Home Care of Baltimore
Application for Employment – Personal Care Provider
Date Received: ________

Personal Information
Last NameFirst Name

Street Address

City

State

Home Phone: (_____)________-________________
Work Phone: (_____)________-________________
Other:

Today’s Date

Middle Name

Zip Code

Are you a United States Citizen or legally eligible to work in
the U. S.? ______Yes ______No (if hired, you will be required
to provide documentation that you are eligible to work in the
U.S.)(_____)________-________________

Email address ______________________________Are you 18 or over?

____Yes ____No
Date Available to Work

Title of Position Applying For

Have you been previously interviewed or employed by Home Care of Baltimore?
If Yes, list date(s) and job title(s):____Yes ____No

What is the lowest pay you will accept?

Are you employed now?

If so, may we contact your present employer?

List all other professional licenses, registrations, andcertificates:_______________________________________________
List any special skills you possess that would be appropriate for the job for which you
are applying:___________________________________________________________________________________________________
List times you will be willing/able to work:(Mornings:)________________(Afternoons)__________________(Evenings)__________________(Weekend) ________________ (Live-In)__________________1

Do you have transportation available? Yes______ No_______

Please list the zip codes or areas within Baltimore County where you are willing/able toaccept patients for personal care services:___________________________________________________________________________________________________Are you fluent in any languages other than English?
________________________________
Education
Name and Location
High School# Years Completed

Major Area of Study

Degree/Diploma

College

Graduate
SchoolTechnical
or
Certificate
Programs

Employment History

Please provide the following information for your previous three employers, beginningwiththe most recent: (Please attach an additional page if necessary, do not use “see attachedresume”.)
Employer:

Dates Employed:

Job Title:

From_____________

To______________

Address:

Telephone:

Weekly Pay

Job Duties:

Start:

Finish:Reason for Leaving:2

Employer:

Dates Employed:

Job Title:

From_____________

To______________

Address:

Telephone:

Weekly Pay

Job Duties:

Start:

Finish:Reason for Leaving:

Employer:

Dates Employed:

Job Title:

From_____________

To______________

Address:

Telephone:

Weekly Pay

Job Duties:

Start:

Finish:Reason for Leaving:

Describe your qualifications for the type of employment you are seeking: (Please include skills, special training,etc.)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

References
Name

Please list names of supervisors, managers, or others who can comment directly on your abilities:
Address

Phone #

Relationship/Occupation

3

Years
Known

Have you ever been disciplined or asked to resign from any position? ( ) Yes ( ) No
If yes,explain:___________________________________________________________________________________Can you perform the functions of the job for which you are applying with or without reasonableaccommodations?
( ) Yes ( ) No

TO BE COMPLETED BY ALL APPLICANTS

Home Care of Baltimore is an Equal Opportunity Employer. It is the policy of Home Care of Baltimore ot to discriminate
in employment matters on the basis of race, creed, color, age, marital status, physical or mental disability, national origin,sex, or sexual orientation.
******
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I
understand that if employed, false statements on this application shall be considered sufficient cause of dismissal. You are
hereby authorized to make investigation of my personal references.

________________________________
Signature of Applicant______________________________Date

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR
DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVEEMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUALSUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN
EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANORAND SUBJECT TO A FINE NOT EXCEEDING $100.

4DICLOSURE STATEMENT BACKGROUND CHECK RELEASE FORM
HOME CARE OF BALTIMOREI hereby authorize Home Care of Baltimore and its designated agents and representatives to
conduct a comprehensive review of my background through a consumer report and/or aninvestigative consumer report to be generated for employment, promotion, reassignment or
retention as an employee. I understand that the scope of the consumer report/investigative
consumer

reportmay

include,

but

is

not

limitedto,thefollowingareas:

