CDS Participant's New Attendant Check List

Transcription

1 CDS Participant's New Attendant Check List Participant : The person receiving care through the Medicaid-funded program Consumer Directed Services (CDS). This person is the employer of the attendant. May also be referred to as consumer, client or employer. Attendant : The person providing care to a Participant. This person is the employee of the Participant. May also be referred to as aide or employee. Prospective Attendant : A person who has completed all necessary paperwork to be hired as an attendant, but SCIL has not yet received a clean background check from the Family Care Safety Registry. Participant's Name: (please print clearly) Prospective Attendant's Name: (please print clearly) Your answer to the first 6 questions should be YES before you request the enclosed documents be processed for you by SCIL's CDS Payroll Department - Incomplete applications cannot be processed. Have you requested SCIL CDS Payroll staff complete an EDL Check prior to letting your Prospective Attendant perform CDS program work? Have you included a copy of your Prospective Attendant's Driver's License and Social Security Card with this packet? Have you verified with your Prospective Attendant that they do not have a criminal history, abuse/neglect investigations, etc? Have you filled out all shaded lines marked with a and has your Prospective Attendant filled out all shaded lines marked with a on this paperwork? Pay special attention to all shaded areas. Has your Prospective Attendant completed the entire Employment Application? Has your Prospective Attendant filled out ONLY Line 7 on their Missouri and Federal W-4 tax forms, OR ONLY Line 5 (& optionally Line 6)? They cannot complete both 5 & 7. YES NO YES NO YES NO YES NO YES NO YES NO Please circle either YES or NO as your answer to the following questions. If your answer is YES, then please include the answer with each question prior to sending these documents to SCIL. Is your Prospective Attendant related to you? YES NO If your answer is yes, how are you related? Does your Prospective Attendant live with you? YES NO If your answer is yes, is this permanent or temporary? Permanent Temporary Have you, the Participant, filled out the I-9 employment verification form like the example below? YES NO List A Document title: Issuing authority: Document #: Expiration Date (if any): Document #: Expiration Date (if any): OR List B and List C MO Drivers Lic. State of MO A /1/2010 Social Sec. Card Fed. Govt N/A

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3 Attendant must complete all shaded areas. Complete either line 5 or line 7, not both.

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5 Attendant must complete all shaded areas. Complete either line 5 or line 7, not both. 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)

6 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.

7 Medicaid Non-Public Entity OHCDS Organized Health Care Delivery System Home and Community Based Services Request for Proposal Attendant Care Contract [Services to be Subcontracted by Center for Independent Living] A. Participant s Name: B. Attendant s Name: C. Date of Contract: ATTENDANT CARE CONTRACT This Attendant Care Contract ( Contract ) is made by the Center for Independent Living (CIL) and the Attendant identified in line B above [who will be employed by the Participant identified in line A above] and the Participant identified in line A above as of the Date of Contract specified in line C above. 1. Definitions and responsibilities. In order to make this Contract more easily understood, certain terms are defined and various responsibilities are described as follows: a. The term Participant means the individual identified in line A above who requires attendant care services in his/her home. Hereafter, the Participant will be referred to as Participant. Participant is the employer of the Attendant and as such is responsible for directing, managing, scheduling, and supervising the Attendant. Participant is responsible for reviewing all timesheets connected with Attendant s hours of service for accuracy, and Participant is responsible for promptly forwarding the same to CIL. Participant, through the fiscal intermediary, will pay the Attendant for services authorized in Participant s Department of Health and Senior Services (DHSS) Plan of Care and by this Contract. b. The term Attendant means the individual identified in line B above who, as a party to this Contract, agrees to provide attendant care services to Participant in Participant s home. Hereafter, the Attendant will be referred to as Attendant. Attendant shall have and maintain the minimum qualifications necessary per Missouri statutes and regulations to perform the attendant care services described and authorized in Participant s Plan of Care before rendering any attendant care services to Participant. Attendant is not entitled to be paid through the CDS program until and unless he/she has met/maintained all qualifications for rendering attendant care services. Attendant agrees that he/she will accept as payment in full for the services described and authorized in Participant s Plan of Care the payments he/she receives pursuant to this Contract. c. The term attendant care services or attendant care means those services that Participant needs to have provided to him/her within his/her home in order to achieve independent living within the community. Attendant care services may include but are not limited to helping Participant with eating, dressing, meal preparation, toileting, bathing, grooming, transferring, and specific health maintenance tasks, as well as some incidental housekeeping tasks that ensure Participant s health and safety, like grocery shopping and laundry. The attendant care services that Attendant will perform within the CDS program will be described and authorized in the Participant s Plan of Care. A copy of the pertinent parts of the Plan of Care will be provided to Attendant. Page 1 of 4

