Application PDF

AR4EC
Employee’s Withholding Exemption Certificate
Print Full Name*
Social Security Number*
Phone Number*
Please enter a valid phone number.
DL/State ID Number*
High school/GED Graduate:*

YesNo
Are you currently employed?*

YesNo
Are you eligible to work in the US?*

YesNo
Have you ever been convicted of a felony?*

YesNo
Email Address
example@example.com
Address*

Home Address

Street Address Line 2

CityState

Zip

Hours Available
Sunday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Monday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Saturday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Sunday
(example: 9:00 - 5:00)
Monday
(example: 9:00 - 5:00)
Tuesday
(example: 9:00 - 5:00)
Wednesday
(example: 9:00 - 5:00)
Thursday
(example: 9:00 - 5:00)
Friday
(example: 9:00 - 5:00)
Saturday
(example: 9:00 - 5:00)

Employee Withholding Exemption Certificate

State of Arkansas
1. CHECK ONE OF THE FOLLOWING FOR EXEMPTIONS CLAIMED

a. You claim yourself. (Enter one exemption)b. You claim yourself and your spouse. (Enter two exemptions)c. Head of Household, and you claim yourself. (Enter two exemptions)
Enter one exemption
Enter two exemptions
Enter two exemptions
2. NUMBER OF CHILDREN or DEPENDENTS. (Enter one exemption per dependent)
3. TOTAL EXEMPTIONS. (Add 1 and 2) If no exemptions or dependents are claimed, enter zero
4. Additional amount, if any, you want deducted from each paycheck. (Enter dollar amount)
5. I qualify for the low-income tax rates.

YesNo
5. I qualify for the low-income tax rates. (See below for details)

SingleMarried Filing JointlyHead of Household

Division of Medical Services Medicaid Provider Enrollment Unit

Gainwell Technologies P.O. Box 8105, Little Rock, AR 72203-8105
PRACTITIONER IDENTIFICATION NUMBER REQUEST FORM
Please select one of the following:*

Physician Assistant NV (Include a W9 for the Individual)Non-Independent Licensed Clinician NW (Include license)Certified Behavioral Analyst Paraprofessional BPCertified Peer Recovery Support Specialist BH/SU RSPharmacist RX (Include license)Resident NUQBHP NTCommunity Support Staff CSPersonal Care Aide NT
Practitioner Name*
NPI
Taxonomy Code
Social Security Number*
Physical Work Address
Date of Birth*

MonthDayYear
Date
Physical Address Line 1*
Physical Address Line 2*
Physical Address City*
State*
ZIP+4*
Physical Address County*
Phone Number (Include area code)
Mail to Address
Mail to Address Line 1
Mail to Address Line 2
Mail to City
State
ZIP+4
Mail to County
Phone Number (Include area code)
Individual Email Address
enter previous email if you only have one
Place of Residency
NU-Residents Only
Effective Date of Residency

MonthDayYear
Date
Date of form submission

MonthDayYear
Date

Employee’s Withholding Certificate
Department of the Treasury Internal Revenue Service

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:
First name and middle initial*
Last name*
Social security number*
Address
City or town, state, and Zip code
Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead 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)
Step 2: Multiple Jobs or Spouse Works
Complete this step if you:
1. Hold more than one at a time.
2. Are married filing jointly and your spouse also works.
Do only one of the following:
1. Use the estimator at www.irs.gov/W4App for the most accurate withholding for this step and Steps 3–4 If you or your spouse have self-employment income, use this option
2. Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4c
3. If there are only two jobs total, you may check the box down below.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
C.

Two jobs in total
Step 3:

Claim Dependent and Other Credits
Complete Steps 3–4(b) 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
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
Step 4 (optional):

Other Adjustments
(a) Other income.
If you want tax withheld for other income youexpect this year that won’t have withholding, enter the amount of other income here.This may include interest, dividends, and retirement income
(b) Deductions.
If you expect to claim deductions other than the standard deduction and want to reduce your withholding, enter the result here.
(c)Extra withholding.
Enter any additional tax you want withheld each pay period.

Step 2(b)—Multiple Jobs Worksheet
If you choose the option in Step 2(b), 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 4. 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 .
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 4. 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.
1.
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.