Verification of Social Security Number, current and previous residences, employment history
including all personnel files, education, character references, credit history and reports, criminal
history records from any criminal justice agency in any or all federal, state county jurisdictions,birth records, motor vehicle records to include traffic citations and registration and any otherpublic records.
I________________________________, authorize the complete release of these records or data
pertaining to me which an individual, company, firm, corporation, or public agency may have. I
understand that I must provide my date of birth to adequately complete said screening, andacknowledge that my date of birth will not affect any hiring decisions. I hereby authorize andrequest any present or former employer, school, police department, financial institution or otherpersons having personal knowledge of me, to furnish bearer with any and all information in theirpossession regarding me in connection with an application for employment. This authorization andconsent shall be valid in original, fax, or copy form. I hereby release Home Care of Baltimore, andits agents, officials, representatives, or assigned agencies, including officers, employees, or
related personnel both individually and collectively, from any and all liability for damages ofwhatever kind, which may at any time, result to me, my heirs, family or associates because ofcompliance with this authorization and request to relapse. You may contact me as indicatedbelow; I understand that a copy of this authorization may be given to me at any time, provided I
request it in writing. Information on this application and results of the backgroundinvestigation will be maintained in confidence in accordance with company hiring practices.
Name:_____________________________________________________________________________________
Social Security Number:__________________________

SEX:______

Race:______

D/O/B:________________
Current Address:_______________________________________________________________________
City______________________________State:____________

Zip: ___________________________________

Drivers License Number:___________________________

State of Issuance:______

May we contact Your Current Employers:__________________________________________________

Signature______________

Date_______________________________

5

Hepatitis B Immunization Consent/Refusal Form
Please check one:o

Yes, I want to receive the Hepatitis B vaccine.

I read the information given to me about Hepatitis B virus and Hepatitis B vaccine and I
had the opportunity to ask questions. My questions were answered.
I want to participate in the vaccination program. I understand this includes three
injections at prescribed intervals over a six month period. I understand that there is no
guarantee that I will become immune to Hepatitis B. I understand that I might experience anadverse side effect as the result of the vaccination.
Employee Name
City, State, Zip
Social Security NumberoNo, I don't want to receive the Hepatitis B Vaccine.

I understand that due to my occupational exposure to blood or other potentially
infectious material, I may be at risk of acquiring Hepatitis B Virus (HBV). I was given theopportunity to be vaccinated with Hepatitis B vaccine at no charge to me. However, I
decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I
continue to be at an increased risk of acquiring Hepatitis B, a serious disease.
If in the future, I want to be vaccinated with the Hepatitis B vaccine, I understand that I
can receive the vaccine series at no charge to me.
Employee Name
City, State, Zip
Social Security Number
Signature
PRIVACY ACT INFORMATION
Agency: Home Care of Baltimore
Address: 2 Jill ct., Reisterstown MD, 21136
Telephone Number: 410-978-8236
Date:

6

Home Care of Baltimore
Job
Description
Personal Care Aide—

Policy No. HC 450

Page 1 of 2

Personnel and Contractors

Date of Origin: 09-24-2010

Reviewed:

Effective Date: 09-24-2010

Date: 09-24-2010

Approved:

Position: Personal Care Aide
Reports to: Home Care Supervisor
Summary of Responsibilities:
The Personal Care Assistant provides personal care and household assistance to clients in theirown homes. The Personal Care Assistant works under the supervision of the Home Care
Supervisor and is assigned specific tasks through the Home Care Plan of Care.
Specific duties include:
Assists clients with personal care, which may include bathing, shampooing, shaving, toileting,
dressing, transfers, ambulation and positioning.
Performs household services essential to the client's safety and care at home including; laundry,
meal preparation, housekeeping, transportation and shopping.
Performs only the tasks defined in the Home Care Plan of Care for the client and observes,
documents and reports any changes in the client's condition. May assist with medications as
indicated in the plan of care.
Reports to the Home Care Supervisor any changes in the client's mental or physical condition as
well as changes in the client's need for care.
Follows agency policies and procedures.
Meets the requirements for submission of time cards and documentation of assignments.
Respects the rights of clients and families to have different beliefs, opinions, cultures andcustoms.
Attends orientation and in-service training as required by the agency.
As a member of the home care team keeps and maintains a professional attitude in the client's
home.

7

Job Description — Personal Care
Aide

Policy No.450

I Page 2 of 2

Skills Requirements:
1. Possesses and maintains good physical stamina and mental health. Prior to patient
contact, presents a pre-employment health clearance.
2. Is self-directing with the ability to work with little direct supervision.
3. Demonstrates empathy for the needs of the ill, injured, frail and the impaired.
4. Demonstrates flexible and cooperation in fulfilling role obligation.
5. Demonstrates tact, patience, and good personal hygiene.
6. They usually are trained on the job by registered nurses or other experienced aides.
7. Aides are should be able to cook for a client, including on special diets.
8. Aides arc should be able to pass the test for basic housekeeping, such as making a bed
and keeping the home sanitary and safe for the client.
9. Aides are should be able to learn how to respond to an emergency.
10. Aides are should be able to learning basic safety techniques.

