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Get Ny Doh-5017 2010-2025
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How to fill out the NY DOH-5017 online
The NY DOH-5017 form, issued by the New York State Department of Health, is essential for verifying employment details related to health insurance programs. This guide will provide you with step-by-step instructions to navigate the form efficiently and accurately.
Follow the steps to complete the NY DOH-5017 form online.
- Click the ‘Get Form’ button to access the document and open it in your designated editing tool.
- In the first section, enter the employee's name in the provided field. Ensure the spelling is correct.
- Fill in the application registration or case number as applicable. This number may be provided by the agency requesting the form.
- Input the social security number of the employee in the designated box, using the format XXX-XX.
- Provide the employee's address, including street, city, state, and zip code in the specified fields.
- In the section labeled 'To be completed by the employer,' write the name of the employer or company. This is essential for official verification.
- Next, indicate the employee's position with a brief description of what the employee does.
- Select the payment schedule by checking one box that corresponds to how frequently the employee is paid: Weekly, bi-weekly, twice per month, or monthly.
- Answer the question regarding access to New York State Health Insurance (NYSHIP) by selecting 'Yes' or 'No.'
- If applicable, indicate whether the employee has dependents enrolled in employer-sponsored coverage.
- Provide the last consecutive weeks of work for the employee. Fill in the dates paid and the gross pay, ensuring to include tips, commissions, and bonuses.
- If the employee is no longer employed, enter the date they last worked.
- Complete the section for the business name, business address, and business phone number.
- The employer must print their name, sign the form, include their title, and date it.
- Once all sections are completed, review the information for accuracy before saving changes, downloading, printing, or sharing the form.
Take action now and complete your documents online for a seamless submission process.
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The NY ST-120 form does not have a set expiration date; it remains valid as long as the details provided remain accurate. However, it is advisable to keep the form updated regularly, especially if your business circumstances change. This kind of diligence supports compliance with the intricacies surrounding the NY DOH-5017.
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