Find the amount from the appropriate table on page 4 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
2a
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 4 and enter this amount
2b
2c. Add the amounts from lines 2a and 2b and enter the result here.
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. .
Pay periods
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here for the highest paying job (along with any other additional

amount you want withheld)
4.
Step 4(b)—Deductions Worksheet
1. Enter an estimate of your 2025 itemized deductions
2. Enter:{ • $22,500 if you’re head of household • $15,000 if you’re single or married filing separately • $30,000 if you’re married filing jointly or a qualifying surviving spouse}
3. If answer 1 is greater than answer 2, subtract answer 2 from answer 1 and enter the result here. If answer 2 is greater, enter "-0-"
4. Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments.
5. Add lines 3 and 4. Enter the result here

Health Care Personnel (HCP)

Baseline Individual TB Risk Assessment
HCP should be considered at increased risk for TB if any of the following statements are marked “Yes”:

Temporary or permanent residence of ≥1 month

in a country with a high TB rate

Any country other than the United States, Canada, Australia, New Zealand,

Current or planned immunosuppression,

including human immunodeficiency virus (HIV) infection, organ transplant

recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or

other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or

other immunosuppressive medication

Close contact with someone who has had

infectious TB disease since the last TB test

	YES	NO
Temporary or permanent residence of ≥1 monthin a country with a high TB rate
Current or planned immunosuppression
Close contact with someone who had infectious TB disease since the last TB test

Employment Eligibility Verification

Department of Homeland Security
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.

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)
Name

First Name (Given Name)Other Last Names Used (if any)
Middle Initial (if any)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
Apt. Number (if any)
State*
ZIP Code*
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
U.S. Social Security Number*
Employee's Email Address
example@example.com
Employee's Telephone Number*
Check one of the following boxes to attest to your citizenship or immigration status
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.*

1. A citizen of the United States2. A noncitizen national of the United States See Instructions3. A lawful permanent resident Enter USCIS or A-Number4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)
Enter USCIS or A-Number
(exp. date, if any)

MonthDayYear
Date
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
Signature of Employee
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
I had a translator assist me in completing this form*

YesNo
*Please see Preview and download before submitting.

Any extra pages will be submitted in person. (download button will be in the right hand corner of the preview page.)

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

Department of Homeland Security
Name

First Name (Given Name) from Section 1.Middle initial (if any) from Section 1.Last Name (Family Name) 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 I-9.

Translator 1
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 (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Middle Initial (if any)Last Name (Family Name)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
State
ZIP Code

Translator 2
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 (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Middle Initial (if any)Last Name (Family Name)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
State
ZIP Code

Translator 3
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 (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Middle Initial (if any)Last Name (Family Name)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
State
ZIP Code

Translator 4
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 (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Middle Initial (if any)Last Name (Family Name)
Address

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
State
ZIP Code

Reverification and Rehire (formerly Section 3)
Name

First Name (Given Name) from Section 1.Middle initial (if any) from Section 1.Last Name (Family Name) from Section 1.
Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-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 I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274)
Date of Rehire (if applicable) New Name (if applicable) Last Name (Family Name) Date (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name (Given Name)Middle InitialDate of Rehire (if applicable) New Name (if applicable) Last Name (Family Name) Date (mm/dd/yyyy)
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)

MonthDayYear
Date
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 (mm/dd/yyyy)

MonthDayYear
Date
Today's Date (mm/dd/yyyy)

Check here if you used an alternative procedure authorized by DHS to examine documents.
Additional Information Initial and date each notation

MonthDayYear
Date
Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name)

MonthDayYear
Date
Name

First Name (Given Name)Middle InitialDate of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name)
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)

MonthDayYear
Date
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 (mm/dd/yyyy)

MonthDayYear
Date
Check here if you used an alternative procedure authorized by DHS to examine documents.
Additional Information Initial and date each notation

MonthDayYear
Date
Date of Rehire (if applicable)

MonthDayYear
Date
Name

First Name (Given Name)Middle Initial Last Name (Family Name)
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)

MonthDayYear
Date
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 (mm/dd/yyyy)

MonthDayYear
Date
Additional Information Initial and date each notation

MonthDayYear
Date
Should be Empty:

AR4EC

Employee Withholding Exemption Certificate

Direct Deposit Enrollment / Change Form

Division of Medical Services Medicaid Provider Enrollment Unit

PRACTITIONER IDENTIFICATION NUMBER REQUEST FORM

Physical Work Address

Mail to Address

Employee’s Withholding Certificate

Step 1:

Step 2: Multiple Jobs or Spouse Works

Step 3:

Step 4 (optional):

(a) Other income.

(b) Deductions.

(c)Extra withholding.

Step 2(b)—Multiple Jobs Worksheet

Two jobs.

Three jobs.

Health Care Personnel (HCP)

Employment Eligibility Verification

Check one of the following boxes to attest to your citizenship or immigration status

*Please see Preview and download before submitting.

Reverification and Rehire (formerly Section 3)