TYPE OF APPLICATION (select one): PERSONAL ASSISTANT COMMUNITY SPECIALIST SUPPORT BROKER

Transcription

1 Missouri Self-Directed Supports EMPLOYEE APPLICATION Based on the pre-employment information you provided, we have pre-populated this application and most of the forms included in your enrollment packet. Please review and complete this application and other forms required for your employment. TYPE OF APPLICATION (select one): PERSONAL ASSISTANT COMMUNITY SPECIALIST SUPPORT BROKER PROGRAM QUALIFICATIONS (Responses to these three questions are REQUIRED.) 1. Are you a spouse of, legal guardian for, or designated representative to the Individual? Yes No 2. Are you under 18 years old? Yes No 3. Is the Individual you are applying to provide service for a minor (under age 18) and is he or she your child? Yes No If you responded YES to any of the questions above, you do NOT qualify for employment. Individual First Name: INDIVIDUAL INFORMATION Individual Last Name: EMPLOYEE INFORMATION Employee First Name: Employee M.I.: Employee Last Name: Employees Maiden/Alias Name(s): Date of Birth: Social Security Number: Gender: Female Male Relationship to Individual: Parent / Step Parent Child Sibling Grandparent Grandchild Other Relative Non-Relative Physical Address (no P.O. Box): PHYSICAL ADDRESS Physical Address 2 (apt, number, etc.): City: State: Zip Code: County: DMH-DD: NEW Employee Application Page 1 of 9 Version 1.1

2 INDIVIDUAL NAME: EMPLOYEE NAME: Mailing Address: MAILING ADDRESS (if different from Physical Address) Mailing Address 2 (apt, number, etc.): City: State: Zip: Phone Number: CONTACT INFORMATION Cell Phone Number: Address: Emergency Contact Name: EMERGENCY CONTACT INFORMATION Emergency Contact Phone Number: AUTHORIZATION TO WITHHOLD CITY PAYROLL TAX Instructions: Check the box next to the statement that best describes where you live and your status regarding payroll tax liability for Kansas City or the city of St. Louis, Missouri. Outside Kansas City and the city of St. Louis I do not reside in Kansas City or the city of St. Louis, Missouri. My place of employment under the Self-Directed Supports Program is neither in Kansas City nor the city of St. Louis, Missouri. Therefore I am not subject to City Earnings Tax from these municipalities. Kansas City I reside in, or my place of employment under the Self-Directed Supports Program is Kansas City, Missouri. I acknowledge that I am required to pay City Earnings Tax and authorize Public Partnerships, LLC to deduct the City Earnings Tax from my earnings and to pay the amount due to the city. St. Louis I reside in, or my place of employment under the Self-Directed Supports Program is the city of St. Louis, Missouri. I acknowledge that I am required to pay City Earnings Tax and authorize Public Partnerships, LLC to deduct the City Earnings Tax from my earnings and to pay the amount due to the city. IMPORTANT: It is the responsibility of the Employee to Notify Public Partnerships if their City Earnings Tax liability status changes. This will NOT be done automatically. DMH-DD: NEW Employee Application Page 2 of 9 Version 1.1

