group home facility, intermediate care facility for the developmentally disabled, or residential habilitation center; or
2. Is eligible to receive services from the agency under this chapter, commits a felony of the second degree, punishable as provided in ss. 775.082, s. 775.083, or s. 775.084. A covered person may be found guilty of violating this subsection without having committed the crime of sexual battery.
The consent of the resident to sexual activity is not a defense to prosecution under this section.
This section does not apply to a covered person who is legally married to the resident.
A covered person who witnesses sexual misconduct, or who otherwise knows or has reasonable cause to suspect that a person has engaged in sexual misconduct, shall immediately report the incident to the central abuse hotline of the Department of Children and Family Services and to the appropriate local law enforcement agency. The covered person shall also prepare, date, and sign an independent report that specifically describes the nature of the sexual misconduct, the location and time of the incident, and the persons involved. The covered person shall deliver the report to the Executive Director, who is responsible for providing copies to the agency's local office and the agency's inspector general.
(a) Any person who is required to make a report under this section and who knowingly or willfully fails to do so, or who knowingly or willfully prevents another person from doing so, commits a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

(b) Any person who knowingly or willfully submits inaccurate, incomplete, or untruthful information with respect to a report required under this section commits a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

(c) Any person who knowingly or willfully coerces or threatens any other person with the intent to alter testimony or a written report regarding an incident of sexual misconduct commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
The provisions and penalties set forth in this section are in addition to any other civil, administrative, or criminal action provided by law which may be applied against an employee.

History.— s. 1, ch. 2004-267; s. 30, ch. 2006-227; s. 8, ch. 2008-244; s. 75, ch. 2014-19.

Name

Signature

Date

CHARACTER REFERENCE CHECK

This person has applied to work for Pathway to Purpose for Males I/II, LLC and provided your information as a character reference. Please answer the following questions below and mail back in the self-addressed stamped envelope. This form must be filled out by non-relatives.

NAME OF APPLICANT

Social Security #

Job Title Considered For

Individual Completing Form

Date

Phone

Date

1. How long have you known the applicant?

2. What is your relationship to the applicant?

3. This applicant has applied to work with teenage males 12-17 years of age that are currently in the foster care system. Do you know any reason why this person should not be allowed to work with children? If yes, please explain:

5. Name three good traits that would describe the applicant:

4. Do you think this person is reliable?

6. Can you think of any traits that would hinder the applicant's ability to work with children that may display behaviors?

Signature

Date

REFERENCE CHECK FORM

Applicant Name

Position Applied for

Date

Upon completion of the interview process a pre-employment reference check shall be made of the selected candidate. The reference check should attempt to collect the following minimum information:

Current/Last Employer

Phone

Person Contacted

Title

Dates of Employment: (From)

To:

Position Held

Salary

What is/was your employment relationship with this person (current or former supervisor, second-line supervisor, etc.)?

What is/was the nature of his/her position/duties?

How would you describe the quality of his/her work?

How well does/did he/she respond to pressure (e.g. from high volume, deadlines, multiple tasks, public contact)?

How well does/did he/she plan and organize his/her work, and were assignments completed timely and accurately?

What is/was the amount and type of supervision required for him/her?

How well does/did he/she get along with other people (e.g., clients, co-workers, supervisors)?

How does/did he/she respond to criticism/interpersonal conflict?

What are/were his/her strongest skills as an employee?

What areas of his/her performance needed improvement?

How would you describe his/her attendance and punctuality? NOTE: Do not ask or collect information on Family Medical Leave Act absences or disability questions prohibited by the Americans with Disabilities Act.

What was the reason for leaving your employment?

Would you rehire him/her?

Any other comments you would like to include?

IF A REFERENCЕ СНЕСK WAS NOT CONDUCTED, WHY?

