IM-12B Instructions

NEW HIRE INFORMATION

PURPOSE:   Form IM-12B is sent to applicants or participating EUs when a New Hire match is received by the county office. A New Hire match is generated when the applicant or participating EU member has completed a Missouri Employee’s Withholding Allowance Certificate, MO W-4 form.

NOTE:   The FA-315 New Hire Information form is generated by the system for cases in FAMIS. The IM-12B form is not required for FAMIS cases.

MANUAL REFERENCE:

Food Stamps FS Manual 1115.000.00 - 1115.040.00
Temporary Assistance TA Manual 0210.000.00

NUMBER OF COPIES AND DISPOSITION:   For situations in which the applicant is in the county office and has not returned a pending New Hire letter, complete this form using the hard copy (IM-12B) or the electronic version.

The following instructions are applicable when form IM-12B is completed in the county office. Complete one copy for the case record.

FROM:   The caseworker or case manager enters his/her name, office telephone number and date the letter is being sent. Write or type the county address or use the county address label.

TO:   Enter the name and address of the head of EU.

RE:   Enter the case name and case number of the head of EU.

NAME, DCN::  Enter the name and DCN of the individual identified by the New Hire match.

REASON FOR COMPLETING W-4 (USE CODE BELOW)::  The individual selects the reason the W-4 was completed from the list given. The due date to return the letter is 15 calendar days. List the due date for return of the letter. The head of the EU enters the reason s/he completed the W-4 form. The reasons are:

  1. Was hired for a job.
  2. Changed my withholding because of marriage or divorce.
  3. Changed my dependents.
  4. Signed the W-4 during job interview.
  5. Signed the W-4 for a temporary agency, but was not called for a job or given an assignment.
  6. Other (such as change of name). If “other” is selected, the individual lists the reason.

EMPLOYMENT INFORMATION:   The individual completes the employment information.

EMPLOYEE NAME: The individual lists the name of the employee.

EMPLOYER NAME: The individual lists the employer name.

EMPLOYER ADDRESS: The individual lists the address of the employer.

DATE HIRED: The individual lists the date s/he was hired by the employer.

IF EMPLOYMENT TERMINATED, LIST THE LAST DAY YOU WORKED: The individual lists the last day s/he worked for the employer.

RATE OF PAY PER HOUR: The individual lists his/her hourly rate of pay.

AVERAGE NUMBER OF HOURS WORKED PER PAY PERIOD: The individual lists the average number of hours worked per pay period.

HOW OFTEN PAID: The individual checks (3) that s/he is paid either weekly, every other week, twice monthly, monthly or other. If s/he selects other, s/he explains.

PARTICIPANT SIGNATURE/DATE:   The participant signs and dates the form.

10.2004