3 INDIVIDUAL NAME: EMPLOYEE NAME: PERSONAL ASSISTANT EMPLOYMENT REQUIREMENTS Type of Personal Assistant (PA): Regular PA Enhanced Behavioral Enhanced Medical A Personal Assistant must meet one of the following education requirements: High School Diploma* GED* Regional Office Exemption* PRE-EMPLOYMENT TRAINING The Individual/Designated Representative may exempt the following requirements if the exemption is due to: [A] Duties of the PA named above will not require skills to be attained from this training requirement. [B] The PA named above has adequate knowledge or experience. To grant an exemption, the appropriate reason code must be marked in the exemption column and justification for the exemption and safeguards in place must be documented in the ISP. American Red Cross, American Heart Association, or Division of DD approved competency based CPR Training* (Cannot be exempted for Enhanced Medical PA) Check APPLICABLE EXEMPTION CODE(S) A B First Aid Training* (Cannot be exempted for Enhanced Medical PA) A B Medication Administration Training* (Cannot be exempted for Enhanced Medical PA and passing A B medications.) Behavior Intervention Crisis Management Training: Mandt* NCI/CPI* PCMA/SCM* A B (Cannot be exempted for Enhanced Behavioral PA if physical intervention is needed) Behavior Intervention-Positive Behavior Supports Training: "Tools of Choice"* Columbus PBS* College of Direct Support PBS* A B Other training approved by RO QE dept. or Div. Chief Behavior Analyst* (Cannot be exempted for Enhanced Behavioral PA) Abuse and Neglect Training*(Cannot be exempted) *Proof of education and training or supporting documentation must be provided to Public Partnerships. All training and certifications must be kept current for the duration that the employee is employed. COMMUNITY SPECIALIST EMPLOYMENT REQUIREMENTS Are you a family member (parent, step parent, sibling, child by blood, adoption, or marriage, spouse, grandparent, or grandchild to the program Individual you are apply for? Yes No A Community Specialists must meet one of the following education and experience requirements: Bachelor degree from an accredited university plus one year experience*; Registered Nurse (with an active license in good standing, issued by the Missouri State Board of Nursing)*; Associate degree from an accredited university or college plus three years of experience.*; PRE-EMPLOYMENT TRAINING Abuse and Neglect Training* (Cannot be exempted) *Proof of degree/experience and training or supporting documentation must be provided to Public Partnerships. All training and certifications must be kept current for the duration that the employee is employed. DMH-DD: NEW Employee Application Page 3 of 9 Version 1.1

4 INDIVIDUAL NAME: EMPLOYEE NAME: SUPPORT BROKER EMPLOYMENT REQUIREMENTS Are you a family member (parent, step parent, sibling, child by blood, adoption, or marriage, spouse, grandparent, or grandchild to the program Individual you are apply for? Yes No A Support Broker cannot serve as a personal assistant or perform any other waiver services for the individual. A Support Broker must meet one of the following education requirements: High School Diploma* GED* Regional Office Exemption* The Support Broker must have experience or Division of DD approved training* in the following areas: Ability, experience and/or education to assist the individual/designated representative in the specific areas of support as described in the ISP*; Competence in knowledge of Division of DD policies and procedures: abuse/neglect; incident reporting; human rights and confidentiality; prevention of sexual abuse; knowledge of approved and prohibited physical management techniques*; Understanding of Support Broker responsibilities, of advocacy, person-centered planning, and community services*; Understanding of individual budgets and PPL fiscal management policies*. Abuse and Neglect Training*(Cannot be exempted) PRE-EMPLOYMENT TRAINING *Proof of education and training or supporting documentation must be provided to Public Partnerships. All training and certifications must be kept current for the duration that the employee is employed. APPLICATION FOR DIFFICULTY OF CARE FEDERAL INCOME TAX EXCLUSION Certain payments received by an employee for providing Medicaid services in the Employer's home are considered Difficulty of Care payments excludable from federal income tax. To determine if you are eligible for the income exclusion, complete the following steps. If you are eligible, PPL will not report the payments as income and will not withhold federal income taxes. STEP 1: Review information regarding the Difficulty of Care Federal Income Tax Exclusion. Information is available on PPL s website at: STEP 2: Check all that apply: I provide services to the individual participant in my home. (Please note that in order to self-direct supports the individual must live in their own private residence or that of your family member.) I do not have a separate home where I reside. This is the home where I reside and regularly perform the routines of private life, including shared meals and holidays with family. STEP 3: If all of the above do not apply, you are not eligible for the Difficulty of Care Federal Income Tax Exclusion. STEP 4: If all of the above apply, you are eligible for the Difficulty of Care Federal Income Tax Exclusion. Under penalties of perjury, I declare that I am an individual care provider receiving payments under a state Medicaid Home and Community-Based Services program. I live in the home with, and I provide services to, the individual listed at the top of this form. IMPORTANT: If you no longer reside with the individual you provides services to, you must notify PPL and terminate your Difficulty of Care Federal Income Tax Exclusion. DMH-DD: NEW Employee Application Page 4 of 9 Version 1.1