REFERENCE CHECKED BY:

Name

Title

Signature

Date

Participate in all team meetings and team trainings
Review documentation daily to ensure appropriate recording
Monitor petty cash and residents’ personal spending, when applicable
May observe staff interactions and other comments or suggestions for improvement; train staff as needed
Administer medications, as prescribed and instructed, as needed
Work weekends, evenings, and holidays as required by program
Abide by, enforce and participate in the implementation and ongoing oversight of all safety standards and regulations

Competencies:

To perform the job successfully, you must demonstrate the following competencies:

Communications: Clearly expresses ideas and thoughts verbally; clearly expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.
Cooperation: Establishes and maintains effective relations; exhibits tact and consideration; displays positive outlook and pleasant manner; offers assistance and support to co-workers; works cooperatively in group situations; works actively to resolve conflicts.
Relationship Building: Builds rapport up, down and across the organization; establishes collaborative relationships to achieve objectives; seeks win-win solutions to conflict; develops network of professional contacts; displays empathy and tolerates diverse viewpoints.
Care of Individuals: Responds to individuals concerns with accurate information in an effective and timely manner; takes personal responsibility to improve service; works professionally and effectively with family members and guardians; acts professionally with individuals and strives to solve problems.
Teamwork:Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone's efforts to succeed
Job Knowledge: Follows policies and procedures; completes administrative tasks correctly and on time or notifies appropriate person with alternate plan; supports organization's goals and values; strives to continuously build knowledge and skills.
Quality: Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality, while increasing productivity at the same time; applies feedback to improve performance; monitors own work to ensure quality.
Initiative: Undertakes self-development activities; seeks increased responsibilities; looks for and takes advantage of opportunities; asks for and offers help when needed.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or experience

Direct care staff shall have a high school diploma from an accredited high school or a GED and 2 years of college or HS/GED and 1 year working with individuals with development disabilities in a residential setting is preferred. Training requirements for staff working Behavior Focus include PCM, Behavior Assistant ServiceF, and Reactive Strategies. 90 hours or greater of in classroom training can be used in lieu of the above requirements.

Reasoning Ability

Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form.

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or clients.

Mathematical Skills

Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals.

Physical Requirements

Must be able to operate a variety of equipment (wheel chairs, lifts, etc). Must be able to exert up to seventy-five pounds of force occasionally and/or frequently to lift, carry, push, pull or otherwise move objects. Physical demands are in excess of sedentary work; position requires walking, standing, reaching, fingering, stopping, etc. Will lift no more than forty pounds independently.

Employee Name (Printed)

Signature

Executive Director Name (Printed)

Signature

CERTIFICATE OF ORIENTATION

Person to Person Care Center

6309 E. Florida Cir. Apollo Beach, FI 33572 813-928-8538

Hereby Recognizes

has successfully completed the required

Employment Orientation

Orientation Components

Orientation regarding vision, , resources, policies, and services; a. Mission, Vision, Philosophy (0.5 hours)
b. Employee Handbook 1 hour
c. Operating Procedures (8.0 hours)
i. Admission Procedures/Care Goals
i1. Admission Packet
iii. MyALFTraining
iv.Support Plans/ Implementation Plans/TRAIN site
V.Documentation
vi.Emergency Documentation Procedure
vii. Incident reports/Family Notifications/Call-outs

Date of Completion

Dr. Oriant M. Person DNP, APRN, FNP-C Executive Director

CERTIFICATE OF ORIENTATION

Person to Person Care Center

6309 E. Florida Cir. Apollo Beach, FI 33572 813-928-8538

Hereby Recognizes

has successfully completed the required

Comprehensive Emergency Management Plan And Emergency Preparedness

Date of Completion

Dr. Oriant M. Person DNP, APRN, FNP-C Executive Director APRN9249347

This form is provided as a sample and may not be suitable for every situation. This form should not be considered legal advice or legal opinion. There may be state or municipality specific information that would affect your use of this form. You should review applicable law in your jurisdiction and consult experienced counsel for legal advice. If you use this form (either “as is" or by modifying the form), you are responsible for all content.

