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Fill and Sign the Hampshire Probate and Family Court Sample Separation Agreement Form

Fill and Sign the Hampshire Probate and Family Court Sample Separation Agreement Form

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Aetna Inc. Proof of Eligibility Form For Small Employer (2-50) Sole Proprietors, Partners or Corporate Officers (To be used for eligible employees that are not reported on a quarterly wage and tax form) Full Name (First, MI, Last) Phone No. Title Percentage of Ownership in Firm Company Name Address City / State / Zip code Please check one of the following: Sole Proprietor ►Sole Proprietor ►Franchise ►Limited Liability Company operating as a sole proprietor or single member LLC Partner ►Partnership ►Limited Liability Partnership (member) Corporate Officer ►Limited Liability Company operating as a Corporation ►C-Corporation ►Personal Service Corporation ►S-Corporation (Anyone eligible must appear on the below documents) In order to satisfy the Small Employer Requirements for Proof of Eligibility, the following most recent documents are required: Submit all applicable: ►Filed Assumed Name Certificate (Fictitious Name or DBA) ►Filed Certificate of Organization (only required for LLC) ►Filed Business License Must Submit one of the following: ►IRS Form 1040 C or 1040 F ►IRS Form 1040 SE ►IRS Form 1040 ES (estimated tax) Submit all applicable: ►Partnership Agreement (Filed) ►Filed Assumed Name Certificate (Fictitious Name or DBA) if applicable ►Filed Certificate of Organization (only required for LLC or LLP) ►Filed Business License Must Submit one of the following: ►IRS Form 1065 schedule K-1 ►IRS Form 1040 SE ►IRS Form 1040 ES (estimated tax) Submit all applicable: ►Filed Assumed Name Certificate (Fictitious Name or DBA) ►Articles of Incorporation or (complete, including name of officers, shareholders and directors) ►Filed Certification of Qualification (if incorporated in a different state) Must Submit one of the following: ►IRS Forms 1120, 1120 A or 1120 W (C-Corp & Personal Service Corp) ►IRS Form 1120 S schedule K-1 or 1040 ES (estimated tax) (S-Corp) ►IRS Form 8832 (Entity Classification treated as a corporation) I attest that while I am not listed on the state quarterly wage and tax statement for this company, all of the following are true: 1. 2. I am a sole proprietor, partner or corporation officer of the company indicated above; and I am actively at work at this company on a full time, permanent basis working no less than the minimum number of hours required by the applicable State Laws; and 3. I draw wages, compensation, dividends or other distributions from this company on a regular basis and do not derive substantial earned income from any other employment; and 4. I have satisfied the designated waiting period before health insurance coverage is to become effective. Signature: 9/15/2006 Date:

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