Employee/PCA Registration Form

Transcripción

1 6 Southside Road Danvers, MA Phone , Fax Employee/PCA Registration Form Instructions: 1. Employee/PCA should not start working until the hiring process is complete. 2. Record the consumer number at the top of each form and complete the forms in this package. 3. The consumer, surrogate or legal guardian may sign as the employer. 4. Once complete; fax, mail, or drop off the paperwork to our office. 5. We will contact you if there is a problem with the paperwork and phone you when the Employee/PCA becomes active in our system (approximately 7 business days). 6. Once the Employee/PCA is active, please begin submitting timesheets. Timesheets received before this time cannot be processed and will be mailed back to you. Reminder: A Masshealth and SCO consumers cannot hire his/her spouse, parent (if consumer is a minor), surrogate, foster parent, or legally responsible relative. CONSUMER S INFORMATION Name: Consumer#: Street: Phone #: City: State: Zip: Employee/PCA Start Date: (The date the Employee/PCA began or will begin working for you) Check One: Masshealth SCO Self-Direct SURROGATE S INFORMATION (if applicable): Name: Street: Phone#: City: State: Zip: EMPLOYEE/PCA S INFORMATION Name: Birth Date: Street: City: State: Zip: Home Phone #: Cell Phone #: Address: Social Security#: Union#: (For FI use only) Rev. 4/24/13

2 6 Southside Road Danvers, MA Teléfono , Fax Formulario de Registración del Empleado/PCA Instrucciones: 1. El Empleado/PCA no debe de empezar a trabajar antes de que se complete el proceso de contratación. 2. Marque el número de consumidor en la parte de arriba de cada uno de los formularios que complete. 3. Sólo el consumidor, Sustituto o el Guardián Legal puede firmar como el Empleador. 4. Cuando estén completos los documentos, lo puede faxear, mandar por correo o entregarlo en nuestra oficina. 5. Nosotros le contactaremos si hay algún problema con los documentos y le llamaremos cuando su Empleado/PCA este activo en nuestro sistema. (Aproximadamente 7 días laborables). 6. Cuando el Empleado/ PCA este activo, puede comenzar a mandar sus hojas de tiempo. Hojas de tiempo recibidas antes de este tiempo no podrán ser procesadas y serán devueltas a usted por correo. Recordatorio: Un consumidor con cobertura de Masshealth y SCO no puede contratar a su Esposo/Esposa, Padre/Madre (si el consumidor es menor), Sustituto, Padres Foster, o cualquier relativo legalmente responsable de él. INFORMACION DEL CONSUMIDOR Nombre: #de Consumidor: Calle: # Telefónico: Ciudad: Estado: Zip: Primer día del Empleado/PCA: (La fecha en que el Empleado/PCA comenzara a trabajar para usted)) Marque Uno: Masshealth SCO Self-Direct INFORMACION DEL SUSTITUTO (si aplica): Nombre: Calle: # Telefónico: Ciudad: Estado: Zip: INFORMACION DEL EMPLEADO/PCA Nombre: Fecha de Nacimiento: Calle: Ciudad: Estado: Zip: # Teléfono de casa: Teléfono Celular #: Dirección Electrónica: # Seguro Social: Union#: (For FI use only) Rev. 4/24/13

3 Employee/PCA Package Check List Consumer Number: Please complete ( ) this list as you complete forms in this package. A copy of the form must be returned with the completed package FORM Employee/PCA Registration Form Personal Care Attendant Signature Form Did the PCA check the box which represents their relationship? Did the PCA sign this form? Form W-4 Did the PCA complete Line 1 to 3? Did the PCA complete Line 4 if applicable? Did the PCA fill out line 5 or 7 for exemptions, not both? Did the PCA fill out Line 6 if they wanted additional taxes taken out of their paycheck? Did the PCA sign this form? Did you write in the consumer name and address on line 8? Form M-4 (OPTIONAL- Complete if PCA wants to claim different state exemptions from federal exemptions W-4) Did the PCA complete Line 4? Did the PCA complete line 5 or line 5D, not both? Did the PCA sign this form? Form I-9 PCA/EMPLOYEE must present original documents at the time of hire It is consumer s responsibility for ensuring this form is properly filled out Did the PCA complete Section 1 and sign this form? Was ID information verified and documented in section 2? ID title, number and expiration date, if applicable. (Check back of I-9 to view acceptable documents) Did the consumer fill in the date of hire and sign the Certification Section in Section 2? The business address is the consumer s address. Direct Deposit Application (OPTIONAL-but highly recommended) Did the PCA include a voided check or an official bank form? Work Permit Needed if the PCA is under age 18. (Can be completed by your local high school or city hall) COMPLETED BY CONSUMER ( ) For FI Use only Received For FI Use only Forms Completed REMINDERS: - You must notify Northeast Arc FI of your most current contact information including address, phone numbers, and bank account information. This will allow us to send you any live PTO check, FICA refund check and/or year end W-2. Rev. 4/24/2013