5 INDIVIDUAL NAME: EMPLOYEE NAME: RELATIONSHIP QUESTIONNAIRE This information is necessary, so that we can determine if you are eligible for tax withholding exemptions. 1. Are you a non-resident alien temporarily in the United States on an F-1, J-1, M-1, or Q-1 visa admitted to the US for the purpose of providing domestic services? YES, that description fits my status. 2. Are you the child of the employer (includes adopted children)? YES, my employer is my parent (mother or father). 3. Are you the spouse of the employer? YES, my employer is my spouse (husband or wife). 4. Are you the parent of the employer (includes adopted children)? YES, my employer is my child (son or daughter). NO, that description does not fit my status. NO, my employer is not my parent. NO, my employer is not my spouse. NO, my employer is not my child. 5. If you answered, YES, to Question 4, check any of the following that apply. If you answered, NO, proceed to Question 6. YES, I also provide care for my grandchild or step-grandchild in my child s home. YES, my grandchild or step-grandchild is under 18, or has a physical or mental condition that requires personal care of an adult for at least four continuous weeks during the calendar quarter in which services are performed. YES, my child (son or daughter) is widowed and divorced and not remarried, or living with a spouse who has a mental or physical condition which prohibits the spouse from caring for my grandchild for at least four continuous weeks during the calendar quarter in which services are performed. 6. Are you under the age of 18 or do you turn 18 this calendar year? YES, I am under 18 or am turning 18 this calendar year. NO, I am over 18. If you answered, YES, to Question 6, answer the following question. If you answered, NO, skip the question below. Is this job of performing household services (respite or nursing) your principal occupation? Note: Do not answer, YES, if you are a student. YES, this is my principal occupation. NO, this is not my principal occupation. DMH-DD: NEW Employee Application Page 5 of 9 Version 1.1

6 INDIVIDUAL NAME: EMPLOYEE NAME: SERVICE AND RATE INFORMATION This information is necessary in order to process your payments. Please check off ALL applicable services & enter rates for ALL applicable services. Service Name Service Code Employee Pay Rate Personal Assistant (PA) Enhanced Behavioral PA Enhanced Medical PA Team Collaboration PA Community Specialist Support Broker T1019U2 T1019TG T1019TG G9007U2 T1016U2 T2041U2 PAYMENT INFORMATION If a payment selection is not checked, then PPL will issue you and deposit your payments to an ADP ALINE pay card. Payment Type: (please check only one box) Account Type: (please check one box) Direct Deposit Pay Card ACCOUNT INFORMATION: Checking Account Savings Account ADP ALINE TM Payroll Card Other Pay Card REMITTANCE ADVICE I do not have access to the BetterOnline Web Portal, please send my paystub in the mail. ACCOUNT DOCUMENTATION 1. If selecting Checking Account, submit documentation from your financial entity confirming your account and routing numbers all information must be pre-populated including your full name. PPL cannot accept hand written documentation. 2. If selecting Savings Account, submit documentation from your financial entity confirming your account and routing numbers all information must be pre-populated including your full name. PPL cannot accept hand written documentation. 3. If selecting ADP Aline Payroll Card, no additional documentation is needed in this section. 4. If Direct Deposit is selected and documentation for a Checking Account or Savings Account is not provided, then PPL will send you your payments by paper check until one of these items are provided. 5. Direct Deposit can be cancelled by calling customer service. If you are changing your bank account information, this form must be submitted. DMH-DD: NEW Employee Application Page 6 of 9 Version 1.1