Other qualifications. Aides should have a desire to help people. They should be
responsible, compassionate, patient, emotionally stable, and cheerful. In addition, aides
should be tactful, honest, and discreet, because they work in private homes. Aides also
must be in good health. A physical examination, including State-mandated tests fortuberculosis and other diseases, may be required. A criminal background check and agood driving record also may be required for employment

Signature:___8

Home Care of Baltimore
Orientation Processof 1
Personnel, Contractors andVolunteer Policies
Effective Date: 09-24-2010

Policy No. HC 435

Page 1

Date of Origin: 09-24-2010

Reviewed:

Date:

Approved:

09-24-2010

PERSONNEL ORIENTATION TRAINING
The following areas of orientation have been reviewed and understood by:

Employee Name:______________________________________________
Philosophy of care
Job description
Time cards and pay periods
Personnel requirements
Documentation of care
Policy and Procedure review
Client's Bill of Rights
ClientCare

Policies

andProcedures General Policies
Communication with clients
Detection

of

Abuse

and

Neglect Infection Control
ControlofCommunicable

Disease Medication Assistance
Emergency Procedures I
tome Care Plan of Care
Supervision of Personal Care Aides

Employee Signature:____________________

9

Date:_________________

INTERVIEW CHECK LIST
Name of Candidate______________________________________
Time of interview ________________________________________ _____________
Salary________________________________________________
Appearance/Demeanor_________________________________
Date_________________________________________________

When evaluating the candidate post interview make sure to consider how the person
interacted with others, energy level, genuine interest in your agency and position andalso evaluate personal qualities, organizational fit, common- sense and good judgment
Technical Questions:
Qt. What made you decide to apply for this job?

A1._____________________________________
Q2. Do you have any work experience in care giving or similar areas?
A2.____________________________________________
Q3 Tell us about specific training or courses pertaining to in-home health work
A3._________________________________________
Accomplishments:
Ql. How did you fill downtime at your last job?
A1.____________________________________
Q2.When you have a lot of work to do and not enough time or assistance to get it all done,
how do you handle it?
A2.___________________________________________
Q3. It Is your lunch break and you see a client fall. What do you do?
A3.___________________________________________

Patient/Customer Service Questions:
Qt How have you responded when your supervisor asked you to work a different shift to fillvacancies

Al.___________________________________
Q2. What is your relationship with your grandparents?
A2.________________________________________
Q3. How do you feel about the philosophy of the customer always being right?

A3.____________________________________
Other: (List other questions which are important for this position)
Q1. How do you respond if you know the customer is wrong?
Al._____________________________________
Q2. What does being responsible mean to you?
A2.________________________________________

10

Home Care of Baltimore
Policy and Procedures Addendum 05/18/2017
Attn: Personal Care Providers
Memo: Compliance with Deficit Reduction Act - Employee Education
Fraud
Caregiver must follow the next rules, while providing services through the Agency:
1. Providers can only bill for direct care, meaning the staff provider MUST be providing care to the client at all
times. If the staff provider needs to run errands for the client, the client MUST be present. The staff provider may
never bill through ISAS while the client is not present. No service will be reimbursed while the participant isadmitted to the Emergency room, hospital, admitted to a nursing facility, admitted to an institution for mental
disease, attending a day care program. (COMAR 10.09.20.01).
2. Personal Assistance services can only be reimbursed if they are provided in the participant’s presence. Errands,
including for groceries or medications, cannot be reimbursed unless the participant is escorted by the aide.
(COMAR 10.09.84.02).
3. Services provided during vacation must be: within POS hours, not out of state of Maryland for more than 14 days
per year, within the US, logged in ISAS using phone listed on client POS or OTP device. For clock in and out
staff providers MUST use the client’s home phone. If personal OTP device is assigned to the participant,provider can use any other phones. OTP device MUST be kept with the Participant or in an easily accessible
location at the Participants home at all times (COMAR 10.09.36.04)