4 Lista de chequeo del Paquete para el Empleado/PCA Numero del Consumidor: Por favor, complete ( ) esta lista de la forma en la que completa los formularios en este paquete. Una copia de este formulario debe ser retornada junto al paquete completo. COMPLETADO For FI Use only For FI Use only FORMULARIO POR EL CONSUMIDOR Received Forms ( ) Completed Formulario de Registración del Empleado/PCA Formulario para la Firma Del Asistente de Cuidado Personal El PCA marcó la casilla en la que establece su relación? El PCA firmó este formulario? Formulario W-4 El PCA completó las Líneas 1 a la 3? El PCA completó la Línea 4 si aplica? El PCA completó las líneas 5 ó 7 de las excepciones, no ambas? El PCA completó la Línea 6 si desea que impuestos adicionales sean deducidos de sus cheques? El PCA firmó este formulario? Usted escribió el nombre y dirección del consumidor en la Línea 8? Formulario M-4 (OPCIONAL- Complete si el PCA desea clamar excepciones estatales diferentes de las Federales especificadas en el W-4) El PCA completó la Línea 4? El PCA completó la línea 5 o la línea 5D, pero no ambas? El PCA firmó este formulario? Formulario I-9 El PCA/EMPLEADO debe presentar documentos originales al momento de la contratación. Es la responsabilidad del consumidor de asegurarse que este formulario este completado apropiadamente. El PCA completó la Sección 1 y firmó este formulario? Está la información de la identificación verificada y documentada en la sección 2? Titulo de la identificación ID, número y fecha de expiración, si aplica. (Vea la parte de atrás del I-9 para revisar la lista de documentos aceptables) El consumidor completó la fecha de contratación y firmó la Certificación en la Sección 2? La dirección del negocio es la dirección del consumidor. APLICACIÓN PARA DEPOSITO DIRECTO (OPCIONAL-Pero muy recomendado) El PCA incluyó un cheque cancelado o una carta oficial del banco? Permiso de Trabajo Necesario si el PCA is menor de 18 años de edad. (Puede ser completado por su Escuela secundaria local o Alcaldia) RECORDATORIOS: - Usted debe mantener informado al Northeast Arc de su más actualizada información de contacto, incluyendo su dirección, teléfono, e información de su cuenta bancaria. Esto nos permitirá enviarle cualquier cheque de PTO, cheque de compensación de FICA o su W-2 a fin de año. Rev. 4/24/2013

5 Personal Care Attendant Signature Form Name of fiscal intermediary (FI) NORTHEAST ARC C MassHealth THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and I I I ' e All PCAs hired by a PCA consumer must fill out and sign this form and give it to their employer (the PCA consumer). "'The PCA's employer (the PCA consumer) must submit this form to the Fl, along with all other paperwork required by the Fl and MassHealth. $The Fl cannot pay a PCA until all required paperwork is received and complete. <!} MassHealth and the Fl cannot pay a PCA to work o when the PCA consumer is in an inpatient facility, such as a hospital or nursing facility; or o when the amount of time that has been authorized by MassHealth has been exhausted or is insufficient. 'l' The PCA must read the rest of this form and sign below before receiving payment from the Fl. 1. I I agree to accept the position of personal care attendant (PCA) for.... (name of PCA consumer). I understand that my employer is the PCA consumer. My employer is responsible for hiring, firing, training and scheduling PCAs. My employer may select another person (a surrogate) to help manage his or her PCA services. I must notify my employer and the sun ogate (if any), of any in my circumstances that would affect my ability to perform my duties as a PCA I must complete and provide accurate Activity Forms (time sheets) to my employer or the Fl as soon as I can.the Fl will process payroll for my employer. My employer is responsible for giving the check to me (unless I requested that my check be directly into my bank account). I must provide proof of my identity to my employer to complete the Employment Eligibility Verification form (Form 1-9). which the Department of Homeland Security requires all employees to complete. (The Fl will give my employer this form.) I understand that the MassHealth PCA program pays for personal care services provided by a PCA only when the PCA provides physical assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to an eligible PCA consumer who has obtained prior authorization from MassHealth for PCA services. PCA services must be provided in accordance with the PCA consumer's authorized PCA evaluation or reevaluation, service agreement, and MassHealth regulations at 130 CMR I understand that ADLs include physically assisting the PCA consumer with transferring, walking, using medical equipment taking medications, bathing and grooming, dressing and undressing, passive range-of-motion exercises, eating, and toileting. I understand that IADLs include household services that are essential to the PCA consumer's care such as laundry, shopping, housekeeping, meal preparation and cleanup, transportation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiving personal care services, and other activities approved by MassHealth as being instrumental to the health care needs of the PCA consumer. I understand that my employer (the PCA consumer) will tell me which of these services require me to provide physical assistance. I understand that I cannot be paid as a PCA if I am a spouse, parent (if the PCA consumer is a minor child). surrogate, foster parent or legally responsible relative of the PCA consumer. The following describes my relationship to my employer (the PCA consumer). (Please check one.) adult child (I 8 yrs. or older) of member parent of adult ( 18 yrs. or older) member daughter-in-law of member other relative (describe) son-in-law of member nonrelative (describe) I certity under pains and penalties of pe~ury that the information on this signature form, and any accompanying statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete to the best of my knowledge.! also certify that I understand my duties, rights, and responsibilities as a PCA and that all the information I have provided to my employer (the PCA consumer), to the fiscal intermediary. to the personal care management agency, or to MassHealth is true and accurate to the best of my knowledge.! understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. Print PCA Name Date PCA signature

