CONSUMER S INFORMATION. Street: Phone #: City: State: Zip: Employee/PCA Start Date: Check One: Masshealth SCO Self-Direct One-Care

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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. Write the consumer number at the top of each form and complete all 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 call you when the Employee/PCA becomes active in our system (approximately 5 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: Masshealth, SCO or One Care 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 One-Care 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. 7/21/14

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 5 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, SCO o One Care 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: Calle: #de Consumidor: # 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 One-Care 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. 7/21/14

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 For FI Use For FI Use only only COMPLETED FORM BY CONSUMER ( ) Received Forms Completed 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 (This is a 2 page document) 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. Other Forms of Payment (OPTIONAL-but highly recommended) Direct Deposit Application Did the PCA include a voided check or an official bank form? Debit Card Application Work Permit Needed if the PCA is under age 18. (Can be completed by your local high school or city hall) 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. 7/8/2014

4 Lista de chequeo del Paquete para el Empleado/PCA Número 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. FORMULARIO COMPLETADO POR EL CONSUMIDOR ( ) For FI Use only For FI Use only 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 (Este es un documento de 2 páginas) 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? Título 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? OTRAS FORMAS DE PAGO (OPCIONAL-Pero muy recomendado) Aplicación para Depósito Directo El PCA incluyó un cheque cancelado o una carta oficial del banco? Aplicación para Tarjeta de Débito Permiso de Trabajo Necesario si el PCA es menor de 18 años de edad. (Puede ser completado por su Escuela secundaria local o Alcaldía) 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. 7/8/2014

5 Personal Care Attendant Signature Form THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services Name of fiscal intermediary (FI) Northeast Arc Consumer # 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 FI, along with all other paperwork required by the FI and MassHealth. The FI cannot pay a PCA until all required paperwork is received and complete. MassHealth and the FI 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. The PCA must read the rest of this form and sign below before receiving payment from the FI. 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 ser vices. I must notify my employer and the surrogate (if any), of any changes 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 FI as soon as I can.the FI will process payroll for my employer. My employer is responsible for giving the check to me (unless I requested that my check be deposited directly into my bank account). I must provide proof of my identity to my employer to complete the Employment Eligibility Verification form (Form I-9), which the Depar tment of Homeland Security requires all employees to complete. (The FI will give my employer this form.) I understand that the MassHealth PCA program pays for personal care ser vices 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 ser vices. PCA ser vices must be provided in accordance with the PCA consumer s authorized PCA evaluation or reevaluation, ser vice 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 ser vices that are essential to the PCA consumer s care such as laundr y, shopping, housekeeping, meal preparation and cleanup, transpor tation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiving personal care ser vices, 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 ser vices 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 (18 yrs. or older) of member daughter in-law of member son-in law of member parent of adult (18 yrs. or older) member other relative (describe) nonrelative (describe) I cer tify under pains and penalties of perjur y 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. I also cer tify 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 intermediar y, to the personal care management agency, or to MassHealth is true and accurate to the best of my knowledge. I 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 PCA-S (Rev. 06/11)

