City of baltimore employee benefits
[PDF File]CMS 1763 Request for Termination of premium Hospital an/or ...
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REQUEST FOR TERMINATION OF PREMIUM HOSPITAL ... CITY, STATE, ZIP CODE ADDRESS (Number and Street, City, State and Zip Code) ... Baltimore, Maryland 21244-1850. Form CMS-1763 . Title: CMS 1763 Request for Termination of premium Hospital an/or supplementary Medical insurance
[PDF File]Request for Social Security Earnings Information
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Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following: 1.
[PDF File]CMS-L564 Request for Employment Information
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REQUEST FOR EMPLOYMENT INFORMATION WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with …
[PDF File]Form W-4V (Rev. February 2018)
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City or town State . ZIP code . 4 . Claim or identification number (if any) you use with your payer. 5 . I want federal income tax withheld from my unemployment compensation at a rate of 10% of each payment. 6 . I want federal income tax withheld from (a) my social security benefits, (b) my social security equivalent Tier 1 railroad retirement ...
[PDF File]Declaration for Federal Employment* OMB No. 3206-0182
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organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the ... (Include city and state or country) ... of benefits, and other debts to the U.S. Government ...
[PDF File]Form W-9 (Rev. October 2018)
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City, state, and ZIP code. Requester’s name and address (optional) 7. List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).
[PDF File]Statement of Claimant or Other Person - The United States ...
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STATEMENT OF CLAIMANT OR OTHER PERSON. Form Approved OMB No. 0960-0045 Name of Wage Earner, Self-employed Person, or SSI Claimant. Social Security Number Name of Person Making Statement (If other than above wage earner, self-employed person, or SSI claimant) Relationship to Wage Earner, Self-Employed Person, or SSI Claimant
[PDF File]U.S. Department of Labor PAYROLL Wage and Hour Division ...
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Rev. Dec. 2008 While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a).
[DOC File]Aid Codes Master Chart (aid codes) - Medi-Cal
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Code Benefits SOC Program/Description 0L Restricted to pregnancy-related, postpartum, emergency and LTC services No Breast and Cervical Cancer Treatment Program (BCCTP) Transitional coverage until the County makes a determination of Medi-Cal eligibility. It covers: ... Aid Codes Master Chart (aid …
[PDF File]Form N-648, Medical Certification for Disability Exceptions
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Form N-648, Medical Certification for Disability Exceptions. ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must
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