6 Ayudante de atenci6n individual Formulario para Ia firma MassHealth THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services I r Nombre del intermediario fiscal (FI, por sus siglas en ingles): e Todos los Ayudantes de atenci6n individual (PCA. por sus siglas en ingles) contratados por un usuario de PCA debercin llenar y firmar este formulario y entregarselo a su empleador (el usuario de PCA). e El empleador de PCA (el usuario de PCA) debera enviarle este formulario al intermediario fiscal, junto con toda Ia document-,aci6n adicional que exijan el intermediario y MassHealth. e El Fl no podra realizarle pagos a un PCA hasta que se haya recibido toda Ia documentaci6n requerida y esta este completa. e Mass Health y el Fl no pod ran pagarle a un PCA par trabajar: o cuando el usuario de PCA este internado en un hospital o centro de enfermerla; o o cuando Ia cantidad de tiempo que MassHealth haya avtorizado se haya agotado o no sea suficiente. G El PCA deber<i leer el resto de este formulario y firmar en el espacio siguiente antes de recibir pagos del IF. Estoy de acuerdo en aceptar el puesto de ayudante de atenci6n individual (PCA, por sus siglas en inglt~s) para (nombre del usuario de PCA). Entiendo que mi empleador es el usuario de PCA Mi empleador esti a cargo de contratar; despedir; capacitar y elaborar los horarios de los PCA Mi empleador puede escoger a otra persona (un sustituto) que le ayude a manejar los servicios de PCA. Debo notificarles ami empleador y al sustituto (si lo hubiera) cualquier cambia en mi situaci6n que afecte mi capacidad para desempeiiar mis labores de PCA Debo llenar y entregarle ami empleador o al sustituto Formularies de actividad (planillas de control de horas) exactos tan pronto como pueda. El Fl procesari los pagos que deba realizarme mi empleador. Mi empleadortendri Ia responsabilidad de entregarme el cheque (a menos que yo haya solicitado que mi cheque se deposite directamente en mi cuenta bancaria).tendre que proporcionarle ami empleador prueba de mi identidad para llenar el Formulario de verificaci6n de cumplimiento de los requisites de empleo (Formulario 1-9), que el Departamento de Seguridad Nacional (Department of Homeland Security) requiere a todos los empleados. (EI Fl le entregara a mi empleador este formulario.) Entiendo que el programa PCA de MassHealth solamente paga por los servicios de atenci6n individual que preste un PCA cuando este proporcione asistencia trsica para realizar actividades de Ia vida diaria (ADLs, por sus siglas en ingles) o actividades instrumentales de Ia vida diaria (IADLs, par sus siglas en ingles) a un usuario de PCA elegible que haya obtenido autorizaci6n previa de MassHealth para recibir servicios de PCA. Los servicios de PCA deberin prestarse de conformidad con Ia evaluaci6n o reevaluaci6n autorizada del usuario de PCA, con el contrato de servicios y las regulaciones de MassHealth en 130 CMR Entiendo que las ADLs comprenden asistir ffsicamente al usuario con las actividades cotidianas comprende ayudarle a trasladarse, a caminar; a utilizar aparatos medicos, a to mar medicamentos, a baiiarse y arreglarse, a vestirse y desvestirse, a realizar ejercicios pasivos para mejorar Ia amplitud de movimientos, a comer y a ir al baiio. Entiendo que las IADLs comprenden servicios domesticos esenciales para Ia atenci6n del usuario, tales como lavar Ia ropa, hacer las compras, mantener Ia casa ordenada, preparar las comidas y recoger los plates, llevarlo a citas m dicas, realizar el mantenimiento de sill as de ruedas u otros equipos medicos, llenar los documentos requeridos para recibir los servicios de atenci6n individual y otras actividades que MassHealth haya aprobado por ser instrumentales para satisfacer las necesidades relativas al cuidado de Ia salud del usuario de PCA Entiendo que mi empleador (el usuario de PCA) me informari en cuiles de estos servicios se requiere que yo le preste asistencia trsica. Entiendo que no me podrin pagar como un PCA si soy el c6nyuge, el padre/la madre (si el usuario de PCA es un hijo menor de edad), el sustituto, el padre/la madre de crianza o el pariente legal mente responsable del usuario de PCA La s.iguiente es mi relaci6n con mi empleador (el usuario de PCA). (Por favor marque una opci6n.) [] Hijo adulto (de 18 afios o mas) del afiliado D Nuera del afiliado [:JYerno del afiliado [] Padre/madre del afdiado adulto ( 18 afios o mas) Otro pariente ( describa) No soy pariente ( describa) Certifico bajo los castigos y penas de pe~urio que Ia informacion que contiene este formulario para Ia firma y toda declaraci6n adjunta que yo haya suministrado, han sido revisadas y firmadas por mf y son verdaderas, exactas y completas a mi mejor entender: Tambi n certifico que entiendo mis debe res, derechos y responsabilidades como PCA y que toda Ia informacion que he proporcionado a mi emp!eador ( el usuario de PCA), al intermediario fiscal, a Ia agenda de administraci6n de atenci6n individual o a MassHealth es verdadera y exacta a mi mejor entender: Entiendo que yo podrla ser objeto de sanciones de car3.cter civil o de denuncia penal por cualquier falsificaci6n, omisi6n u ocultaci6n de cualquier hecho fundamental incluido en este documento. Nombre del PCA en imprenta: Firma del PCA y fecha: Firma del PCA:

7 Form W-4 (2014) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2014 expires February 17, See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity iincome, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter 1 if: { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit... F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($95,000 if married), enter 2 for each eligible child; then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible children. If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter 1 for each eligible child... G H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Form W-4 Department of the Treasury Internal Revenue Service Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2014)

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9 EN E S V B E M V I E T O FORM M-4 MASSACHUSETTS EMPLOYEE S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/12 Print full name... Social Security no.... Print home address... City... State... Zip... DEPARTMENT OF MASSACHUSETTS S P E TI T P L A C I D A M REVENUE L IBERTATE Employee: File this form or Form W-4 with your employer. Otherwise, Massachusetts Income Taxes will be withheld from your wages without exemptions. Employer: Keep this certificate with your records. If the employee is believed to have claimed excessive exemptions, the Massachusetts Department of Revenue should be so advised. HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS 1. Your personal exemption. Write the figure 1. If you are age 65 or over or will be before next year, write If married and if exemption for spouse is allowed, write the figure 4. If your spouse is age 65 or over or will be before next year and if otherwise qualified, write 5. See Instruction C Write the number of your qualified dependents. See Instruction D Add the number of exemptions which you have claimed above and write the total Additional withholding per pay period under agreement with employer $ D D D A. Check if you will file as head of household on your tax return. D B. Check if you are blind. C. Check if spouse is blind and not subject to withholding. D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income will not exceed $8,000. EMPLOYER: DO NOT withhold if Box D is checked. I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. Date Signed... THIS FORM MAY BE REPRODUCED THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE A. Number. If you claim more than the correct number of exemptions, civil and criminal penalties may be imposed. You may claim a smaller number of exemptions. If you do not file a certificate, your employer must withhold on the basis of no exemptions. If you expect to owe more income tax than will be withheld, you may either claim a smaller number of exemptions or enter into an agreement with your employer to have additional amounts withheld. You should claim the total number of exemptions to which you are entitled to prevent excessive overwithholding, unless you have a significant amount of other income. If you work for more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer. If you are married and if your spouse is subject to withholding, each may claim a personal exemption. B. Changes. You may file a new certificate at any time if the number of exemptions increases. Youmust file a new certificate within 10 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son s income indicates that you will not provide over half of his support for the year, you must file a new certificate. C. Spouse. If your spouse is not working or if she or he is working but not claiming the personal exemption or the age 65 or over exemption, generally you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemptions for your spouse or for any dependents that will not be claimed on your annual tax return. If claiming a wife or husband, write 4 in line 2. Using 4 is the withholding system adjustment for the $4,400 exemption for a spouse. D. Dependent(s). You may claim an exemption in line 3 for each individual who qualifies as a dependent under the Federal Income Tax Law. In addition, if one or more of your dependents will be under age 12 at year end, add 1 to your dependents total for line 3. You are not allowed to claim federal withholding deductions and adjustments under the Massachusetts withholding system. If you have income not subject to withholding, you are urged to have additional amounts withheld to cover your tax liability on such income. See line 5. IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