Waste
Caregiver can help to prevent pollution, illness by following a few rules when disposing the sharp objects and any
contaminated materials:
1. Lancets, sharps, needles, syringes and other sharp objects should be stored in metal containers with a tightly
screwed on lid.
2. Before discarding a container, be sure to reinforce the lid with heavy-duty tape. Do not put sharp objects in any
container you plan to recycle and do not use glass or clear plastic containers
3. Keep all containers with sharp objects out of the reach of visitors such as children and pets.
4. When disposing medical gloves, bandages, sheets they should be secured in regular plastic trash bag if not visibly
soiled; and should be secured to the bag with Biohazard label if visibly soiled with blood or potentially infectious
material.
Abuse & Neglect
1. Caregiver must not be involved in unauthorized use of participant’s funds, steal cash or household goods, misuseparticipants credit cards or accounts
2. Caregiver must not be involved in emotional/psychological/sexual abuse: caretaker cannot yell, threat, ignore theparticipant, and cannot isolate the client from his / her friends.
3. Caregiver cannot neglect the participant: should respond to clients needs in a timely manner, provide the meals,
medication or hygienic activities on time and respond to clients fall with or without injury immediately and call
911 when required.
I have read, understand and agree to abide by the terms of Home Care of Baltimore policy regarding the prevention ofwaste/fraud/ abuse of the participant.
Caregiver name:_____________________
Caregiver Signature__________________

Date___________________________________

11

USCIS
Form I-9

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0047
Expires 10/31/2022►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because thedocumentation presented has a future expiration date may also constitute illegal discrimination.

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)
Address (Street Number and Name)
Date of Birth (mm/dd/yyyy)

Middle Initial

First Name (Given Name)
Apt. Number

U.S. Social Security Number-

Other Last Names Used (if any)
State

City or Town

ZIP Code

Employee's Telephone Number

Employee's E-mail Address-

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents inconnection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident(Alien Registration Number/USCIS Number):

4. An alien authorized to work

until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)
QR Code - Section 1
Do Not Write In This Space

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:OR

2. Form I-94 Admission Number:OR

3. Foreign Passport Number:Country of Issuance:
Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):
I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 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 myknowledge the information is true and correct.
Today's Date (mm/dd/yyyy)

Signature of Preparer or Translator
Last Name (Family Name)

Address (Street Number and Name)First Name (Given Name)City or Town

State

ZIP Code

Employer Completes Next Page
Form I-9 10/21/2019

Page 1 of 3

USCIS
Form I-9

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0047
Expires 10/31/2022

Section 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Listsof Acceptable Documents.")
Employee Info from Section 1

Last Name (Family Name)

List A

Identity and Employment Authorization

M.I.

First Name (Given Name)OR

List B

Citizenship/Immigration Status

AND

Identity

List C

Employment Authorization

Document Title

Document Title

Document Title

Issuing Authority

Issuing Authority

Issuing Authority

Document Number

Document Number

Document Number

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

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

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

Document Title
QR Code - Sections 2 & 3
Do Not Write In This Space

Additional Information

Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge theemployee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):
Signature of Employer or Authorized Representative
Last Name of Employer or Authorized Representative(See instructions for exemptions)

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Address (Street Number and Name)City or Town

Employer's Business or Organization NameStateZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)

B. Date of Rehire (if applicable)
First Name (Given Name)

Middle Initial

Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
Document Title

Document Number

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

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 document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative

Form I-9 10/21/2019

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

Page 2 of 3

Form

W-4

Department of the Treasury
Internal Revenue Service

Step 1:Enter
Personal
Information

Employee’s Withholding Certificate

OMB No. 1545-0074

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.

2024(a) First name and middle initial(b) Social security number

Last name

Address

Does your name match thename on your social security
card? If not, to ensure you getcredit for your earnings,
contact SSA at 800-772-1213
or go to www.ssa.gov.

City or town, state, and ZIP code(c)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.)Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who canclaim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

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 spousealso 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 most accurate withholding for this step (and Steps 3–4). If youor your spouse have self-employment income, use this option; or(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This
option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at thehigher paying job. Otherwise, (b) is more accurate . . . . . . . . . . . . . . . . . .