7 EMPLOYMENT TERMS AND CONDITIONS The Employer/Designated Representative has elected to hire me to perform care services for the Individual Receiving Services (Individual) in accordance with the Missouri Department of Mental Health, Division of Developmental Disabilities (DMH-DD), Self-Directed Supports Program. I understand that PCG Public Partnerships, LLC (PPL) is the Fiscal Employer Agent (F/EA) who assists the employer with employer-related tasks and IS NOT my employer. The Federal Employer Identification Number (FEIN) holder is my employer. The employer may select a Designated Representative (DR) to be responsible for managing employees. Enrollment - I have received an Employee Enrollment Packet that contains mandatory forms and information on trainings. I am responsible for understanding the information, and completing all documents. Supervision - The Employer/DR is responsible for training, managing and supervising the Employee and controlling the Employee's workplace activities. The Employer/DR is solely responsible for the decisions to hire and retain or not retain Employee. Training Employee acknowledges that they must complete the pre and post-employment training requirements detailed in this application to be eligible for initial and on-going employment. Post-employment training must be completed within 30 days of employment. All training certifications must be remain current. Employees who do not to complete or maintain post-employment trainings and certifications will not be eligible for on-going employment. All employees must be trained annually on the Individuals new Support Plan (ISP). All employees must complete abuse and neglect training every two years. Effective Date - Employment will be effective upon completion and review of the Employee Enrollment Packet and associated training modules. Your Employer/Designated Representative must receive a Good to Go notification before you begin work. Age and Education Eligibility - Employee acknowledges that they meet the age and education eligibility requirements under the Self-Directed Supports Program: I am more than 18 years old and have a high school diploma or GED. If working as a Community Specialist, I have a bachelor's degree plus one year relevant experience, or I am licensed Registered Nurse, or I have an associate degree plus three years relevant experience. Family as Caregiver Eligibility - Family is defined as a parent, step-parent, sibling, child by blood, adoption, or marriage, spouse, grandparent or grandchild. In order for a family member to be authorized as a paid caregiver, the following terms and conditions must be adhered to: No self-directed service may be provided by an Individual s spouse, Legal Guardian, Designated Representative or the Individual s parent if the Individual is a minor (under the age of 18). The Individual for whom the services are authorized must not be opposed to the family member providing the services. The Individual for whom the services are authorized has the right to make a change in selecting a paid personal assistant. The services to be provided are solely for the Individual and not household tasks expected to be shared with people living in the family unit. The planning team has determined the family member providing the service will best meet the Individual s needs. Only the hours of service determined necessary through the assessment and person-centered planning process may be authorized. DMH-DD: NEW Employee Application Page 7 of 9 Version 1.1

8 A family member cannot be paid for more than 40 hours per week. Any support provided above this amount would be considered a natural or unpaid support that a family member would typically provide. A family member cannot be hired as a Support Broker or Community Specialist. Other Conditions - The quality, appropriateness and timeliness of services reimbursed through this Agreement shall be subject to evaluation, thorough inspection or other means by the regional office of DMH-DD. The Support Coordinator shall monitor services on at least a quarterly basis. Other employment conditions include: Employees working more than 40 hours per week cannot be billed to the Medicaid Waiver program. Hours worked over 40 hours per week are the responsibly of the employer/designated representative and must be paid through the FMS in order to ensure employer related taxes are withheld. Per the Medicaid Waiver program, Personal Assistant, services does not allow for payment of employees for sleep time. If an employer schedules an employee to work 24 hours or more, the employer and employee agree to exclude from hours worked up to 8 hours of sleep time if: The employer furnishes sleep facilities The employee can usually sleep uninterrupted Acknowledgement - I acknowledge the following: I am an Employee of the Individual or their Guardian, and am not the Employee of PPL or the State of Missouri. I declare that I am an Employee receiving payments under a state Medicaid Home and Community- Based Services program. This Agreement does not guarantee the Employee a specific number of hours of work, nor does it limit the Employer from hiring other Employees under the Self-Directed Supports Program. This Agreement does not prohibit the Employee from working for more than one Individual under the Self- Directed Supports Program. Information shared with the Employee by the Employer/Designated Representative or the DMH-DD Regional Office and affiliated agencies regarding the Individual shall be confidential. I agree to carry out assigned duties and responsibilities explained by the Employer/Designated Representative, as outlined in the Individual Service Plan. I agree to fulfill and maintain all training requirements as outlined in this application. I understand I am expected to be dependable and report to work on time. I agree to call the Employer/Designated Representative with as much advance notice as possible if I am ill or unable to report to work on time. I agree to give the employer two weeks written notice if I decide to terminate this employment. The Employer/Designated Representative shall set the conditions of employment, and termination of employment shall be the prerogative of the Employer/Designated Representative. The Employer/Designated Representative will immediately dismiss the Employee if (1) they have been found to have been placed on an Employee Disqualification Registry or List maintained by either the Missouri Dept. of Health and Senior Services or the Missouri Dept. of Mental Health, (2) have committed abuse, neglect, or misuse of funds or property of an Individual receiving services, (3) have committed fraud or violated the terms of this Agreement, or (4) do not maintain annual training requirements. I understand I will be subject to an employee background screening through the Missouri Department of Health and Senior Services Family Care Safety Registry prior to employment and that that the results of the background screening may be shared with the Missouri Department of Mental Health, Division of Developmental Disabilities (DMH-DD) and/or the Individual Receiving Services/Designated Representative with whom I work. DMH-DD: NEW Employee Application Page 8 of 9 Version 1.1