6 Ayudante de atención individual Formulario para la firma THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services Nombre del intermediario fiscal (FI, por sus siglas en inglés): Northeast Arc Consumer # Todos los Ayudantes de atención individual (PCA, por sus siglas en inglés) contratados por un usuario de PCA deberán llenar y firmar este formulario y entregárselo a su empleador (el usuario de PCA). El empleador de PCA (el usuario de PCA) deberá enviarle este formulario al intermediario fiscal, junto con toda la documentación adicional que exijan el intermediario y MassHealth. El FI no podrá realizarle pagos a un PCA hasta que se haya recibido toda la documentación requerida y esta esté completa. MassHealth y el FI no podrán pagarle a un PCA por trabajar : o cuando el usuario de PCA esté internado en un hospital o centro de enfermería; o o cuando la cantidad de tiempo que MassHealth haya autorizado se haya agotado o no sea suficiente. El PCA deberá 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 atención individual (PCA, por sus siglas en inglés) para (nombre del usuario de PCA). Entiendo que mi empleador es el usuario de PCA. Mi empleador está 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 a mi empleador y al sustituto (si lo hubiera) cualquier cambio en mi situación que afecte mi capacidad para desempeñar mis labores de PCA. Debo llenar y entregarle a mi empleador o al sustituto Formularios de actividad (planillas de control de horas) exactos tan pronto como pueda. El FI procesará los pagos que deba realizarme mi empleador. Mi empleador tendrá la responsabilidad de entregarme el cheque (a menos que yo haya solicitado que mi cheque se deposite directamente en mi cuenta bancaria).tendré que proporcionarle a mi empleador prueba de mi identidad para llenar el Formulario de verificación de cumplimiento de los requisitos de empleo (Formulario I-9), que el Depar tamento de Seguridad Nacional (Depar tment of Homeland Security) requiere a todos los empleados. (El FI le entregará a mi empleador este formulario.) Entiendo que el programa PCA de MassHealth solamente paga por los ser vicios de atención individual que preste un PCA cuando éste proporcione asistencia física para realizar actividades de la vida diaria (ADLs, por sus siglas en inglés) o actividades instrumentales de la vida diaria (IADLs, por sus siglas en inglés) a un usuario de PCA elegible que haya obtenido autorización previa de MassHealth para recibir ser vicios de PCA. Los servicios de PCA deberán prestarse de conformidad con la evaluación o reevaluación autorizada del usuario de PCA, con el contrato de ser vicios y las regulaciones de MassHealth en 130 CMR Entiendo que las ADLs comprenden asistir físicamente al usuario con las actividades cotidianas comprende ayudarle a trasladarse, a caminar, a utilizar aparatos médicos, a tomar medicamentos, a bañarse y arreglarse, a vestirse y desvestirse, a realizar ejercicios pasivos para mejorar la amplitud de movimientos, a comer y a ir al baño. Entiendo que las IADLs comprenden ser vicios domésticos esenciales para la atención del usuario, tales como lavar la ropa, hacer las compras, mantener la casa ordenada, preparar las comidas y recoger los platos, llevarlo a citas médicas, realizar el mantenimiento de sillas de ruedas u otros equipos médicos, llenar los documentos requeridos para recibir los ser vicios de atención individual y otras actividades que MassHealth haya aprobado por ser instrumentales para satisfacer las necesidades relativas al cuidado de la salud del usuario de PCA. Entiendo que mi empleador (el usuario de PCA) me informará en cuáles de estos ser vicios se requiere que yo le preste asistencia física. Entiendo que no me podrán pagar como un PCA si soy el cónyuge, 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 legalmente responsable del usuario de PCA. La siguiente es mi relación con mi empleador (el usuario de PCA). (Por favor marque una opción.) Hijo adulto (de 18 años o más) del afiliado Nuera del afiliado Yerno del afiliado Padre/madre del afiliado adulto (18 años o más) Otro pariente (describa) No soy pariente (describa) Cer tifico bajo los castigos y penas de perjurio que la información que contiene este formulario para la firma y toda declaración adjunta que yo haya suministrado, han sido revisadas y firmadas por mí y son verdaderas, exactas y completas a mi mejor entender.también cer tifico que entiendo mis deberes, derechos y responsabilidades como PCA y que toda la información que he proporcionado a mi empleador (el usuario de PCA), al intermediario fiscal, a la agencia de administración de atención individual o a MassHealth es verdadera y exacta a mi mejor entender. Entiendo que yo podría ser objeto de sanciones de carácter civil o de denuncia penal por cualquier falsificación, omisión u ocultación de cualquier hecho fundamental incluido en este documento. Nombre del PCA en imprenta: Firma del PCA y fecha: Firma del PCA: PCA-S (Rev. 06/11)

7 Form W-4 (2015) 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 2015 expires February 16, 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 $1,050 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 income, 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 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $65,000 and $84,000 ($100,000 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. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service 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) 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. City or town, state, and ZIP code 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 2015, 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 (2015)