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:Claim
Dependent
and Other
Credits
Step 4(optional):
Other
Adjustments

Step 5:Sign
Here

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 tothis the amount of any other credits. Enter the total here . . . . . . . . . .

3(a) Other income (not from jobs). If you want tax withheld for other income you
expect this year that won’t have withholding, enter the amount of other income here.
This may include interest, dividends, and retirement income . . . . . . . .

4(a) $(b) Deductions. If you expect to claim deductions other than the standard deduction andwant to reduce your withholding, use the Deductions Worksheet on page 3 and enter
the result here . . . . . . . . . . . . . . . . . . . . . . .

4(b) $(c) Extra withholding. Enter any additional tax you want withheld each pay period .

4(c) $

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.)Employers
Only

.

$

Employer’s name and address

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

DateFirst date of
employment

Cat. No. 10220Q

Employer identification
number (EIN)

Form W-4 (2024)

MARYLAND
FORM

MW507
Purpose. Complete Form MW507 so that your employer can withhold the correct
Maryland income tax from your pay. Consider completing a new Form MW507
each year and when your personal or financial situation changes.
Basic Instructions. Enter on line 1 below, the number of personal exemptions
you will claim on your tax return. However, if you wish to claim more exemptions,or if your adjusted gross income will be more than $100,000 if you are filingsingle or married filing separately ($150,000, if you are filing jointly or as headof household), you must complete the Personal Exemption Worksheet on page
2. Complete the Personal Exemption Worksheet on page 2 to further adjust your
Maryland withholding based on itemized deductions, and certain other expenses
that exceed your standard deduction and are not being claimed at another job orby your spouse. However, you may claim fewer (or zero) exemptions.
Additional withholding per pay period under agreement with employer. If
you are not having enough tax withheld, you may ask your employer to withhold
more by entering an additional amount on line 2.
Exemption from withholding. You may be entitled to claim an exemption fromthe withholding of Maryland income tax if:
a. Last year you did not owe any Maryland Income tax and had a right to a fullrefund of any tax withheld; AND,b. This year you do not expect to owe any Maryland income tax and expect to havea right to a full refund of all income tax withheld.
If you are eligible to claim this exemption, complete Line 3 and your employer will
not withhold Maryland income tax from your wages.
Students and Seasonal Employees whose annual income will be below the minimum filing requirements should claim exemption from withholding. This provides
more income throughout the year and avoids the necessity of filing a Maryland
income tax return.
Certification of nonresidence in the State of Maryland. Complete Line 4. Thisline is to be completed by residents of the District of Columbia, Virginia or West
Virginia who are employed in Maryland and who do not maintain a place of abodein Maryland for 183 days or more.
Residents of Pennsylvania who are employed in Maryland and who do not maintaina place of abode in Maryland for 183 days or more, should complete line 5 to exempt themselves from the state portion of the withholding tax. These employees
are still liable for withholding tax at the rate in effect for the Maryland county inwhich they are employed, unless they qualify for an exemption on either line 6 orline 7. Pennsylvania residents of York and Adams counties may claim an exemption from the local withholding tax by completing line 6. Pennsylvania residents
living in other local jurisdictions which do not impose an earnings or income tax
on Maryland residents may claim an exemption by completing line 7. Employees
qualifying for exemption under 6 or 7, should also write “EXEMPT” on line 4.
Line 4 is NOT to be used by residents of other states who are working in Maryland,because such persons are liable for Maryland income tax and withholding from