9 I understand that I must report possible neglect, abuse or misuse of funds or property of an Individual to Individual's Service Coordinator immediately. Employee may also call the DMH-DD hotline at I understand that I not authorized to begin employment until the results of the background screening have been received and approved, I have completed all trainings, and my employer has received an "Good to Go notification from PPL. I understand that I will be covered by workers' compensation insurance and unemployment insurance. I understand that PPL will pay me on behalf of the employer on a biweekly basis, following the submission of accurate and approved timesheets and service documentation. I understand that I must record daily service documentation that describe various covered activities in which the Individual participated and record situations or incidents (good or bad) that arise affecting the Individual. I understand that I may not bill Medicaid if the Individual becomes ineligible for Medicaid Services, (2) the Employee performs unauthorized tasks or works more hours than are approved on the Individual Service Plan, or (3) the Employee begins work prior to receiving notice of Good-to-Go from PPL. I understand that payment will be for normal services rendered as assigned by the Employer/DR and as outlined in the Individual Service Plan at the rate(s) described in this document. I understand that must notify PPL if/when my address or personal information changes or if I wish to change my payment and tax withholding preferences. SIGNATURES By signing below, I and my Employer attest that we have read and understand all program rules and responsibilities and certify that all the answers and information given herein are true and complete to the best of my knowledge. I understand I must sign and return this form as a condition of employment in this program, and that I cannot begin working until this form is completed and returned to PPL. I further attest by signing below, that I understand what is being requested of me, and I agree to abide by these terms and conditions. I further understand and agree that violation of any of the terms and/or conditions o may result in termination of this agreement and payment for employment to any Medicaid Recipient of this program. EMPLOYER/DESIGNATED REPRESENTATIVE NAME: EMPLOYER/DESIGNATED REPRESENTATIVE SIGNATURE: DATE: EMPLOYEE NAME: EMPLOYEE SIGNATURE: DATE: DMH-DD: NEW Employee Application Page 9 of 9 Version 1.1