YOU SHOULD REMOVE THIS TEXT BEFORE USING THE FORM IN YOUR WORKPLACE

Emergency Contact Form

Employee Name

Address

Phone Number

Special Instructions: In the event of a medical emergency, are there any emergency procedures or restrictions on medications of which emergency personnel should be aware? If yes, please explain.

Emergency Contacts

Primary Contact in case of emergency:

Name

Address

Relationship Phone Number

Alternate Phone Number

Secondary Contact in case of emergency:

Name

Address

Relationship Phone Number

Alternate Phone Number

YOU SHOULD REMOVE THIS TEXT BEFORE USING THE FORM IN YOUR WORKPLACE

Physician Contact

Doctor's Name

Address

Phone Number

Employee Authorization

I have voluntarily provided the above contact information and authorize __________ and its representatives to contact any of the above individuals on my behalf in the event of an emergency.

Employee signature

Date

Full Service Direct Deposit

Your Pay Goes into the Bank. You Don’t.

Here’s a new employee benefit that takes the hassle out of payday.

Full Service Direct Deposit automatically deposits your paycheck into the bank account(s) you select. Distribute your pay among multiple accounts (checking, savings, Christmas clubs, investment accounts, etc.) at different financial institutions. You won’t have to stand in long check-cashing lines to deposit your pay anymore. Your pay will be in your account(s), ready for immediate use—even if you can’t get to the bank.

Full Service Direct Deposit is...

Convenient. It deposits your net pay automatically to the bank account(s) of your choice. Full Service Direct Deposit also makes your money instantly available on payday for withdrawal or check writing—even if you aren’t in the office on payday!
Safe. Full Service Direct Deposit eliminates the chance of lost, stolen, or damaged paychecks.
Confidential. Full Service Direct Deposit reduces handling of your personal payroll information by others.
Reliable. Full Service Direct Deposit provides complete paystub information and deposit confirmation every payday.
Free. All these benefits are offered to employees at no additional charge.

How to Enroll...

To sign up for Full Service Direct Deposit, complete the enrollment form and give it to your payroll manager. Take advantage of Full Service Direct Deposit today!

Employee Direct Deposit Enrollment Form

Payroll Manager-Please complete this section and enter data into your ADP Payroll system for employee enroliment. Then contact your CSR or AE for further instructions on how to update your employee's direct deposit information to ADP. NOTE: YOUR COMPANY NAME MUST BE FILLED IN BEFORE DISTRIBUTING THIS FORM TO YOUR EMPLOYEE FOR COMPLETION. (Please print.)

Company Code

Company Name

Employee File Number

Untitled

Payroll Mgr. Signature

LISTS OF ACCEPTABLE DOCUMENTS

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 selection from List C. Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A Documents that Establish Both Identity and Employment Authorization	OR	LIST B Documents that Establish Identity	AND	LIST C Documents that Establish Employment Authorization
U.S. Passport or U.S. Passport Card Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Foreign passport with temporary I-551 stamp or notation Employment Authorization Document with photo (Form I-766) Foreign passport with Form I-94 or I-94A indicating temporary work authorization Passport from FSM or RMI with Form I-94 or I-94A	OR	Driver’s license or ID card issued by a State ID card issued by federal, state, or local government School ID card with a photograph Voter’s registration card U.S. Military card or draft record Military dependent’s ID card U.S. Coast Guard Merchant Mariner Card Native American tribal document Canadian driver’s license For persons under age 18: School record or report card Clinic, doctor, or hospital record Day-care or nursery school record	AND	Social Security Account Number card (no restrictions) Certification of birth abroad (FS-545, DS-1350, FS-240) U.S. birth certificate Native American tribal document U.S. Citizen ID Card (Form I-197) Identification Card for Use of Resident Citizen (Form I-179) Employment authorization document issued by DHS

LIST A

Documents that Establish Both Identity and Employment Authorization

LIST B

Documents that Establish Identity

AND

LIST C

Documents that Establish Employment Authorization

U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport with temporary I-551 stamp or notation
Employment Authorization Document with photo (Form I-766)
Foreign passport with Form I-94 or I-94A indicating temporary work authorization
Passport from FSM or RMI with Form I-94 or I-94A