FORM

MW507

their wages is required.
If you are domiciled in the District of Columbia, Pennsylvania or Virginia and maintain a place of abode in Maryland for 183 days or more, you become a statutory
resident of Maryland and you are required to file a resident return with Maryland
reporting your total income. You must apply to your domicile state for any tax
credit to which you may be entitled under the reciprocal provisions of the law. If
you are domiciled in West Virginia, you are not required to pay Maryland income
tax on wage or salary income, regardless of the length of time you may havespent in Maryland.
Under the Servicemembers Civil Relief Act, as amended by the Military Spouses
Residency Relief Act, you may be exempt from Maryland income tax on yourwages if (i) your spouse is a member of the armed forces present in Maryland incompliance with military orders; (ii) you are present in Maryland solely to be withyour spouse; and (iii) you maintain your domicile in another state. If you claim
exemption under the SCRA enter your state of domicile (legal residence) on Line8; enter “EXEMPT” in the box to the right on Line 8; and attach a copy of your
spousal military identification card to Form MW507. In addition, you must also
complete and attach Form MW507M.
Duties and responsibilities of employer. Retain this certificate with your records. You are required to submit a copy of this certificate and accompanying
attachments to the Compliance Division, Compliance Programs Section, 301 West
Preston Street, Baltimore, MD 21201, when received if:
1. You have any reason to believe this certificate is incorrect;
2. The employee claims more than 10 exemptions;3. The employee claims an exemption from withholding because he/she had notax liability for the preceding tax year, expects to incur no tax liability this year
and the wages are expected to exceed $200 a week;
4. The employee claims an exemption from withholding on the basis of nonresidence; or
5. The employee claims an exemption from withholding under the Military Spouses Residency Relief Act.
Upon receipt of any exemption certificate (Form MW507), the Compliance Division
will make a determination and notify you if a change is required.
Once a certificate is revoked by the Comptroller, the employer must send any newcertificate from the employee to the Comptroller for approval before implementing
the new certificate.
If an employee claims exemption under 3 above, a new exemption certificate mustbe filed by February 15th of the following year.
Duties and responsibilities of employee. If, on any day during the calendar
year, the number of withholding exemptions that the employee is entitled to claim
is less than the number of exemptions claimed on the withholding exemption certificate in effect, the employee must file a new withholding exemption certificate
with the employer within 10 days after the change occurs.

Employee’s Maryland Withholding Exemption Certificate

Print full nameSocial Security Number

Street Address, City, State, ZIP

County of residence (Nonresidents enter Maryland county (or Baltimore City) where you are employed.)

SingleMarried (surviving spouse or unmarried Head of Household) Rate

Married, but withhold at Single rate

1. Total number of exemptions you are claiming not to exceed line f in Personal Exemption Worksheet on page 2. . . . . . . . . . . . . . . . . . . . . . . .

1._______________

2. Additional withholding per pay period under agreement with employer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. I claim exemption from withholding because I do not expect to owe Maryland tax. See instructions above and check boxes that apply.

2._______________

a. Last year I did not owe any Maryland income tax and had a right to a full refund of all income tax withheld andb. This year I do not expect to owe any Maryland income tax and expect to have the right to a full refund of all income tax withheld.
(This includes seasonal and student employees whose annual income will be below the minimum filing requirements).
If both a and b apply, enter year applicable _____________ (year effective) Enter “EXEMPT” here . . . . . . . . . . . . . . . . . . . . . . . . . .
4. I claim exemption from withholding because I am domiciled in one of the following states. Check state that applies.
District of Columbia
Virginia
West Virginia
I further certify that I do not maintain a place of abode in Maryland as described in the instructions above. Enter “EXEMPT” here. . . . . . . . . . .

3._______________

4._______________

5. I claim exemption from Maryland state withholding because I am domiciled in the Commonwealth of Pennsylvania and I do not
maintain a place of abode in Maryland as described in the instructions on Form MW507. Enter “EXEMPT” here.. . . . . . . . . . . . . . . . . . . . . . .  5._______________
6. I claim exemption from Maryland local tax because I live in a local Pennysylvania jurisdiction within York or Adams counties.
Enter “EXEMPT” here and on line 4 of Form MW507.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6._______________
7. I claim exemption from Maryland local tax because I live in a local Pennsylvania jurisdiction that does not impose an earnings or income
tax on Maryland residents. Enter “EXEMPT” here and on line 4 of Form MW507. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7._______________
8. I certify that I am a legal resident of the state of ____________ and am not subject to Maryland withholding because l meet the requirements set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Enter “EXEMPT” here.. . .  8._______________
Under the penalty of perjury, I further certify that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption
from withholding, that I am entitled to claim the exempt status on whichever line(s) I completed.
Employee’s signature

Date

Employer’s name and address including ZIP code (For employer use only)

Federal Employer Identification Number

COM/RAD-036

20-49

Authorization for Direct Deposit - Employee Form
Home Care of Baltimore
This authorizes ______________________________________________________________________________(the “Company”)
to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, tomy (our) account(s) indicated below and to other accounts I (we) identify in the future (the “Account”). This authorizes the financial
institution holding the Account to post all such entries.
Note: Enter your company name in the blank space above.