8 d. The term Center for Independent Living means the agency signing this Contract. Hereafter, the Center for Independent Living will be referred to as CIL. It is recognized as a vendor of Consumer- Directed Services and enrolled as an Organized Health Care Delivery System with the Department of Social Services, MO HealthNet Division. CIL is authorized to provide administrative support to Participant. CIL is authorized to enter into payroll service contracts with payroll service companies to provide fiscal intermediary services as set forth below. e. The term fiscal intermediary means a payroll service company, under contract with CIL, retained to perform fiscal intermediary services. These include calculating the amount that an Attendant is to be paid, writing payroll checks (or making direct deposits), withholding and paying state and federal income taxes to the appropriate authorities, and withholding and paying Social Security (FICA) and Medicare payments and/or Participant s portions as is required by law or regulation and paying them to the appropriate authorities. The fiscal intermediary will provide Attendant with a written summary of all deductions and payments made. The fiscal intermediary will prepare and provide Participant and Attendant with end-of-year tax information and forms within the time prescribed by law, such as W-2 s, so that Participant and Attendant may comply with all tax filing requirements. The fiscal intermediary will maintain copies of all records required by law or regulation for tax and other purposes, and these shall be the official records documenting the employer/employee (Participant/Attendant) relationship. f. The term CDS program means the consumer-directed services (CDS) program offered in the State of Missouri for participant controlled attendant services. Participant control means that the Participant with a disability who receives services is the actual employer of the Attendant and is responsible to, among other things, hire and direct his/her Attendants. The CDS program is a Missouri Medicaid funded program administered by the Department of Health and Senior Services (DHSS). 2. Purpose and background information. The purpose of this Contract is to allow Participant to interview, hire, direct, manage, schedule, supervise, and discharge his/her Attendant. CIL is a vendor of Consumer-Directed Services and as such it is authorized by the Missouri Department of Health and Senior Services to provide administrative support for Consumer-Directed Services. CIL may contract with payroll service companies to act as fiscal intermediary. The fiscal intermediary will act as an agent for and provide payroll services for Participant, as explained herein. Participant will employ Attendant to work in Participant s home, at the direction and under the supervision of Participant, to provide the attendant care services described and authorized in Participant s Plan of Care. The fiscal intermediary will perform fiscal intermediary services as described above and prepare and write payroll checks to Attendant on behalf of Participant. 3. Basis for payment. Attendant agrees to perform the attendant care services described and authorized in Participant s Plan of Care at an initial rate to be set by the Participant, which rate may be increased from time-totime with or without notice to Attendant. Attendant will be paid through the CDS program only for those services described and authorized in Participant s Plan of Care, and no others. Medicaid will provide funds to the fiscal intermediary to pay Attendant for authorized attendant care services actually performed for Participant. For purposes of the CDS program, Attendant is not permitted to work in excess of the number of hours authorized during a given month. If he/she does so, he/she will not be paid through the CDS program for those hours through this Contract. For purposes of the CDS program, Attendant is not permitted to off-set excess hours in one month against scheduled hours in another month, even if this is agreeable to Participant. 4. Method of payment. CIL will provide Participant with documents authorizing payment for the services described and authorized in Participant s Plan of Care. With respect to the CDS program, the documents will set forth: a) the maximum number of hours to be worked during a specific time period; b) the rate of compensation Page 2 of 4