Driver’s license or ID card issued by a State
ID card issued by federal, state, or local government
School ID card with a photograph
Voter’s registration card
U.S. Military card or draft record
Military dependent’s ID card
U.S. Coast Guard Merchant Mariner Card
Native American tribal document
Canadian driver’s license

For persons under age 18:

School record or report card
Clinic, doctor, or hospital record
Day-care or nursery school record

AND

Social Security Account Number card (no restrictions)
Certification of birth abroad (FS-545, DS-1350, FS-240)
U.S. birth certificate
Native American tribal document
U.S. Citizen ID Card (Form I-197)
Identification Card for Use of Resident Citizen (Form I-179)
Employment authorization document issued by DHS

Receipt for a replacement of a lost, stolen, or damaged List A document.
Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.
Form I-94 with “RE” notation or refugee stamp issued to a refugee.

Receipt for a replacement of a lost, stolen, or damaged List B document.

Receipt for a replacement of a lost, stolen, or damaged List C document.

Supplement A, Preparer and/or Translator Certification for Section 1

Last Name (Family Name) from Section 1.

First Name (Given Name) from Section 1.

Middle initial (if any) from Section 1.

Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form 1-9. 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 Translator

Date

Last Name (Family Name)

First Name (Given Name)

Middle Initial (if any)

Address

Address (Street Number and Name) City or Town State ZIP Code

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 Translator

Date

Last Name (Family Name)

First Name (Given Name)

Middle Initial (if any)

Address

Address (Street Number and Name) City or Town State ZIP Code

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 Translator

Date

Last Name (Family Name)

First Name (Given Name)

Middle Initial (if any)

Address

Address (Street Number and Name) City or Town City or Town ZIP Code

Supplement B, Reverification and Rehire (formerly Section 3)

Last Name (Family Name) from Section 1.

First Name (Given Name) from Section 1.

Middle initial (if any) from Section 1.

Instructions: This supplement replaces Section 3 on the previous version of Form 1-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form 1-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form 1-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form 1-9 (M-274)

Date of Rehire (if applicable)

New Name (if applicable)

Date

Last Name (Family Name)

irst Name (Given Name

Middle Initial

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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Today's Date

Additional Information (Initial and date each notation.)

Date of Rehire (if applicable)

New Name (if applicable)

Date

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title

Document Number (if any)

Expiration Date (if any) (mm/dd/yyyy)

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Additional Information (Initial and date each notation.)

Date of Rehire (if applicable)

New Name (if applicable)

Date

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Document Title

Document Number (if any)

Expiration Date

Name of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Date

Additional Information (Initial and date each notation.)

Employee'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.

Step 1: Enter Personal Information

First name and middle initial

Last name

ocial security number

Address

Street Address City State / Province / Region ZIP / Postal Code

Single or Married filing separately

Married filing jointly or Qualifying surviving spouse

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.)

TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if you are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs), deductions, or credits.

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5.

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 the most accurate withholding.

(b) Use the Multiple Jobs Worksheet and enter the result in Step 4(c).

(c) If there are only two jobs total, you may check this box:

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs.

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):

(a) Multiply the number of qualifying children under age 17 by $2,200

(b) Multiply the number of other dependents by $500

Step 4: 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

(b) Deductions. Use the Deductions Worksheet on page 4 to determine the amount deductions you may claim, which will reduce your withholding. (If you skip this line, your withholding will be based on the standard deduction.) Enter the result here

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.)

Date

Employer's name and address

First date of employment

Employer identification number (EIN)

W-4 General & Specific Instructions

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future Developments

For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505, Tax Withholding and Estimated Tax.

Exemption from withholding

You may claim exemption from withholding for 2026 if you meet both of the following conditions: you had no federal income tax liability in 2025 and you expect to have no federal income tax liability in 2026. You had no federal income tax liability in 2025 if (1) your total tax on line 24 on your 2025 Form 1040 or 1040-SR is zero (or less than the sum of lines 27a, 28, 29, and 30), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status.