Account #1
Account #1 Type (check one): F Checking

F Savings____________________________________________________
Employee Bank Name____________________________________________________ ____________________________________________________
Bank Routing # (ABA#)
Account #________________________________________________
Percentage or Dollar Amount to be Deposited to This Account

Account #2 (remainder to be deposited to this account)
Account #2 Type (check one): F Checking

F Savings____________________________________________________
Employee Bank Name____________________________________________________ ____________________________________________________
Bank Routing # (ABA#)
Account #This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable
opportunity to act on it.
____________________________________________________
Signature____________________________________________________
Printed Name____________________________________________________ ____________________________________________________
Employee ID #Date
IMPORTANT: This document must be signed by employees requesting automatic deposit of paychecks and retained on fileby the employer.

Employee: Please fill out and return to your employer.

Employer: Please save for your files only.

Employee Waiver Form
This waiver form must be completed by any eligible employee who has voluntarily elected to waive his/her opportunity toparticipate in the dealership's employer-sponsored group health plan.
Name (Last, First, MI)

Sex

Street Address

Birth Date

Marital Status

Social Security #City, State & Zip

Phone #

Date of Hire

I hereby certify that the medical benefits provided by my employer have been explained to me, and that I elect to decline toparticipate in the plan. I understand by declining this offer I may not be offered another opportunity to participate unless I
marry, divorce, have a child (natural or adoption), have an involuntary loss of other health benefits, or any other involuntarycause as defined under section 125 of the IRS code. I must request to enroll within 30 days after a qualifying event. I may
also enroll during the next open enrollment period. I also understand that my employer has offered me a compliant healthplan as defined by the Affordable Care Act (ACA). I understand that by electing not to enroll in this ACA compliant plan, I will
not be eligible for a premium subsidy at either a state based or federally operated insurance exchange.
Reason for decline (please choose one):
I have other insurance through other job or spouse's employer.
I have other insurance through my parent(s).
I have other insurance through the military.
I have other insurance through my former employer (COBRA or Retirement).
I have my own insurance directly with an insurance carrier.
I have state or federal coverage through Medicare or Medicaid.
I have no health insurance and do not want any.
Other (please explain):

Signature

Date

19

HOME CARE OF BALTIMOREPROCEDURES/SKILL CHECKLIST
I ___________________________ verify that all the below procedures/skills were taught to me by a Registered
Nurse and I successfully demonstrated them back to the nurse. I understand all of the skills and feel comfortable incompleting any of them as needed.

GlovesSemi-Fowler’s Position

Supine Position
Sit On Edge of Bed

Walking

Assist with Walker

Drape and Undrape
Range of Motion

Rub Back
Change Gown

Occupied Bed
Denture Care
Feeding
Assist to Bathroom
Oral Temperature
Falling and Fainting

Fingernail Care
Oral Care
ShoweringBedside Commode
Axillary temperature
Hand Washing

Lateral position
Assist Resident to Move to
Head of Bed
Assist to Chair
Heel or Elbow Protectors
Dressing a Dependent
Resident
Safety Razor
Comb Hair
Bed bath
WeightChoking
Blood Pressure

Staffs signature:
Date:
Nursing Supervisors signature:
Date:

20

Fowlers position
Protective Devices
Transfer to Wheelchair
and Transport
Check Skin
Unoccupied Bed
Electric Razor
Assist to Eat
Perineal Care
Pulse and Respirations
Fire

21

22

23

24

EMPLOYEE/CONTRACTOR PHYSICAL EXAMINATION(Need to be completed within 30 days of employment)

Name:____________________________ Telephone:____________________________
Address:_________________________________________________________________
General: Age________ Weight________ Height________
Temperature________ Pulse________ Respiration_____________
Blood Pressure: Systolic_____ Diastolic_____ Respiration______X_ if findings are normal_O_ if findings are abnormal (describe)

Skin____________________ Speech_________________________
Head/Neck____________________ Chest/Breast _________________________
Eyes/Ears/Nose ____________________ Abdomen_________________________
Mouth/Throat ____________________ Blood Vessels _________________________
Lymph Nodes ____________________ Neurological _________________________
Lungs____________________ Extremities_________________________
Heart____________________ Mental Health _________________________
Is patient free of communicable diseases? Yes_____ No_____TBT Test:
Date ____________________
Please circle one
Chest X-Ray
PPD
Result___________________________________________________________________
Hepatitis B Test:
Date_____________________
Result __________________________________________________________________Name and Signature of examining physical_____________________________________
Date____________________

