Form Hr Ben 066 – Fill Out and Use This PDF

Form HR Ben 066 is a highly sought resource for Human Resources departments across the nation. It is recognised as providing invaluable and up to date information on all aspects of recruiting, onboarding and other key operations within modern day Human Departments. It is also widely regarded as essential help when navigating managing intricate compliance matters. Because of this longstanding popularity, Form HR Ben 066 has been updated and revised multiple times over the years to ensure it remains sufficiently flexible and applicable not just today, but into the future, helping those in the HR sector remain centralised and productive no matter what the uncertainties that lie ahead.

Form Hr Ben 066 PDF Details

Form Hr Ben 066 is a tax form that employees in the United States must submit if they wish to claim exemption from federal income tax withholding. The form is short and simple to complete, and most employees will only need to fill out a few basic details. Completing Form Hr Ben 066 is an important step in ensuring that you do not have too much money withheld from your paycheck. If you have any questions about how to complete the form, be sure to speak with your employer or payroll specialist.

Question	Answer
Form Name	Form Hr Ben 066
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	SSN, MTA, Suffix, BSC

Form Preview Example

Short Term Disability Form

HR-BEN-066

Section 1 - Information and Instructions

The purpose of this form is to apply for short term disability benefits. The hospital and/or Physician responsible for treating the patient must complete the reverse side of this form.

Please fax a signed copy of the form to 212-852-8700 or e-mail a signed copy of the form to bscservice@mtabsc.org.

If you have any questions, please contact MTA Business Service Center (BSC) at 646-376-0123 or bscservice@mtabsc.org.

Section 2 - Employee Information

Print Name							BSC ID
	Last		First		M.I.	Suffix

Agency	BSC	B&T	CC	HQ Civilian	HQ Police
Agency							Department
(check one)	LI Bus	LIRR	MNR	MTA Bus	NYCT		Department
(check one)

Street Address

City

State

Zip Code

Phone (H)

Phone (W)

E-mail

Employee’s Supervisor / Dept. Head

Supervisor’s Phone

Section 3 - Illness / Injury Information

Illness / Injury Date

Occupation-Based Illness / Injury

Yes

Report Type Initial

Follow-up/Interim

Other (Explain)

Location Where Injury Occurred

Section 4 - Other Benefits Employee is Receiving

Check all that apply.

None
Worker’s Compensation	Dates (from/to)
Personal Injury Damages	Dates (from/to)
Federal SSA Disability Benefits	Dates (from/to)
Railroad Retirement	Dates (from/to)

Other (Provide Dates)	Dates (from/to)

Indicate any Short-Term Disability benefits
previously received from other MTA Agencies

Section 5 - Authorization

Employee Signature		Date	SSN Last 4 Digits

Signature of Person Other Than Employee		Date

Print Name and Relationship
	Physician must complete this section
	Physician must complete this section
Business Service Center HR-BEN-066			Page 1 of 2
Business Service Center HR-BEN-066			Page 1 of 2

Short Term Disability Form

HR-BEN-066

Section 6 - Hospital Certification (if applicable)

Hospital Name				Main Phone Number

Hospital Address
Street		City		State	Zip

Description of Treatment / Surgical Procedure
Additional Information Attached

Hospital Stay
Admittance Date		Discharge Date

Name of Hospital Official				Title of Hospital Official

Signature of Hospital Official				Date


Section 7 - Physician’s Certification

Physician’s Name				Phone Number

Physician’s Address
Street:			City:		State:	Zip:

Period of Treatment	From date(s)	To date(s)

First date unable to work		Date suitable to return to work			Work-related condition?		Yes	No

Employee may return to work as follows
(Check all that apply)	Full-time	Part-time	Temporarily (provide details)		Full duty	Light duty

Description of condition, diagnosis or treatment					Physician’s tax I.D. number
					Physician’s tax I.D. number

Additional Information Attached
Date(s) of future treatment(s)
Physician’s Signature	Date	Physician’s Seal must be placed here.

Business Service Center HR-BEN-066

Page 2 of 2

How to Edit Form Hr Ben 066 Online for Free

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Step 1: Firstly, open the pdf tool by clicking the "Get Form Button" at the top of this site.

Step 2: With this handy PDF editor, you are able to do more than simply fill in blank fields. Try all the features and make your documents appear professional with custom textual content added in, or optimize the file's original input to excellence - all comes along with the capability to incorporate almost any graphics and sign it off.

It will be simple to finish the document using this practical guide! Here's what you have to do:

1. To start off, when filling in the applicable, start out with the part with the following fields:

2. The next part would be to submit all of the following fields: Check all that apply, None, Workers Compensation, Personal Injury Damages, Dates fromto, Dates fromto, Federal SSA Disability Benefits, Dates fromto, Dates fromto, Dates fromto, Railroad Retirement, Other Provide Dates, Indicate any ShortTerm Disability, Section Authorization, and Employee Signature.

People generally get some points wrong while completing None in this section. Make sure you read again whatever you enter right here.

3. This next stage is straightforward - fill in all of the blanks in Section Hospital Certification, Hospital Name, Hospital Address, Main Phone Number, Street City State Zip, Description of Treatment Surgical, Additional Information Attached, Hospital Stay, Admittance Date Discharge Date, Name of Hospital Official Title of, Signature of Hospital Official Date, Section Physicians Certification, Physicians Name, Physicians Address, and Phone Number in order to complete the current step.

4. All set to complete this fourth portion! Here you have these Physicians Address, Street City State Zip, Period of Treatment From dates To, First date unable to work Date, Yes, Employee may return to work as, Check all that apply, Fulltime, Parttime, Temporarily provide details, Full duty, Light duty, Description of condition diagnosis, Physicians tax ID number, and Additional Information Attached blanks to complete.

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Form Hr Ben 066 – Fill Out and Use This PDF

Form Hr Ben 066 PDF Details

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