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11 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-9 OMB No Expires 03/ ,.START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State Zip Code Date of Birth (mm/ddlyyyy) I r ]~[j~[ Numbj Address Telephone Number I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following): D A citizen of the United States D A noncitizen national of the United States (See instructions) D A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number!USCIS Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS Number: OR 2. Form 1-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) 3-D Barcode Do Not Write in This Space I Signature of Employee: I Date (mmldd/yyw): Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator: I Date (mmlddlyyyy): Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) 'City or Town I State I Zip Code Employer Completes Next Page Form /08/13 N Page 7 of9

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13 Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List 8 and one document from List C as listed on the "Lists of Acceptable Documents on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: List A Identity and Employment Authorization Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): OR List B Identity Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): AND ListC Employment Authorization Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmldd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): Document Title: 3-D Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mmlddlyyyy)" (See instructions for exemptions) Signature of Employer or Authorized Representative I Date (mmldd/yyyy) I Title of Employer or Authorized Representative Last Name (Family Name) First Name (Given Name) I Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) I City or Town I State I Zip Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial I B. Date of Rehire (if applicable) (mmlddlyyyy): C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title: I Document Number: Expiration Date (if any)(mmldd/yyyy): I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative: Date (mmlddlyyyy): Print Name of Employer or Authorized Representative: Form /08/13 N Page 8 of9

14 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A LIST B LISTC Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND 1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number li>. State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary stamp or temporary INS AUTHORIZATION printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545) 3. SchooiiD card with a photograph 5. For a nonimmigrant alien authorized 3. Certification of Report of Birth to work for a specific employer 4. Voter's registration card issued by the Department of State because of his or her status: (Form DS-1350) 5. U.S. Military card or draft record a. Foreign passport; and 4. Original or certified copy of birth b. 6. Military dependent's ID card certificate issued by a State, Form 1-94 or Form I-94A that has county, municipal authority, or the following: 7. U.S. Coast Guard Merchant Mariner territory of the United States (1) The same name as the passport; Card bearing an official seal and 8. Native American tribal document 5. Native American tribal document (2) An endorsement of the alien's nonimmigrant status as long as 9. Driver's license issued by a Canadian 6. U.S. Citizen ID Card (Form 1-197) that period of endorsement has government authority not yet expired and the... ' 7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or, unable to present a document States (Form 1-179) 6. limitations identified on the form. 1 listed above: 8. Employment authorization Passport from the Federated States of I. 10. School record or report card document issued by the Micronesia (FSM) or the Republic of Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts. Form I-9 03/08/13 N Page 9 of9

15 Consumer #: 6 Southside Road, Danvers, MA Fax Direct Deposit Application Employee/PCA s Name: Bank Name: Routing#: Account#: Checking Account Please attach a copy of a voided check. This check must show your name and address pre-printed on it and contain a valid bank routing number and checking account number. Please tape or glue a voided check here Savings Account Please attach an official bank form from your bank indicating your name, bank routing number, and savings account number. I hereby authorize my employer (hereinafter Company ) to deposit any amounts owed me by initiating credit entries to my account at the financial institution (hereinafter Bank ) indicated on this form. Further, I authorize the Bank to accept and to credit any credit entries indicated by the Company to my account. In the event the Company deposits funds erroneously to my account, I authorize the Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until the Company and the Bank have received written notice from me of its termination in such time and such manner as to afford the Company and the Bank reasonable opportunity to act on it. Employee/PCA s Signature: Date: Rev. 5/4/2012

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