Phone___________________

Home Care of Baltimore

25

AGENCY PRIVACY REQUIREMENTS FOR NONCRIMINAL JUSTICE APPLICANTS
Authorized governmental and non-governmental agencies/officials that conduct a national
fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose(such as employment or a license, immigration or naturalization matter, security clearance, or
adoption) are obligated to ensure the applicant is provided certain notices and that the results ofthe check are handled in a manner that protects the applicant’s privacy. All notices must be
provided in writing.1 These obligations are pursuant to the Privacy Act of 1974, Title 5, UnitedStates Code (U.S.C.), Section 552a, and Title 28, Code of Federal Regulations (CFR), Section 50.12,
among other authorities.
•

•

•
•

•

Officials must ensure that each applicant receives an adequate written FBI Privacy Act
Statement (dated 2013 or later) when the applicant submits his/her fingerprints andassociated personal information.2
Officials must advise all applicants in writing that procedures for obtaining a change,
correction, or update of an FBI criminal history record are set forth at 28 CFR 16.34.
Information regarding this process may be found athttps://www.fbi.gov/services/cjis/identity-history-summary-checks andhttps://www.edo.cjis.gov.
Officials must provide the applicant the opportunity to complete or challenge the accuracyof the information in the FBI criminal history record.
Officials should not deny the employment, license, or other benefit based on information in
the FBI criminal history record until the applicant has been afforded a reasonable time tocorrect or complete the record or has declined to do so.
Officials must use the FBI criminal history record for authorized purposes only and cannot
retain or disseminate it in violation of federal statute, regulation or executive order, or rule,
procedure or standard established by the National Crime Prevention and Privacy Compact
Council.3

The FBI has no objection to officials providing a copy of the applicant’s FBI criminal history
record to the applicant for review and possible challenge when the record was obtained based on
positive fingerprint identification. If agency policy permits, this courtesy will save the applicant thetime and additional FBI fee to obtain his/her record directly from the FBI by following theprocedures found at 28 CFR 16.30 through 16.34. It will also allow the officials to make a more
timely determination of the applicant’s suitability.
Each agency should establish and document the process/procedures it utilizes for how/when it gives
the applicant the FBI Privacy Act Statement, the 28 CFR 50.12 notice, and the opportunity tocorrect his/her record. Such documentation will assist State and/or FBI auditors during periodic
compliance reviews on use of FBI criminal history records for noncriminal justice purposes.

sign/date1

Written notification includes electronic notification, but excludes oral notification.
See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement3
See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c);28 CFR 20.21(c), 20.33(d), 50.12(b) and 906.2(d).
2Updated 11/06/2019

STATE OF MARYLANDDEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICESCRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORYLIVESCAN PRE-REGISTRATION APPLICATIONAPPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY)
Name:
Date of birth:
Height:

ft.

Race:

Black

SSN:
inches

Weight:White

Gender:lbs.

Eye Color:)Asian/Pacific Islander

Place of Birth:

Male

Female(Please check)

Hair Color:
Native American

Other (Please check)

Citizenship:

Current address:
City:

State:

Daytime Phone:

Evening Phone:

ZIP Code:-

Driver’s License #:AGENCY INFORMATION
Agency Authorization #: 1100006320
ORI # (if required):

Reason fingerprinted?

Position Applied for: Personal Caregiver
Request Type: (Choose one ONLY)
Adult Dependent Care
Attorney/ClientChild care
Criminal JusticeGold Seal/ Adoption
Gold Seal/Letter/VISA
Government Employment

Government Licensing or Certification
Immigration/VISA
Individual Challenge
Individual Review
MSP Licensing
Private Party Petition
Public Housing

Mail Response to:(Mailing option only available for Visa Gold Seal and/or Individual Review)

Name: Home Care of Baltimore________________________________________________________________________________________
Address: 2 Reservoir Circle, Suite 102___________________________________________________________
City, State, Zip code: Pikesville, MD 21208______________________________________________________________________________