If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2026 tax return. To claim exemption from withholding, certify that you meet both of the conditions by checking the box in the Exempt from withholding section. Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2027.

Your privacy

Steps 2(c) and 4(a) ask for information regarding income you received from sources other than the job associated with this Form W-4. If you have concerns with providing the information asked for in Step 2(c), you may choose Step 2(b) as an alternative; if you have concerns with providing the information asked for in Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c) as an alternative.

When to use the estimator

Consider using the estimator at www.irs.gov/W4App if you:

Are submitting this form after the beginning of the year;
Expect to work only part of the year;
Have changes during the year in your marital status, number of jobs, dependents, deductions, or credits;
Receive dividends, capital gains, social security, bonuses, or business income, or are subject to additional taxes;
Prefer the most accurate withholding for multiple job situations.

TIP: Have your most recent pay stub(s) from this year available when using the estimator to account for federal income tax already withheld. At the beginning of next year, use the estimator again to recheck your withholding.

Self-employment

Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from wages. If you want to pay these taxes through withholding, use the estimator at www.irs.gov/W4App to determine the amount.

Nonresident alien

If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens before completing this form.

Specific Instructions

Step 1(c)

Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2

Use this step if you have more than one job or are married filing jointly and both spouses work. Submit a separate Form W-4 for each job.

Option (a) provides the most accurate calculation. Option (b) is slightly less accurate. If you and your spouse have only two jobs, you may check option (c). This splits tax brackets and standard deduction between jobs.

CAUTION: Complete Steps 3–4(b) on only ONE Form W-4 (highest paying job) for best accuracy.

Step 3

Determine the child tax credit and credit for other dependents. The child must be under 17, live with you more than half the year, and have a valid SSN. You can also include other credits such as education or foreign tax credits.

Step 4(a)

Enter other estimated income (not from jobs). This helps avoid estimated tax payments.

Step 4(b)

Enter deductions if you plan to itemize or claim additional deductions such as student loan interest, IRAs, etc.

Step 4(c)

Enter any extra tax you want withheld each pay period. This reduces your paycheck but may increase your refund or reduce tax owed.

Step 2(b)-Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job. To be accurate, submit a new Form W-4 for all other jobs if you have not updated your withholding since 2019. Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1) Two jobs. If you have two jobs or you're married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 5. Using the "Higher Paying Job" row and the "Lower Paying Job" column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3

2) Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3. a) Find the amount from the appropriate table on page 5 using the annual wages from the highest paying job in the "Higher Paying Job" row and the annual wages for your next highest paying job in the "Lower Paying Job" column. Find the value at the intersection of the two household salaries and enter that value on line 2a

b) b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the "Higher Paying Job" row and use the annual wages for your third job in the "Lower Paying Job" column to find the amount from the appropriate table on page 5 and enter this amount on line 2b

c) Add the amounts from lines 2a and 2b and enter the result on line 2c

3) 3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc.

4) Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (plus any other additional amount you want withheld).

Step 4(b)-Deductions Worksheet (Keep for your records.)

See the Instructions for Schedule 1-A (Form 1040) for more information about whether you qualify for the deductions on lines 1a, 1b, 1c, 3a, and 3b.

1 Deductions for qualified tips, overtime compensation, and passenger vehicle loan interest. a) Qualified tips. If your total income is less than $150,000 ($300,000 if married filing jointly), enter an estimate of your qualified tips up to $25,000

b) Qualified overtime compensation. If your total income is less than $150,000 ($300,000 if married filing jointly), enter an estimate of your qualified overtime compensation up to $12,500 ($25,000 if married filing jointly) of the "and-a-half" portion of time-and-a-half compensation

c) Qualified passenger vehicle loan interest. If your total income is less than $100,000 ($200,000 if married filing jointly), enter an estimate of your qualified passenger vehicle loan interest up to $10,000