9 in effect for the services; and, c) the applicable time period for performance of the attendant care services. CIL will also provide Participant with timesheets to record the services performed by Attendant and the time spent in service. The completed timesheets are the basis for payment to Attendant. Payroll will be processed bi-weekly. At the end of each payroll period, Participant will review and approve the completed timesheet and forward the same to CIL. Timesheets must be received by CIL within three (3) calendar days of the end of a payroll period in order to be included in the next payroll. If CIL does not receive the timesheets within the prescribed time, then payment will not be processed until the next payroll, and Attendant s payment may be delayed. It is imperative that Participant and Attendant accurately record and report services and hours. Falsification or misrepresentation on any timesheet constitutes fraud. Payments made on behalf of Participant as a result of inaccurate timesheets will be recouped from Attendant and/or Participant to the full extent permitted under the law. Any incidents of apparent fraud may be reported to Medicaid and/or other appropriate authorities. 5. Conditions and understandings of Contract. For so long as Medicaid funds are used, in whole or in part, to pay Attendant, the Missouri Department of Social Services and the U.S. Department of Health and Human Services, and/or its/their designee(s), have the right to evaluate, through inspection or other means, the attendant care services rendered and reimbursed hereunder. Attendant understands and agrees that he/she is not an employee of CIL. Attendant will not represent to anyone that he/she is an employee of CIL. Attendant understands and agrees that pursuant to this Contract, he/she is employed solely by Participant. Attendant understands and agrees that this Contract does not guarantee him/her any specific number of hours of work or any hours at all. 6. Liability for work related injury/illness. Attendant understands and agrees that Attendant and/or Participant is/are solely responsible for any injuries or illness Attendant sustains while providing attendant care services and/or acting within the scope of his/her employment, and that neither CIL nor the State of Missouri has any liability for such injuries or illness. 7. Direction and supervision of participant. Attendant understands and agrees that he/she will perform the attendant care services specified in Participant s Plan of Care in Participant s home under the direction and supervision of Participant, on such dates and at such times as agreed upon by Attendant and Participant; however, for purposes of the CDS program, the service time shall not exceed the number of hours authorized for service. 8. Termination. Attendant understands and agrees that he/she is an at-will employee of the Participant and that he/she can resign at any time and Participant may discharge Attendant at any time. Attendant understands that Participant may discharge him/her at any time for no reason or any lawful reason unless Participant and Attendant separately agree to more limited circumstances and notice requirements under which the employment relationship can be terminated. This Contract shall terminate upon the ending of the employment relationship between Participant and Attendant. Participant or Attendant shall inform CIL when Participant s employment relationship with Attendant has ended. This Contract shall also terminate if and when Participant and/or Attendant becomes ineligible to participate in the CDS program for any reason, or is disqualified from participation in the CDS program, or if DHSS otherwise determines that CDS for the Participant is to be discontinued. This Contract shall further terminate if CIL provides Participant with written notice indicating that CIL will no longer provide vendor services to Participant. 9. Confidentiality. Attendant understands that Participant is entitled to have his/her personal health information treated with confidentiality. Attendant agrees to protect and maintain Participant s confidentiality in compliance with HIPAA and any other applicable law. Under no circumstances will Attendant discuss or disclose Page 3 of 4

10 Participant s personal health information without legal authorization to do so. Participant s right to confidential treatment of personal health information survives the termination of this Contract. 10. Miscellaneous provisions. This Contract shall be interpreted in accordance with and governed by the laws of the State of Missouri. The place of contract is the county where CIL has its principal offices. The invalidity or unenforceability of any portion or provision of this Contract shall not effect, impair, or render unenforceable any other portion or provision. It is intended that each provision herein that is invalid or unenforceable as written be valid and enforceable to the fullest extent possible. Under no circumstances may Attendant or Participant assign their obligations, duties, or rights pursuant to or connected with this Contract to any other person or entity. The captions in this Contract are for convenience only and are not to be construed as substantive parts of this Contract. This Contract may not be modified except by a writing signed and dated by all parties. At the time of termination of this Contract, Attendant agrees to promptly provide Participant with current timesheet information so that the last payroll for Attendant may be completed. BY SIGNING BELOW YOU ACKNOWLEDGE YOU HAVE READ THIS CONTRACT, YOU ACCEPT IT, AND AGREE TO ITS TERMS. Center for Independent Living: By: (sign) (Print name) CDS Payroll Data Entry Specialist Attendant: (sign) (Print name and title) Participant: (sign) (Print name and title) END OF DOCUMENT Page 4 of 4

11 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-9 0MB 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-OISCRIMINA TION 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 tater 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 (mmlddlyyyy) U.S. Social Security Number Address I D-D-L I 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/USC IS Number): D An alien authorized to work until (expiration date, if applicable, mm/ddlyyyy). Some aliens may write "NIA" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form l-94 Admission Number: 1. Alien Registration NumberlUSCIS Number: OR 2. Form 1-94 Admission Number: 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 "NIA" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee: Date (mmlddlyyyy): 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: Last Name (Family Name) First Name (Given Name) I Date (mm/ddlyyyy: Address (Street Number and Name) City or Town State Zip Code I Employer Completes Next Page Form /08/13 N Page 7 of9

12 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 fonn. For each document you review, record the following infonnation: 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 List C Employment Authorization Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmldd/yyyy): Document Title: 3-D Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyy: 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): Signature of Employer or Authorized Representative I I Date (mmldd/yyyy) (See instructions for exemptions.) Title of Employer or Authorized Representative Last Name (Family Name) First Name (Given Name) I IEmployer's Business or Organization I Name Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code MO 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): I 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: IExpiration 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/t 3 N Page 8 of9