10 Missouri Department of Health and Senior Services FCSR USE ONLY Family Care Safety Registry Register online at OR mail this form, copy of WORKER REGISTRATION Social Security card, and payment to Missouri Dept. of Health and Senior Services, Fee Receipts, PO Box 570, Jefferson City, MO REGISTRATION TYPE (Check all that apply. Complete column on right only if Long Term Care/Personal Care selected from left.) Adoptive Parent (Agency Name: ) Long Term Care / Personal Care Child Care Subcategories (Complete if LTC/PC selected at left.) Foster Parent/Family Member of Foster Parent (County Office: ) Adult Day Care Hospital x Assisted Living Facility Long Term Care/Personal Care (Please choose subcategory at right.) Mental Health/Psychiatric Hospital Hospice Voluntary (Select voluntary if no other registration type applies.) A one-time registration fee of $12.00 applies to all categories except Foster Parents. Foster Parents must list the Children s Division county office. Register only once. If you believe you have already registered, check our website at or call, toll free, SOCIAL SECURITY NUMBER (Mail copy of card with form.) x Hospital LTAC/Swing Bed Mental Health Residential Facility/ICF Nursing Facility/Skilled Nursing Personal Care Home Health Personal Care In-Home Services Personal Care Consumer Directed Services/Center for Independent Living Personal Care HCY/PDW/DDD/Other PERSONAL INFORMATION (Provide all names you have used, starting with most recent. Include legal names and nicknames.) LAST NAME FIRST NAME MIDDLE NAME SUFFIX (Jr., Sr., II, III) MAIDEN NAME (If applicable) PRIOR NAMES USED (If applicable, list first and last names.) DATE OF BIRTH (mm-dd-yyyy) GENDER - - M F CONTACT INFORMATION MAILING ADDRESS (Enter your street address or post office box. This address must be different from Employer Address.) CITY STATE ZIP CODE COUNTY TELEPHONE (Optional) COUNTRY (Complete only if U.S. territory/outside U.S.) ( ) - EMPLOYER ASSOCIATED WITH THIS REGISTRATION (Complete either left or right column, not both.) My current/potential child care, long term care or mental health care employer is: No Employer, because I am a(n): EMPLOYER NAME Adoptive Parent QUINTIN EDIE Foster Parent/Family Member EMPLOYER ADDRESS Home Child Care Provider EMPLOYER CITY STATE ZIP Private Pay/Private Duty Student EMPLOYER TELEPHONE EMPLOYER CONTACT NAME EMPLOYER CONTACT TITLE Volunteer Other (Explain: ) REGISTRATION AGREEMENT The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to process this request. Furthermore, I authorize the DHSS to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any related background information to the requester of the FCSR for employment purposes only, as provided in , subsection 1, subdivisions (1) and (2), RSMo. For purposes of the FCSR, employment purposes includes direct employer/employee relationships, prospective employer/employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy of the transfer of information to the FCSR within thirty (30) days of receiving the results of the background screening. NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to my designated bank account. I understand that my signature below authorizes my financial institution to deduct this payment from my account. In the event that DHSS or its subcontractor is unable to secure funds from my account or I provide insufficient or inaccurate information regarding my account, my obligation to the DHSS will remain unpaid and further collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees. SIGNATURE OF APPLICANT (Must be signed in blue or black ink.) DATE OF SIGNATURE (Must be within six months of submission.) MO (FP) Rev. 01/15