2 Add lines 1a, 1b, and 1c. Enter the result here.

3) Seniors age 65 or older. If your total income is less than $75,000 ($150,000 if married filing jointly): a) Enter $6,000 if you are age 65 or older before the end of the year

b) b Enter $6,000 if your spouse is age 65 or older before the end of the year and has a social security number valid for employment

4 Add lines 3a and 3b. Enter the result here

5 Enter an estimate of your student loan interest, deductible IRA contributions, educator expenses, alimony paid, and certain other adjustments from Schedule 1 (Form 1040), Part II. See Pub. 505 for more information

6 Itemized deductions. Enter an estimate of your 2026 itemized deductions from Schedule A (Form 1040). Such deductions may include qualifying: a) Medical and dental expenses. Enter expenses in excess of 7.5% (0.075) of your total income

b) State and local taxes. If your total income is less than $505,000 ($252,500 if married filing separately), enter state and local taxes paid up to $40,400 ($20,200 if married filing separately)

c) Home mortgage if interest. If your home acquisition debt is less than $750,000 ($375,000 married filing separately), enter your home mortgage interest expense (including mortgage insurance premiums)

d) Gifts to charities. Enter contributions in excess of 0.5% (0.005) of your total income

e) Other itemized deductions. Enter the amount for other itemized deductions

7) Add lines 6a, 6b, 6c, 6d, and 6e. Enter the result here

8) Limitation on itemized deductions. a) Enter your total income

b Subtract line 4 from line 8a. If line 4 is greater than line 8a, enter -0- here and on line 10. Skip line 9

9) Enter : $768,700 if you're married filing jointly or a qualifying surviving spouse • $640,600 if you're single or head of household ld a Enter your total income Subtract line 4 from line 8a. If line 4 is greater than line 8a, enter -0- here and on line 10. Skip line 9 8b $ ( $768,700 if you're married filing jointly or a qualifying surviving spouse 9

10) If line 9 is greater than line 8b, enter the amount from line 7. Otherwise, multiply line 7 by 94% (0.94) and enter the result here

11) Standard deduction. Enter: $32,200 if you're married filing jointly or a qualifying surviving spouse • $24,150 if you're head of household • $16,100 if you're single or married filing separately

12) Cash gifts to charities. If you take the standard deduction, enter cash contributions up to $1,000 ($2,000 if married filing jointly)

13) Add lines 11 and 12. Enter the result here

14) If line 10 is greater than line 13, subtract line 11 from line 10 and enter the result here. If line 13 is greater than line 10, enter the amount from line 12

15) Add lines 2, 4, 5, and 14. Enter the result here and in Step 4(b) of Form W-4

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If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Married Filing Jointly or Qualifying Surviving Spouse

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0–9,999	$10,000–19,999	$20,000–29,999	$30,000–39,999	$40,000–49,999	$50,000–59,999	$60,000–69,999	$70,000–79,999	$80,000–89,999	$90,000–99,999	$100,000–120,000
$0–9,999	0	0	480	850	850	1020	1020	1020	1020	1020	1020
$10,000–19,999	0	480	1480	1850	2050	2220	2220	2220	2220	2220	2620
$20,000–29,999	480	1480	2480	3050	3250	3420	3420	3420	3420	3820	4820
$30,000–39,999	850	1850	3050	3620	3820	3990	3990	3990	3990	4390	6390
$40,000–49,999	850	2050	3250	3820	4020	4190	4190	4190	4590	5590	7590
$50,000–59,999	1020	2220	3420	3990	4190	4360	4360	4760	5760	6760	8760
$60,000–69,999	1020	2220	3420	3990	4190	4360	4760	5760	6760	7760	9760
$70,000–79,999	1020	2220	3420	3990	4190	4760	5760	6760	7760	8760	10760
$80,000–99,999	1020	2220	3420	4240	5440	6610	7610	8610	9610	10610	12610
$100,000–149,999	1870	4070	6270	7840	9040	10210	11210	12210	13210	14210	16560