13 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 Band 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 0 AND U S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 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, OHS 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. School ID card with a photograph 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) U.S. Military card or draft record a. Foreign passport; and 4. Original or certified copy of birth 6. b. Form 1-94 or Form l-94a that has Military dependent's ID card certificate issued by a State, 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 (2) An endorsement of the alien's 5. Native American tribal document non immigrant 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) limitations identified on the form. listed above: 8. Employment authorization Passport from the Federated States of 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 l-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 5. 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. Forml-9 03/08/13 N Page 9 of9

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15 Family Care Safety Registry Pre-Employment Background Check Waiver I, understand that my Prospective Attendant has applied for a background check through the Family Care Safety Registry as described in Missouri Statute RSMo. It is required that they register within fifteen (15) days of beginning employment. I further understand that under Missouri State Law, Section , RSMo Supp states: No state or federal financial assistance shall be authorized or expended to pay for personal care assistance services provided by a personal care attendant who is listed on any of the background check lists in the family care safety registry under sections to , RSMo, unless a good cause waiver is first obtained from the department in accordance with section , RSMo. I understand that my CDS Attendant s wages may have to be returned to Missouri Medicaid through my DHSS Provider, Southwest Center for Independent Living, by either myself or my Attendant if his/her background screening identifies past and/or present criminal history. I agree to the aforementioned terms, and I wish to hire this Attendant before receiving their background information from the Family Care Safety Registry. I understand that information from their background check will be forwarded to me, and at any time I can terminate the employment of this Attendant. I understand that if there are background check findings, then my Attendant must apply for and receive approval for a Good Cause Waiver with the Family Care Safety Registry before he/she will be allowed to continue to work for me. CDS Attendant Name CDS Participant s Signature / / Date

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17 Authorization to Register On-line with the Department of Health and Senior Services I give permission to Southwest Center for Independent Living to register me on-line with the Family Care Safety Registry for purposes of attaining employment with. Further, I agree to waive any and all claims, demands and causes of action against Southwest Center for Independent Living and its officers, directors, employees and agents (referred to collectively as the Company) for information which arises in any way from the information furnished to the Company. I also agree to indemnify and hold Company harmless from any and all loss, cost or expense, including attorney s fees and costs of defense, in any suit brought against the Company as a result of any information or denial of employment as a result of the information furnished to the Company. Attendant Signature: Date:

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21 Missouri Department of Health and Senior Services PO Box 570 Family Care Safety Registry Jefferson City, MO RESET TOLL FREE: EMPLOYER BACKGROUND SCREENING REQUEST FAX: EMPLOYER INFORMATION The direct employer must be listed below. This form may be submitted for an employer by an approved third party if a signed delegation agreement is on file with the Family Care Safety Registry. Please type or print clearly. EMPLOYER/BUSINESS NAME (Includes DBA Name) PARENT COMPANY NAME (If different from Employer/Business Name) OWNER NAME CONTACT PERSON (If not the Owner) (Optional) Patricia Hayne, Lorie Henry, Kristi Dieleman MAILING ADDRESS CITY STATE ZIP COUNTY c/o SCIL, 2864 S Nettleton Ave Springfield MO Greene ARE YOU STATE LICENSED OR CONTRACTED? (If so, enter number here.) FAX NUMBER PHONE NUMBER State Agency: Lic./Contract No.: ( ) - ( 417 ) ext. PROVIDER TYPE (CHECK ALL THAT APPLY) Child Care Center Adult Day Care Home Health Agency Family Child Care Home/Group Home Assisted Living Facility Hospice Child Placement Service (Adoptive/ Skilled Nursing Facility Hospital: LTAC or Swing Bed Foster Care) Nursing Facility Other Long Term Care Provider Children s Home/Residential Facility Residential Care Facility General Hospital State or Local Government Agency Intermediate Care Facility Mental Health/Psychiatric School: K 12 Intermediate Care Facility/MR School: College/Technical/University Personal Care: CDS/CIL Other Health Care Provider Non-Emergency Medical Transport Personal Care: In-Home Svcs. Other (Please list): Personal Care: HCY/PDW/DDD/Oth. IF MORE THAN ONE PROVIDER TYPE CHECKED, WHICH ONE IS PRIMARY? Please list: EMPLOYEE/APPLICANT TO BE SCREENED LAST NAME (Current/Legal) FIRST NAME (Current/Legal) MI SOCIAL SECURITY NO. DATE OF BIRTH 1 / / 2 / / 3 / / 4 / / 5 / / CERTIFICATION FOR EMPLOYEE BACKGROUND SCREENING AND REQUEST FOR SPECIFIC INFORMATION 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 certify that my request for background information on the individual(s) listed above is for employment purposes only. For purposes of the Family Care Safety Registry, 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 I cannot request background information on former employees. I have read and understand the following: 1) Registry information provided consists only of information relative to the state of Missouri and does not include information from other states or information that may be available from other states; 2) any person who uses the information obtained from the Family Care Safety Registry for any purpose other than that specifically provided for in sections et seq., RSMo, is guilty of a class B misdemeanor; and 3) when any Registry information is disclosed pursuant to section (2), RSMo, the Department of Health and Senior Services will notify the registrant of the name and address of the person making the request. I request that specific information be provided to me in the event that the background screening performed upon the individual(s) identified above indicates that there is information identified in any of the sources checked by the Family Care Safety Registry. I understand that this information is to be used for employment purposes only and anyone using the information for any purpose other than that specifically provided in sections et seq., RSMo., is guilty of a class B misdemeanor. SIGNATURE OF EMPLOYER S AUTHORIZED STAFF MEMBER (Must be signed in blue or black ink.) DATE SIGNED TYPE OR PRINT AUTHORIZED STAFF MEMBER NAME IMPORTANT: Background screening information is provided at no cost to eligible employers through the Family Care Safety Registry (FCSR). Individuals must be registered with the FCSR and their information must be current before a background screening can be conducted. Send this completed form to the Missouri Dept. of Health and Senior Services, FCSR using the address listed at the upper right. Organizations licensed or contracted with the Missouri Dept. of Health and Senior Services can request online access for staff to conduct screenings at any time. Call our toll-free number to ask how, or visit our website at MO Rev. 4/14

