Personal Data

List your previous address if you have lived at your current address for less than one year.

(If you became an employee of HHC, you will be required to provide documentation proving your eligibility to work in the USA.)

(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction will not necessarily bar you from employment.

We will consider the nature of the crime, the time that has expired since its occurrence, and any rehabilitation you have undergone. If yes, state the basis for each conviction and the Date of the conviction:

Hepatitis B Vaccine Declination

I understand that due to my occupational exposure to blood or other potentially infectious materials may be at risk of acquiring hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination currently. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Hepatitis B Vaccination Consent Form

Hepatitis B vaccine is usually well tolerated. The most common side effect is soreness at the local injection site and fatigue. The vaccine is administered in three doses.

CONTRAINDICATIONS: Employees who are pregnant, breast-feeding mothers, have allergies to the vaccine or its components, mercury, or yeast, have a fever or active infection, heart disease, Guillain-Barre Syndrome, or immune deficiency disorders will be referred to their private physician for evaluation, prior to receiving the vaccine.

POSSIBLE ADVERSE REACTIONS: Flushed face, redness, swelling, or warmth at the injection site, muscle aches, fatigue, and dizziness. Low-grade fever (less than 101 degrees F) occurs occasionally.

NJ MVR RELEASE CONSENT FORM

In conjunction with my potential employment at Helena Home Care LLC ("the company"), !_(applicant) consent to the release of my Motor Vehicle Records (MVR) to the company.

I understand the company will use these records to evaluate my suitability to fulfill driving duties
that. may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company.

This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., "Federal Drivers Privacy Protection
Act" and is intended to constitute "written consent" as required by this Act.

DRIVER RECORDS

Regardless of what business you are in, the deadliest hazard faced by American workers is that of the road. More workers are killed in vehicular accidents than by any other cause. Since most accidents are the result of human error, not vehicular condition, one of the best controls available for vehicular accidents, is to properly screen drivers. One of the best tools available for screening drivers is the MVR, or Motor Vehicle Record, of the driver. This is a report, available from the state, listing all tickets, accidents, and other similar infractions for a given driver, over a set period of years (usually 3 years, or 7 years). It is recommended that an MVR be obtained and reviewed prior to hiring an employee who will drive, and certainly before allowing that employee to drive on company business. MVR's should also be reviewed at least annually for all driving
employees. This is the only way to be certain problems have not come up undetected. Drivers do not usually come in and announce a rash of speeding tickets, or a DUI. Many employers assume they know their employees well, and they would know if they got a ticket. This is not the case. A criterion should be set up for the evaluation of MVR's and should be fairly and uniformly applied
to all drivers.

I have received the following information pertaining to Danielle's Law:

In accordance with Danielle's Law, 911 is to be called in life threatening emergencies. As defined in the law, "Life threatening emergency means a situation in which a prudent person could reasonably believe that immediate intervention is necessary to protect the life of a person receiving services, or to protect the lives of other persons at the facility or agency from an immediate threat or actual occurrence of a potentially fatal
injury, impairment to bodily functions or dysfunction of a bodily organ or part." Failure to call 911 in a life-threatening emergency includes monetary fines: $5,000 for the first offense, $10,000 for the second offense, and $25,000 for the third and each subsequent offense. Additionally, a health care professional, licensed or alternately authorized to provide services, may be subject to revocation of that professional license or other authorization to practice as a health care professional.

I have received training on Danielle's Law including a Power Point Presentation on Danielle's Law, Frequently Asked Questions about Danielle's Law, a Fact Sheet on Life Threatening Emergencies, and a copy of Chapter 191, the actual Law. I understand that it is my responsibility to call 911 if a person served by the Division of Developmental Disabilities is experiencing a life-threatening emergency, as defined in Danielle's Law." I understand it is the responsibility of the emergency medical professionals to assess the severity of the emergency. My responsibility is to make the call to 911, provide information regarding the condition of the person, and direct emergency workers to the scene of the emergency. It is also my responsibility to provide immediate care until the emergency medical professionals arrive and take over.

APPENDIX A COMMUNITY AGENCY HEAD AND EMPLOYEE CERTIFICATION,
PERMISSION FOR BACKGROUND CHECK AND RELEASE OF INFORMATION

I hereby authorize the Department of Human Services to conduct a criminal history background check and I agree to be fingerprinted in order to complete the state and federal background check process. I further authorize the release of all information regarding the results of my background check to the Department of Human Services. Check one of the options listed below.

If I have checked Option 2 or the criminal history background check reveals any conviction(s) for the offenses listed below, I understand that I may be subject to termination from employment.

FOR PROVISIONAL EMPLOYEES ONLY: As a provisional employee, I further understand that I may be employed by the agency for a period not to exceed six (6) months during which time a background check will be
completed. I understand that I will work under the supervision of a superior where possible.

Offenses covered under P.L. 1999, C. 358:

In New Jersey, any crime or disorderly person offense: -involving danger to the person as set forth in N.J.S.A. 2C:11-1 et seq. through 2C:15-1 et seq. including the following:

I. Murder
ii.Manslaughter
iii. Death by auto
iv. Simple assault
v. Aggravated assault
vi. Recklessly endangering another person
vii. Terroristic threats
viii. Kidnapping
ix. Interference with custody of children
x. Sexual assault
xi. Criminal sexual contact
xii. Lewdness
xiii. Robbery - against the children or incompetents as set forth in N.J.S.A. 2C:24- 1 et seq.

including the following:
i. Endangering the welfare of a child
ii. Endangering the welfare of an incompetent person
-a crime or offense involving the manufacture, transportation, sale, possession or habitual use of a controlled dangerous substance as defined in N.J.S.A. 2C:24-1 et seq.
-in any other state or jurisdiction, conduct which, if committed in New Jersey, would constitute any of the crimes or disorderly persons offenses described above.

W-4 FORM

Department of the Treasury Internal Revenue Service

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.

OMB No. 1545-0074 2025

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

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. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding.

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 can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

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 for this step (and Steps 3–4). If you or 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 the
higher 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.)

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

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 2025 if you meet both of the following conditions: you had no federal income tax liability in 2024 and you expect to have no federal income tax liability in 2025. You had no federal income tax liability in 2024 if (1) your total tax on line 24 on your 2024 Form 1040 or 1040-SR is zero (or less than the sum of lines 27, 28, and 29), 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 2025 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). 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 17, 2026.

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:
1. Are submitting this form after the beginning of the year;
2. Expect to work only part of the year;
3. Have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), or number of dependents, or changes in your deductions or credits;
4. Receive dividends, capital gains, social security, bonuses, or business income, or are subject to the Additional Medicare Tax or Net Investment Income Tax; or
5. 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 that has already been withheld this year. 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 the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

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 (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work. Submit a separate Form W-4 for each job. Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

Instead, if you (and your spouse) have a total of only two jobs, you may check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

▲! CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. This step provides instructions for determining the amount of the child tax credit and the credit or other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 501, Dependents, Standard Deduction, and Filing Information. You can also include other tax credits for which you are eligible in this step, such as the foreign tax credit and the education tax credits. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2025 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

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.

Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and territories for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. 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.