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9 N P E Consumer # FORM M-4 MASSACHUSETTS EMPLOYEE S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/ 12 Print full name... Social Security no.... Print home address City... State... Zip... U 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 $ A. Check if you will file as head of household on your tax return. 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. You must 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 6 Southside Road, Danvers, MA Fax Direct Deposit Application Consumer #: 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 contains 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. This document must be signed by a Bank Representative and the account information must be typed not handwritten. 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: PLEASE NOTE THAT A DIRECT DEPOSIT ACTIVATION MAY TAKE UP TO 10 BUSINESS DAYS. YOUR FIRST PAYMENT MAY BE A PAPER CHECK. Rev. 4/9/2014

16 Número de Consumidor: Empleado/Nombre del PCA: Nombre del Banco: 6 Southside Road, Danvers, MA Fax Aplicación para Depósito Directo Numero de Ruta: Numero de cuenta: Cuenta de cheques Por favor agregue una copia de un cheque cancelado. Este cheque debe mostrar su nombre y dirección -impreso y debe contener una cuenta de banco y numero de ruta validos. Por favor, pegue el cheque cancelado aquí con cinta adhesiva o con otro material adhesivo. Cuenta de Ahorros Por favor agregue una carta o formulario oficial de su banco indicando su nombre, numero de cuenta y de ruta de su cuenta de ahorros. Este documento debe estar firmado por un representante de su banco y la información de su cuenta debe estar impresa y no escrita a mano. Yo autorizo a mi empleador (de aquí en adelante La Compañía ) a depositar cualquier cantidad que se me deba iniciando entradas de crédito a mi cuenta en la institución financiera (de aquí en adelante El Banco ) indicado en este formulario. Además, yo autorizo que el Banco acepte y acredite cualquier entrada de crédito indicada por La Compañía a mi cuenta. En el caso de que la Compañía deposite fondos erróneamente en mi cuenta, yo autorizo a la Compañía a que debite mi cuenta por el monto que no sobrepase la cantidad depositada por error. Esta autorización se mantendrá en efecto hasta que La Compañía y El Banco hayan recibido notificación por escrito de mi parte para terminación a su debido tiempo y de una manera que ambos puedan actuar a tiempo. Firma del PCA/Empleado: Fecha: POR FAVOR, NOTE QUE LA ACTIVACION DEL DEPOSITO DIRECTOR PUEDE TOMAS HASTA 10 DIAS LABORABLES. SU PRIMER PAGO SERA UN CHEQUE FISICO. Rev. 4/9/2014

17 PaychekPLUS! Select MasterCard Prepaid Card Enrollment Form Consumer# FISCAL INTERMEDIARY: Northeast ARC Thank you for your interest in using the PaychekPLUS! Select MasterCard Prepaid Card ( PaychekPLUS! Select Card ) to receive your pay. By completing this form you will be applying for a PaychekPLUS! Select Card. Use of this card is subject to the terms, conditions and fees outlined in the Cardholder Agreement included with this enrollment form. If you have any concerns about the terms and conditions for the card, please contact the Fiscal Intermediary named above before you submit this form. The PaychekPLUS! Select Card is issued by Comerica Bank pursuant to a license with MasterCard International, Inc. To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We may also use other records to validate your identity. Applicant Information: *Full Name *Home Address *Street: (PO Box is not permitted) *City: *State: *ZIP: Mailing address (if different than Home Address) Street: City: State: ZIP: *SSN *Date of Birth (MM/DD/YYYY) *Phone Number: * These fields are required. Authorization: By signing below, you direct the Fiscal Intermediary identified above to load your pay to your PaychekPLUS! Select Card. You specifically authorize the Fiscal Intermediary to initiate credit entries to, and if necessary, to initiate debit entries to correct a previous credit error to your PaychekPLUS! Select Card. This authorization will remain in effect until the Fiscal Intermediary receives written notice from you terminating your consent and Fiscal Intermediary has a reasonable opportunity to act on that notice. You also understand and agree that to process this application and load your pay to the PaychekPLUS! Select Card, certain personally identifiable information about you and your PaychekPLUS! Select Card account will be collected by and shared between the Fiscal Intermediary and Comerica. Information shared by and with the Fiscal Intermediary and Comerica Bank may include, without limitation, your name, address, social security number, date of birth, prepaid card account status, and direct deposit information for your prepaid card account. By providing a telephone number, I expressly consent to receiving calls regarding my card account at this number, including auto dialed calls and prerecorded or artificial voice message calls. Calls to a mobile number may incur fees from my cellular provider. By signing below, you consent to the Fiscal Intermediary and Comerica Bank sharing this and other information for the purpose of opening, maintaining and loading the requested prepaid account. Employee Signature Date Information below this line will be used by the Fiscal Intermediary only. To assist the Fiscal Intermediary in processing your pay, please provide information about the individual to whom you provide Services (your Client ): Client Name: Client Address Street: Apt/Suite Client No.: City: ZIP:

18 PaychekPLUS! Select MasterCard Prepaid Card Terms of Use Comerica Bank ( we, us and Bank ) is providing you with these terms ( Terms ) and the enclosed MasterCard ( Card ). You may accept certain one-time or recurring payments from your employer(s), certain agencies or other Service Providers (each a Payor ) to by means of the Card. This agreement describes your rights and obligations with respect to the Card. If you have questions, or do not agree with these Terms, you should not activate the Card. You can destroy it by cutting it in half. YOU CANNOT USE THE ENCLOSED CARD UNTIL YOU ACTIVATE THE CARD AND SELECT YOUR PERSONAL IDENTIFICATION NUMBER (PIN). Visit or call us at to activate your card. By selecting your PIN and activating the Card in accordance with the instructions accompanying this form, you will be agreeing to abide by these Terms. Your use of the Card will further attest to your agreement to abide by these Terms. 1. Payments to You. An account has been established with us to fund payments to you. We will make funds available to you in the amounts designated by the Payor, and you will be able to access those funds with the Card. THE ONLY FEDERAL PAYMENTS THAT MAY BE DEPOSITED TO THIS CARD ARE FEDERAL PAYMENTS FOR YOUR BENEFIT. The maximum value of payments to your Card that we will permit each day is $5,000, and the maximum balance allowable on your card is $10, Personal Identification Number (PIN). The Card cannot be used at automated teller machines ( ATMs ) and some point-of-sale ( POS ) terminals without the PIN. You may be asked to sign a sales slip or provide identification, rather than enter your PIN, for certain POS transactions. At some merchants, such as gas stations, you may not be required to sign your name or enter your PIN. 3. Card Transactions. You can use your Card to make purchases at POS terminals, and merchant locations that accept MasterCard debit cards. With your PIN, you may use your Card to obtain cash from any ATM or any POS device, as permissible by merchant, that bears the MasterCard, Maestro, Cirrus, ACCEL, Allpoint, or Comerica Bank Acceptance Mark. When you use the Card to initiate a transaction at certain merchants, such as hotels, a hold may be placed on your available Card funds for an amount equal to or in excess of your ultimate transaction. The held funds will not be available to you for any other purpose. Any excess will be released for your use when the transaction is finally settled. Cash refunds will not be made to you for POS purchases. If a merchant gives you a credit for merchandise returns or adjustments, it may do so by processing a credit adjustment, which we will apply as a credit to your Card account. You may not use the Card to perform transactions that exceed the amount of funds made available to you. There may be occasions when deposits are posted to your account in error, or funds added that do not belong to you. You are not authorized to spend these funds because the Payor has not authorized us to make these funds available through the Card. In such events, this error will be corrected once discovered and funds will be adjusted in your account. Should the adjustment result in your account becoming negative, a notice letter will be sent to you explaining the error and the reason for the adjustment. If you have spent the funds before the error is identified, the amount to be repaid may be automatically deducted from future payments to your account as described in Section 9 of this document. Your Card must not be used for any unlawful purpose (for example, to facilitate Internet gambling). You agree not to use your Card or funds for any transaction that is illegal. We reserve the right to deny transactions or authorizations from merchants apparently engaging in the Internet gambling business or identifying themselves through transaction records or otherwise as engaged in such business. You may also stop payment on a preauthorized recurring payment by either calling us or writing us at least three business days before the date of the payment. Please be advised that you may experience difficulties using the Card at: unattended vending machines and kiosks; gas station pumps (you may go inside to pay); and certain other merchants, such as rental car companies, where a preauthorized amount may be held until a final bill is rendered. 4. Card and PIN Security. You agree not to give or otherwise make the Card or PIN available to others. For security reasons, you agree not to write your PIN on the Card or keep it in the same location as the Card. The Card is our property and must be returned to us upon request. 5. Transaction Limitations. We may refuse to authorize a Card transaction if: (a) it would exceed the amount available for your use; (b) the Card is reported lost or stolen; (c) we believe the Card is counterfeit; or (d) we are uncertain whether the transaction is authorized by you or permitted by law. We may temporarily freeze the Card and attempt to contact you if we note transactions that are unusual or appear suspicious. For security reasons, we limit the amount and number of transactions you can make with your Card. For example, common transactions are limited as follows: Transaction Type Maximum Amount per Transaction Total Maximum Amount per Day Maximum Number of Transactions per Day ATM Withdrawals $500 $500 3 Purchases (POS Transactions) $2525 $ Teller Assisted Cash Withdrawals $2525 $ Transfers (to a card or to a bank account) $950 $ Foreign Currency Transactions. If you obtain cash or perform an ATM or POS transaction in a currency other than U.S. dollars, the merchant or MasterCard will convert the amount of the transaction into U.S. dollars to be charged to your Card. Under the currency conversion procedure that MasterCard uses, the non-u.s. dollar transaction amount is multiplied by a currency conversion rate to determine its equivalent in U.S. dollars. The currency conversion rate that MasterCard typically uses is either a government-mandated rate, or a rate selected from a range of rates available in the wholesale currency markets (NOTE: this rate may be different from the