22 WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry, administered by the Missouri Department of Health and Senior Services, provides families and other employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen childcare, 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 Department of Health and Senior Services without good cause, as determined by the department, is guilty of a class B misdemeanor. WHAT IS THE PURPOSE OF THE EMPLOYER BACKGROUND SCREENING REQUEST FORM? Eligible employers may use the Employer Background Screening Request form to obtain background screening information on employees who have completed registration for to the Family Care Safety Registry. The form may take the place of calling the Registry's toll-free telephone line as outlined in section , RSMo. The background screening information is provided at no cost. The registrant will be notified in writing each time a background screening request is made. The written notification will include the name and address of the requesting employer as well as the information provided to the requester. HOW DO I COMPLETE THE EMPLOYER BACKGROUND SCREENING REQUEST? Employer Information List employer's identifying information. If you are not sure if your organization is licensed or contracted with the state of Missouri, do not complete the associated field. Employee/Applicant to be Screened List the full name, social security number, and date of birth of employees or job applicants whose applications for registration have been or are being submitted to the Family Care Safety Registry for processing. All three fields must be complete for each individual and must match what is currently on file with the FCSR in order to conduct a screening. Certification for Employee Background Screening and Request for Specific Information Employer must sign and date the Employer Background Screening Request in ink after reading the certification and request for specific information statement. The employer s signature certifies that the request for background information for employees listed is for employment purposes. The employer s signature also certifies the employer understands Registry information provided consists only of information relative to the state of Missouri and does not include information from other states; any person who uses the information obtained from the Registry for any purpose other than employment purposes is guilty of a class B misdemeanor; and when Registry information is disclosed, the Department of Health and Senior Services will notify the registrant of the name and address of the person making the request. Employers have the right to request specific information regarding the finding(s) identified in any of the sources checked by the Registry. The request must be submitted in writing, and by signing the form, the employer is deemed to have met this requirement. HOW DO I SUBMIT THE EMPLOYER BACKGROUND SCREENING REQUEST? The Employer Background Screening Request may be submitted by mail or FAX. If the employee/applicant is not yet registered, the employer may choose to submit the Employer Background Screening Request along with Worker Registration form, photocopy of social security card and required registration fee, by mail to the Missouri Department of Health and Senior Services, Fee Receipts Unit, P.O. Box 570, Jefferson City, MO, WHEN WILL BACKGROUND SCREENING RESULTS BE KNOWN? The requester will be notified, in writing, of the results of the background screening performed by the Family Care Safety Registry. If the requester contacts the Registry using the toll-free access line, , the employer will be provided the results while on the phone as well as in writing. The registrant will also be notified in writing each time a background screening request is made. The written notification will include the name and address of the individual making the request as well as the information provided to the requester. WHAT IS THE PENALTY FOR MISUSING REGISTRY INFORMATION? Information maintained by the Family Care Safety Registry can be disclosed for employment purposes only. Employment purposes include 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- or elder-care setting. Any person who uses the information obtained from the Registry for any purpose other than employment purposes is guilty of a class B misdemeanor. MO Rev. /1