When you're starting a new business, there are a lot of forms to fill out. The IRS has several forms that you'll need to file in order to declare your business and pay your taxes. Form M13D is one of these forms- it's used to declare your eligibility for the small business deduction under Section 199A of the Internal Revenue Code. This form can be tricky to fill out, so if you're not sure how to do it, you may want to consult with an accountant or tax professional. In this blog post, we'll go over what information you need to include on Form M13D, and we'll also provide some tips on how to complete it correctly. Keep reading for more information!
Question | Answer |
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Form Name | Form M13D |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | hra form download, hra application form, form 13d consumer, hra application form pdf |
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Human Resources Administration |
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Home Care Services Program |
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Form |
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Revised 04/2010 |
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THE CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM APPLICATION |
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1a. CONSUMER IDENTIFYING INFORMATION |
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Consumer's Surname |
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First Name |
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M.I. |
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Social Security Number |
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Address (No. & Street) |
FL./Apt. No. |
Boro |
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Zip |
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Telephone No. |
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Age |
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Date of Birth |
Medicaid |
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Sex |
Medicare A |
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Medicare B |
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Number |
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M F |
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Language(s) Spoken |
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Language(s) Understood |
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LIVING ARRANGEMENTS |
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One Family House |
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Furnished Room |
Hotel |
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If |
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Apartment |
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Boarding House |
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Senior Citizen Housing |
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number of flights _______ |
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Other (Specify)_________________________ |
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1b. PARENT, LEGAL GUARDIAN, OR DESIGNATED REPRESENTATIVE INFORMATION |
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Name |
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Relationship to Consumer |
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Address (No. & Street) |
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FL./Apt. No. |
Boro |
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Zip |
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Telephone No. |
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Business Address (if any) |
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Business Telephone No. |
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2. CONSUMER'S NEXT OF KIN |
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Name |
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Relationship |
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Telephone Number |
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Address (No. & Street) |
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FL./Apt. No. |
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State |
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Zip |
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3. PARENT, LEGAL GUARDIAN, OR DESIGNATED REPRESENTATIVE |
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Name |
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Relationship |
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Telephone Number |
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Address (No. & Street) |
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FL./Apt. No. |
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Zip |
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*
Human Resources Administration
Home Care Services Program
1
Form
Revised 04/2010
4. DESCRIBE CONSUMER'S MEDICAL CONDITION AND PERSONAL SITUATION.
5. SCREENING AND RECRUITMENT PLAN:
A. Describe how the consumer, legal guardian or designated representative will screen and recruit prospective personal assistants.
B. Describe how the consumer, legal guardian, or designated representative will screen and recruit sufficient, additional personal assistants to serve as replacement workers when needed.
C. Describe how the consumer, legal guardian or designated representative will arrange for emergency coverage to maintain continuity of service in the absence of the regularly assigned personal assistant.
D. Explain how the consumer, legal guardian or designated representative will provide orientation to conditions of employment for new personal assistants.
E. Describe how the consumer, legal guardian or designated representative plans to direct and monitor the personal assistant's job performance.
F. Describe how the designated representative will supervise the personal assistant when he/she is performing skilled nursing tasks.
2
Human Resources Administration
Home Care Services Program
Form
Revised 04/2010
G. Describe how the consumer, legal guardian, or designated representative will resolve all personal assistant complaints.
H. Describe how the consumer, legal guardian or designated representative will train personal assistants to provide the needed services.
6. CONSUMER'S DECLARATION:
I, the consumer, parent, legal guardian or designated representative, am willing to assume all of the required obligations in the Consumer Directed Personal Assistance Program.
Signature ______________________________________________
Relationship to Consumer _________________________________
Date __________________________________________________
If the consumer has skilled nursing tasks, a registered nurse must complete the attached certification.
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Form |
Human Resources Administration |
Revised 04/2010 |
Home Care Services Program |
REGISTERED NURSE'S CERTIFICATION |
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Consumer's Name: _____________________________________ |
Social Security Number: ____________________ |
If the consumer is not
Name of Designated Representative (if needed):_____________________________________
THE CONSUMER IS CURRENTLY RECEIVING SERVICES FROM:
Home Care Provider or Hospital: ____________________________________________________________
Name of Contact Person: ___________________________________________________
Title:________________________________ Telephone Number:___________________
In my opinion as a registered nurse who has assessed this consumer's service needs and training capabilities, I have determined the following:
The consumer is
The designated representative is capable of providing assistance, supervision and direction to the personal assistant performing skilled nursing tasks.
Please indicate nursing tasks. Check all that apply: |
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Ostomy Care (specify) _____________ |
Tube feeding |
Decubitus Care |
Administering medication |
Indwelling Catheter Care |
Administering oxygen |
Measuring glucose, sugar and/or acetone to |
Nebulizer treatment |
monitor medical condition |
Other _____________ |
Suctioning |
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Comments _____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
NURSE'S NAME __________________________SIGNATURE__________________________DATE_______
AGENCY_______________LICENSE NUMBER _________________TELEPHONE NUMBER _____________
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Form |
Human Resources Administration |
Revised 04/2010 |
Home Care Services Program |
DESIGNATED REPRESENTATIVE
The Designated Representative
SIGNATURE: _____________________________________________DATE:__________________________
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