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Patient forms

FICA Exemption Form (DCH-4771)

The DCH-4771 form lets qualifying family caregivers claim an exemption from Federal Insurance Contributions Act (FICA) payroll taxes on caregiver wages. Complete this form so we can apply the exemption to your payroll.

  1. 01

    Download the form

    Save it to your computer or phone, then fill it out using whichever option works best for you.

    Download Fillable PDF
  2. 02

    Fill it out

    Pick the option that matches your device:

    Laptop or computer

    Open the PDF in your browser — Chrome, Edge, Safari, or Firefox. Click into each field and type. No app needed.

    Save with Ctrl + S (Windows) or ⌘ + S (Mac).

    iPhone or iPad

    Tap download, then Share → Save to Files.

    Open the Files app, tap the PDF, and use the markup pencil to type or sign.

    Android phone

    Install Adobe Acrobat Reader from the Play Store (free).

    Open the downloaded PDF and tap Fill & Sign.

    By hand

    Print the PDF, fill it in pen, then scan every page back into a single PDF.

  3. 03

    Send it back

    Once your form is signed, send it back using whichever option is easiest:

    Upload it online

    Fastest — goes straight to our intake team.

    Go to upload page →

    Email it

    info@zentrahomecare.com

    PDF attachment only

    Fax it

    (313) 846-4001

    Most doctor's offices can fax directly

    Our intake team follows up within one business day.