11 WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provides families and employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen child care, long term care and mental health workers: State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol Child abuse/neglect records maintained by the Missouri Department of Social Services The Employee Disqualification List maintained by the Missouri Department of Health and Senior Services The Employee Disqualification Registry maintained by the Missouri Department of Mental Health Child care facility licensing records maintained by the Missouri Department of Health and Senior Services Foster parent records maintained by the Missouri Department of Social Services WHO HAS TO REGISTER? Any person hired on or after January 1, 2001, as a child care worker or elder care worker, hired on or after January 1, 2002, as a personal care worker, or hired on or after January 1, 2009, as a mental health worker, as provided in , RSMo, is required to make application for registration in the Family Care Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration form to the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and volunteers from non-state and/or federally regulated entities are NOT REQUIRED to register with the FCSR. HOW DO I COMPLETE THE REGISTRATION FORM? Registration Type Check at least one box from the left column for type of registration that best describes your worker category. If no other type applies, select Voluntary. (A "voluntary registrant" is a person who is not mandated to register with the Family Care Safety Registry pursuant to et seq., RSMo.) If you checked Long Term Care / Personal Care, please also make one or more selections from the column on the right for subcategory. Social Security Number You must provide your Social Security number pursuant to 19CSR (1). This identifying information, including Social Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above. Personal Information List your current Last Name, First Name, Middle Name, and any suffix associated with your last name. List any other names by which you may have been known, including maiden names, past married names, and nicknames (attach additional sheets if needed). For identification purposes, list your gender and date of birth. Contact Information List your address including street address or post office box, city, state, ZIP code, and county. Include your telephone number. We will use this information to notify you of registration results and any background screenings conducted. Registration Agreement Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background screening outlined in , RSMo and to provide the information to requesters for employment purposes, as provided in , RSMo. Employer Associated with this Registration - If you are currently employed by or are seeking employment with a child care or long term care provider, please list the facility name, address, telephone number, and contact person. If registration is not for employment purposes, make a selection from column on right. WHERE DO I SEND MY REGISTRATION FORM? Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior Services, ATTN: Fee Receipts, P.O. Box 570, Jefferson City, MO If you have questions, please call the Registry using the toll-free telephone number, WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND SCREENING? After the background screening has been completed, you will be notified in writing of the results that will be recorded in the Family Care Safety Registry. You will also be notified in writing each time background screening information is provided. The notification will contain the name and address of the person who made the request and the background information disclosed. The person making the request will be informed that information will be released for employment purposes only, pursuant to , RSMo. Any person using Registry information for any other purpose is guilty of a class B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and address of the requester, and determines that the request is for employment or regulatory purposes. To ensure you receive these notifications, it will be important for you to notify the Family Care Safety Registry when you have a change in your mailing address. You can send address changes to Family Care Safety Registry, P.O. Box 570, Jefferson City, MO WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND SCREENING? As provided in , RSMo, you have the right to appeal the information transferred to the Family Care Safety Registry. Your right to appeal is limited to the accuracy of the transfer of information from the state agency that maintains the background information and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal must be filed in writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O. Box 570, Jefferson City, MO, 65102, within 30 days of receiving the results of the background screening determination. An administrative appeal shall be set within 30 days of the filing of the appeal and a decision shall be made within 60 days. This right to appeal is in addition to any other appeal rights granted by state law. WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY? Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. A Registry worker will first confirm whether the person in question is registered. If the person is registered, the Registry worker will disclose whether the person's name is listed in any of the background checks pursuant to , subsection 2, RSMo, and if so, which one(s). Specific information will be disclosed by the Registry pursuant to , subsection 1, subdivision (2). MO (FP) Rev. 01/15

12 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 03/31/2016 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 I-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/dd/yyyy) U.S. Social Security Number - - 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): A citizen of the United States A noncitizen national of the United States (See instructions) A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) (See instructions). Some aliens may write "N/A" in this field. For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number: 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: 3-D Barcode Do Not Write in This Space 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) Signature of Employee: Date (mm/dd/yyyy): 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: Date (mm/dd/yyyy): Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State Zip Code Employer Completes Next Page Form I-9 03/08/13 N Page 7 of 9

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 B 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 OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title: Document Title: Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): Document Title: 3-D Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): 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 (mm/dd/yyyy): (See instructions for exemptions.) Signature of Employer or Authorized Representative Date (mm/dd/yyyy) Title of Employer or Authorized Representative Household Employer Last Name (Family Name) First Name (Given Name) Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State 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 B. Date of Rehire (if applicable) (mm/dd/yyyy): 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: Document Number: Expiration Date (if any)(mm/dd/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 (mm/dd/yyyy): Print Name of Employer or Authorized Representative: Form I-9 03/08/13 N Page 8 of 9

14 Form W-4 (2016) 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 2016 expires February 15, 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 $70,000 ($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 $70,000 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 that apply. to 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 2016, 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 (2016)

15 Form W-4 (2016) Page 2 Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details... 1 $ $12,600 if married filing jointly or qualifying widow(er) 2 Enter: { $9,300 if head of household } $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet Note: If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $0 - $6, ,001-14, ,001-25, ,001-27, ,001-35, ,001-44, ,001-55, ,001-65, ,001-75, ,001-80, , , , , , , , , , , ,001 and over 15 If wages from LOWEST paying job are Enter on line 2 above $0 - $9, ,001-17, ,001-26, ,001-34, ,001-44, ,001-75, ,001-85, , , , , , , ,001 and over 10 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If wages from HIGHEST paying job are Enter on line 7 above $0 - $75,000 $610 75, ,000 1, , ,000 1, , ,000 1, , ,000 1, ,001 and over 1,600 If wages from HIGHEST paying job are Enter on line 7 above $0 - $38,000 $610 38,001-85,000 1,010 85, ,000 1, , ,000 1, ,001 and over 1,600 You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