Single or Married Filing Separately

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0–9,999	$10,000–19,999	$20,000–29,999	$30,000–39,999	$40,000–49,999	$50,000–59,999	$60,000–69,999	$70,000–79,999	$80,000–89,999	$90,000–99,999	$100,000–109,999	$110,000–120,000
$0–9,999	90	850	1020	1020	1020	1070	1870	1870	1870	1870	1870	1970
$10,000–19,999	850	1780	1980	1980	2030	3030	3830	3830	3830	3830	3930	4130
$20,000–29,999	1020	1980	2180	2230	3230	4230	5030	5030	5030	5130	5330	5530
$30,000–39,999	1020	1980	2230	3230	4230	5230	6030	6030	6130	6330	6530	6730
$40,000–59,999	1020	2880	4080	5080	6080	7080	7950	8150	8350	8550	8750	8950
$60,000–79,999	1870	3830	5030	6030	7100	8300	9300	9500	9700	9900	10100	10300
$80,000–99,999	1870	3830	5100	6300	7500	8700	9700	9900	10100	10300	10500	10700
$100,000–124,999	2030	4190	5590	6790	7990	9190	10190	10390	10590	10940	11940	12940
$125,000–149,999	2040	4200	5600	6800	8000	9200	10200	10950	11950	12950	13950	14950
$150,000–174,999	2040	4200	5600	6800	8150	10150	11950	12950	13950	14950	16170	17470
$175,000–199,999	2040	4200	6150	8150	10150	12150	13950	15020	16320	17620	18920	20220
$200,000–249,999	2720	5680	7880	10140	12440	14740	16840	18140	19440	20740	22040	23340
$250,000–449,999	2970	6230	8730	11030	13330	15630	17730	19030	20330	21630	22930	24240
$450,000 and over	3140	6600	9300	11800	14300	16800	19100	20600	22100	23600	25100	26610

Head of Household

Higher Paying Job Annual Taxable Wage & Salary	Lower Paying Job Annual Taxable Wage & Salary
Higher Paying Job Annual Taxable Wage & Salary	$0–9,999	$10,000–19,999	$20,000–29,999	$30,000–39,999	$40,000–49,999	$50,000–59,999	$60,000–69,999	$70,000–79,999	$80,000–89,999	$90,000–99,999	$100,000–109,999	$110,000–120,000
$0–9,999	0	280	850	950	1020	1020	1020	1020	1560	1870	1870	1870
$10,000–19,999	280	1280	1950	2150	2220	2220	2220	2760	3760	4070	4070	4210
$20,000–29,999	850	1950	2720	2920	2980	2980	3520	4520	5520	5830	5980	6180
$30,000–39,999	950	2150	2920	3120	3180	3720	4720	5720	6720	7180	7380	7580
$40,000–59,999	1020	2220	2980	3570	4640	5640	6640	7750	8950	9460	9660	9860
$60,000–79,999	1020	2610	4370	5570	6640	7750	8950	10150	11350	11860	12060	12260
$80,000–99,999	1870	4070	5830	7150	8410	9610	10810	12010	13210	13720	13920	14120
$100,000–124,999	1870	4270	6230	7630	8900	10100	11300	12500	13700	14210	14720	15720
$125,000–149,999	2040	4440	6400	7800	9070	10270	11470	12670	14580	15890	16890	17890
$150,000–174,999	2040	4440	6400	7800	9070	10580	12580	14580	16580	17890	18890	20170
$175,000–199,999	2040	4440	6400	8510	10580	12580	14580	16580	18710	20320	21620	22920
$200,000–249,999	2720	5920	8680	10900	13270	15570	17870	20170	22470	24080	25380	26680
$250,000–449,999	2970	6470	9540	12040	14410	16710	19010	21310	23610	25220	26520	27820
$450,000 and over	3140	6840	10110	12810	15380	17880	20380	22880	25380	27190	28690	30190

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Criminal offenses found in section 435.04, F.S.

Criminal offenses found in section 435.04, F.S. (continued)

Criminal Offenses listed in section 393.0655 (5), F.S.

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