Form 4119 PDF Details

Form 4119 is a variation of the W-9 form used to request income tax withholding information from entities other than individuals. The form is used to collect information about the payer's name, address, taxpayer identification number (TIN), and amount of payments made to the payee. This information is then used by the IRS to determine whether or not to withhold federal income taxes on payments made to the payee. Generally, withholding is required for payments totaling more than $600 during a calendar year. Form 4119 must be completed and submitted with each payment that requires withholding. Penalties may apply for failure to submit Form 4119 timely or accurately. For more information about Form 4119 and its use, please consult your tax advisor or contact the IRS directly. Thank you for your interest in this important form!

QuestionAnswer
Form NameForm 4119
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestexas health human services form 4119, texas aging and disability form 4119, form 4119 form, hhsc form 4119

Form Preview Example

Texas Department of Aging

Form 4119

and Disability Services

February 2012-E

Home and Community-based Services/Texas Home Living Services

Respite Service Delivery Log

Individual Name (First, Last)

Place of Service(s)

Local Case No./Case ID Week Of

Check One:

RSS

SL

At the end of your shift, mark (initial or check) all items that you completed with the individual. If there were any incidents, concerns or special events, please document on bottom of form. For individuals who receive SL service, no night initials or check marks are necessary.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

mm/dd/yy

Activities of Daily Living

Bathing

Dressing

Personal Hygiene

Eating

Meal Planning

Meal Preparation

Housekeeping

Habitation

Improve Independent Living Skills

Community Integration

Develop Socially Valued Behaviors

Use of Natural Supports

Participate in Leisure Activities

IP Skill Development

Assisting With

Ambulation and Mobility

Reinforcing

Reinforcing Specialized Therapies

Transportation

Supervising Safety and Security

Night Shift

Supervising Safety and Security

Monitoring Health

Monitoring Personal Hygiene

Not in Home

Temporary Discharge

Active on Leave

Staff Initials

Staff Initials

Date

Staff Initials

Comments

Employee Signature

Initials

Staff ID

 

 

Employee Signature

Initials

Staff ID

 

 

 

 

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Best ways to complete texas health human services form 4119 portion 1

2. After finishing this step, go on to the subsequent step and complete the necessary details in all these blanks - Reinforcing, Reinforcing Specialized Therapies, Transportation, Supervising Safety and Security, Night Shift, Supervising Safety and Security, Monitoring Health, Monitoring Personal Hygiene, Not in Home, Temporary Discharge, Active on Leave, Staff Initials, Staff Initials, Date, and Staff Initials.

texas health human services form 4119 completion process detailed (part 2)

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3. In this particular part, check out Employee Signature, Initials, Staff ID, Employee Signature, Initials, and Staff ID. These should be taken care of with highest accuracy.

Simple tips to fill out texas health human services form 4119 part 3

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