rate MasterCard itself receives). The conversion rate may be different from the rate in effect on the date of your transaction and the date it is posted to your Card. 7. Record of Your Available Funds and Transactions. You can get a receipt at the time you perform a transaction at an ATM or POS terminal. You may obtain information about the amount of funds available through the Card by calling the Customer Service Center toll free at or by visiting From the web site you can select and print monthly statements for tracking the transactions posted to your Card account. You also have the right to receive a written summary of transactions for the 60 days preceding your request by calling us at Lost or Stolen Card/PIN. If you believe the Card or PIN has been lost or stolen or that someone has transferred or may transfer money from your Card account without your permission, call us at , or write to us at Cardholder Services, P O Box , Jacksonville, FL with details. 9. Adjustments to Your Account Balance. There are occasions when adjustments will be made to your account to reflect a merchant adjustment, resolve a cardholder dispute regarding a transaction posted to your account, or to adjust entries or deposits posted in error. These processing entries could cause your account to have a negative balance. If so, you agree to repay us the amount of any transactions that exceed the authorized amount or cause your account to go negative, either from future deposits posted to your account or by personal check or money order. Unless paid by personal check or money order, the amount to be repaid may be automatically deducted from future payments to your account. 10. In Case of Errors or Questions about Your Transactions. If you think an error has occurred in connection with your Card account, call us at or write us at the address described above as soon as you can. We must allow you to report an error until 60 days after the earlier of the date you electronically access your account, if the error could be viewed in your electronic history, or the date we sent the FIRST written history on which the error appeared. If electronic access to your Card account is not available or if you have not received a written statement, we must hear from you within 120 days the transfer was credited or debited from your account. You may request a written history of your transactions at any time by calling us at or writing us at Cardholder Services, P O Box , Jacksonville, FL You will need to tell us: 1. Your name, address, telephone number and Card number. 2. Why you believe there is an error, and the dollar amount involved. 3. Approximately when the error took place. Please provide us with your address and telephone number, as well, so that we can communicate with you. If the error cannot be resolved over the phone, we will mail you a Request for Investigation form to complete and return. You must return the form within 10 days to Cardholder Services, P O Box , Jacksonville, FL We will determine whether an error occurred within 10 business days after we hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days to investigate your complaint or question. If we decide to do this, we will credit your Card within 10 business days for the amount you think is in error, so that you will have use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10 business days, we may not credit your Card. For errors involving POS or foreign-initiated transactions, we may take up to 90 days to investigate your complaint or question. We will tell you the results within three business days after completing our investigation. If we decide that there was no error, we will send you a written explanation. You may ask for copies of the documents that we used in our investigation. If you need more information about our error-resolution procedures, call us toll-free at Your Liability. Tell us AT ONCE if you believe your Card or PIN has been lost or stolen. Telephoning is the best way of keeping your possible losses down. You could lose all the money associated with your Card. If you tell us within two business days, you can lose no more than $50 if someone used your Card or PIN without your permission. If you do NOT tell us within two business days after you learn of the loss or theft of your Card or PIN, and we can prove that we could have stopped someone from using your Card or PIN without your permission if you had told us, you could lose as much as $500. Note: You will not be liable for the $50 or $500 amounts stated above for transactions where your PIN is not used to verify your identity if you have not reported two or more incidents of unauthorized use in the immediately preceding 12 months, your Card is in good standing, and you have exercised reasonable care in safeguarding your Card from risk of loss or theft. Also, if the written transaction history or other Card transaction information provided to you shows transfers that you did not make, tell us at once. If you do not tell us within 60 days after the transmittal of such information, you may not get back any money you lost after the 60 days if we can prove that we could have stopped someone from taking the money if you had told us in time. If a good reason (such as a long trip or a hospital stay) kept you from notifying us, we will extend the time periods. We will cancel your Card if it is reported to us as lost, stolen or destroyed. Once your Card is canceled, you will have no liability for further transactions involving the use of the canceled Card. 12. Our Liability. If we do not complete an electronic fund transfer to or from the Card on time or in the correct amount according to these Terms, we may be liable for your losses or damages. There are some exceptions, however. We will not be liable, for instance, if: perform the transaction; strike, labor dispute, computer breakdown, telephone line disruption, or a natural disaster) prevents or delays the transfer, despite reasonable precautions taken by us; problem when you started the transaction; available for withdrawal; or 13. Limitation of Time to Sue. An action or proceeding by you to enforce an