16 Form MO W-4 Missouri Department of Revenue Employee s Withholding Allowance Certificate This certificate is for income tax withholding and child support enforcement purposes only. Type or print. Full Name Social Security Number Filing Status Single r Married r Head of Household Home Address (Number and Street or Rural Route) City or Town State Zip Code 706 Daniel Lane r Employee Signature 1. Allowance For Yourself: Enter 1 for yourself if your filing status is single, married, or head of household Allowance For Your Spouse: Does your spouse work? r Yes r No If yes, enter 0. If no, enter 1 for your spouse Allowance For Dependents: Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or dependents that your spouse has already claimed on his or her Form MO W Additional Allowances: You may claim additional allowances if you itemize your deductions or have other state tax deductions or credits that lower your tax. Enter the number of additional allowances you would like to claim Total Number Of Allowances You Are Claiming: Add Lines 1 through 4 and enter total here Additional Withholding: If you expect to have a balance due (as a result of interest income, dividends, income from a part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each pay period. To calculate the amount needed, divide the amount of the expected balance due by the number of pay periods in a year. Enter the additional amount to be withheld each pay period here... 6 $ 7. Exempt Status: If you had a right to a refund of all of your Missouri income tax withheld last year because you had no tax liability and this year you expect a refund of all Missouri income tax withheld because you expect to have no tax liability, write Exempt on Line 7. See information below If you meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act and have no Missouri tax liability, write Exempt on line 8. See information below Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status. Employee s Signature (Form is not valid unless you sign it) Date (MM/DD/YYYY) / / Employer s Name Employer s Address Employer City State Zip Code Date Services for Pay First Performed by Employee (MM/DD/YYYY) Federal Employer I.D. Number Missouri Tax Identification Number / / Notice To Employer: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340, Jefferson City, MO or fax to (573) Visit for additional information regarding new hire reporting. Employee Information You Do Not Pay Missouri Income Tax on all of the Income You Earn! Visit to try our online withholding calculator. Form MO W-4 is completed so you can have as much take-home pay as possible without an income tax liability due to the state of Missouri when you file your return. Deductions and exemptions reduce the amount of your taxable income. If your income is less than the total of your personal exemption plus your standard deduction, you should mark Exempt on Line 7 above. The following amounts of your annual Missouri adjusted gross income will not be taxed by the state of Missouri when you file your individual income tax return. Single Married Filing Combined Head of Household $2,100 personal exemption $6,300 standard deduction $8,400 Total + $1,200 for each dependent + up to $5,000 for federal tax $ 4,200 personal exemption $12,600 standard deduction $16,800 Combined Total (For both spouses) + $1,200 for each dependent + up to $10,000 for federal tax Items to Remember: If your filing status is married filing combined and your spouse works, do not claim an exemption on Form MO W-4 for your spouse. If you and your spouse have dependents, please be sure only one of you claim the dependents on your Form MO W-4. If both spouses claim the dependents as an allowance on Form MO W-4, it may cause you to owe additional Missouri income tax when you file your return. If you have more than one employer, you should claim a smaller number or no allowances on each Form MO W-4 filed with employers other than your principal employer so the amount withheld will be closer to your amount of total tax. Mail to: Taxation Division P.O. Box 3340 Jefferson City, MO Phone: (573) Fax: (573) $ 3,500 personal exemption $ 9,250 standard deduction $12,750 Total + $1,200 for each dependent + up to $5,000 for federal tax If you itemize your deductions, instead of using the standard deduction, the amount not taxed by Missouri may be a greater or lesser amount. If you are claiming an Exempt status due to the Military Spouses Residency Relief Act you must provide one of the following to your employer: Leave and Earnings Statement of the non-resident military servicemember, Form W-2 issued to the nonresident military servicemember, a military identification card, or specific military orders received by the servicemember. You must also provide verification of residency such as a copy of your state income tax return filed in your state of residence, a property tax receipt from the state of residence, a current drivers license, vehicle registration or voter ID card. Form MO W-4 (Revised ) Visit for additional information.