Baltimore city employee benefits website

• [PDF File]CMS 1763 Request for Termination of premium Hospital an/or ...

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_4babdf.html

  REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE . The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and

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• [PDF File]Vaccine Information Statement: Inactivated Influenza Vaccine

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_2ab478.html

  Influenza vaccine does not cause flu. Influenza vaccine may be given at the same time as other vaccines. 3 Talk with your health care provider Tell your vaccine provider if the person getting the vaccine: Has had an allergic reaction after a previous dose of influenza vaccine, or has any severe, life-threatening allergies.

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• [PDF File]Request for Social Security Earnings Information

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_6555c9.html

  Form . SSA-7050-F4 (03-2019) Page 2 of 4. REQUEST FOR SOCIAL SECURITY EARNING INFORMATION . 1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose

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• [PDF File]U.S. Department of Labor PAYROLL Wage and Hour Division (For ...

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_441b12.html

  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).

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• [PDF File]CMS-L564 Request for Employment Information

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_8efb3a.html

  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 disabilities must have large

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• [PDF File]Form SSA-89 (02-2018) Discontinue Previous Editions Page 1 of ...

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_ef6bef.html

  I authorize the Social Security Administration to verify my name and SSN to the Company and/or the Company's Agent, if applicable, for the purpose I identified. The name and address of the Company's Agent is: I am the individual to whom the Social Security number was issued or the parent or legal guardian of a

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• [PDF File]Form W-4V (Rev. February 2018) - An official website of the ...

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_d966e1.html

  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 ...

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• [PDF File]Form N-648, Medical Certification for Disability Exceptions

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_6515b8.html

  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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• [PDF File]Declaration for Federal Employment* OMB No. 3206-0182

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_34736d.html

  Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment) Form Approved: OMB No. 3206-0182 U.S. Office of Personnel Management

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• [PDF File]Form W-9 (Rev. October 2018)

  https://info.5y1.org/baltimore-city-employee-benefits-website_1_7ff93a.html

  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).

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