19 Electronic Timesheets Agreement FAX THIS FORM TO OR MAIL TO: Northeast Arc FI, 6 Southside Rd, Danvers, MA I. About The Electronic Timesheets Module a. The Electronic Timesheets Module is a web based interface through which Consumers, Surrogates, Personal Care Attendants, and Fiscal Intermediary staff can respectively view relevant timesheet information. Additionally, Consumers and their Surrogates, but not Personal Care Attendants, will be able to view their Prior Authorization amounts and utilization. b. Consumers, Surrogates and Personal Care Attendants will be able to use the system to both submit and approve timesheets electronically for payment by the Fiscal Intermediary. c. A Consumer is not required to have a Surrogate in order to use the system. But in cases where a Consumer does have a Surrogate and the Consumer approves the Surrogate to have access to the Electronic Timesheets Submission Interface, both the Consumer and his/her Surrogate will have identical abilities to enter and approve timesheets for payment. If the Consumer does not feel comfortable with the electronic interface, the Surrogate has the ability to handle all of the Consumer s timesheet submission and approval responsibilities. II. Terms and Conditions By signing below, you are agreeing to the following Terms and Conditions: a. The Consumer and/or his/her Surrogate and the Personal Care Attendant must have valid e mail addresses which they access frequently. b. The Consumer, his/her Surrogate (if applicable) and the Personal Care Attendant agree to use the Electronic Timesheets Submission Interface as a method of submitting timesheets. i. Signing this Agreement does not require you to only use the Electronic Timesheets Submission Interface. Other methods of submitting time, such as faxing or mailing, are still acceptable. c. A timesheet may not be submitted electronically if the Consumer and the Personal Care Attendant have not both signed and agreed to use the Electronic Timesheets Submission Interface via this Agreement. i. If the Consumer approves their Surrogate to use the system, then the Surrogate must also sign this Agreement. d. An individual Electronic Timesheets Agreement is required for each Consumer/Personal Care Attendant relationship that chooses to use the Electronic Timesheets Submission Interface. This is true even if the Consumer or Personal Care Attendant is already using the Electronic Timesheets Submission Interface in another Consumer/Personal Care Attendant relationship. Please note: Masshealth does not pay for activity performed by a PCA while the consumer is impatient in a hospital or nursing home. Activity performed by a PCA while the consumer is in a hospital or nursing home is considered as fraud and will be referred to the Bureau of Special Investigations. Consumer Name: Consumer # Consumer E mail: Consumer Signature: Date: Surrogate Name: Surrogate E mail: Surrogate Signature: Date: PCA Name: PCA E mail: PCA Signature: Date: REV

20 I. Acerca del sistema de Hojas de Tiempo Electrónicas a. El sistema de hojas electrónicas es una sistema que se accesa a través del Internet en el cual Consumidores, Sustitutos, Asistentes de cuidado personal y el Personal del Intermediario fiscal podrán ver la información relevante a la información de sus hojas de tiempo. Adicionalmente, el consumidor y su sustituto, pero no el Asistente de cuidado persona, podrán ver el balance de su aprobación del servicio y su utilización. b. Consumidores, Sustitutos y los Asistentes de Cuidado Persona podrán usar este sistema para someter y aprobar hojas de tiempo con las hora que el PCA trabaja para que sean pagadas por el Intermediario Fiscal. c. No es requerido que el Consumidor tenga un sustituto para poder usar este Nuevo sistema. Pero en casos donde el Consumidor tenga un sustituto y el consumidor apruebe al sustituto para que tenga acceso a enviar las hojas de tiempo electrónicas, ambos deben tener habilidades idénticas para entrar y aprobar estas hojas de tiempo para su pago. Si el consumidor no se siente cómodo con este Nuevo sistema, el sustituto debe tener la habilidad y la responsabilidad de manejar este Nuevo proceso de someter y aprobar las hojas de tiempo electrónicas. II. Términos y Condiciones: Al firmar debajo, usted acuerda seguir los siguientes términos y condiciones: a. El consumidor y/o su sustituto y el Asistente de Cuidado Personal deben tener una dirección de correo electrónico valida a la cual accesan de manera frecuente. b. El consumidor, su Sustituto (si aplica) y el Asistente de Cuidado Personal están de acuerdo en usar el Sistema electrónico de Hojas de tiempo como método para someter las horas de trabajo del PCA. i. El firmar este acuerdo no requiere que solo pueda utilizar este medio para someter las horas trabajadas por su PCA. Otros métodos como faxear o enviar por correo la hoja de tiempo de papel, es aun aceptable. c. Una hoja de tiempo no será sometida electrónicamente si el consumidor o su asistente de cuidado personal no han firmado y acordado el uso de Hojas de tiempo electrónicas a través de este acuerdo. ii. Si el consumidor aprueba a su sustituto a usar el sistema, entonces el sustituto debe también firmar este acuerdo. d. Se es requerido un acuerdo de uso de hojas electrónicas para cada relación de Consumidor/PCA que deseen utilizar este método para someter sus horas trabajadas. Esto es correcto aunque el consumidor o el Asistente de cuidado personal ya este usando este sistema de hojas electrónicas en otra relación de consumidor/asistente de cuidado personal. Recordatorio: Masshealth no pagara por trabajo hecho por un PCA mientras el consumidor este interno en un hospital o en una casa de recuperación. Todo trabajo hecho por el PCA mientras el consumidor estuvo interno será considerado como fraude y será reportado al Bureau of Special Investigations. Nombre del Consumidor: # Del Consumidor Correo Electrónico del Consumidor: Firma del Consumidor: Acuerdo de uso de Hojas de Tiempo Electrónicas ENVIE POR FAX AL O POR CORREO: Northeast Arc FI, 6 Southside Rd, Danvers, MA Fecha: Nombre del Sustituto: Correo Electrónico del Sustituto: Firma del Sustituto: Fecha: Nombre del PCA: Correo Electrónico del PCA: Firma del PCA: Fecha: REV

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