0 A ttendant Services

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1 0 A ttendant Services A Din.\ ion of Alpha One Personal Support Specialist Hiring Document Checklist Complete and mail all original hiring documents within 3 days of hire date. Documents that are faxed or ed will not be accepted Cross outs or white outs on documents will not be accepted Please be sure you are using the current year hiring packet documents Please use the following check list to guide you in completing your hiring documents: [ I Personal Support Specialist Competency Certification Statement Due within 21 days of hire [ I Personal Support Specialist Application [ I Federal W-4 [I Maine W-4 [ I Federall-9 It is important this form is completed appropriately and mailed within 3 days In Section 2 under Certification, the surrogate is the employer [ 1 Photocopies of the I D's used on the 1-9 one from list A or from list 8 and C [ 1 Personal Support Specialist Policy Form [ 1 Smoking and Oxygen Policy Form [ I Direct Deposit Whether oxygen is used or not Account Number and Routing Number must be verified by your bank or credit union. [ ] Check to see that PSS's and Surrogate's signatures are on each form properly

2 ;\ A ttendant ~ S ervices A Di1 is ion of' A ltjiw 011.: Personal Support Specialist Competency Certification Statement Surrogate's name: Current Address City State Zip I certify that (PSS's name): Current Address City State Zip SSN#:, has been employed since_ I_ I_ (date of hire) Complete section A orb, not both. A separate form must be used for each PSS. A. Competency of my PSS [ 1 Is able to follow my instructions [ 1 Is able to carry out tasks as directed by me [ I Transportation for covered services only [ I Uses adaptive equipment appropriately [ 1 Assists with bathing, shampoo, hygiene [ ] Basic housework to include mopping, dusting, washing dishes, laundry [ I Assist with skin care [ 1 Bladder/bowel assistance [ 1 Health maintenance activities [ 1 Understands disability awareness [ 1 Assists with transfers, mobility/ambulation [ I Assists with dressing/undressing [ I Food prep, feeding or use of feeding aides, provision of assistance with shopping [I Other: B. Termination of PA [ I My PSS was terminated on_ I_ I_ (date of termination) Reason for Termination (please explain): [ I Incompetent []Other: Surrogate Signature PSS Signature. Date Date. (NOTE: if certification is not received within 21 days from date of hire, PSS cannot be paid.) Mail to: PO Box 2128 South Portland, ME Fax: Tel: (v/tty)

3 0 A ttendant S ervices A Di1 isicm of Alpha One Personal Support Specialist Application Form Last name First name Middle Initial Current Address City State Zip How long have you lived there? SSN# Home Phone Cell Phone Name of consumer you are applying to work for: Are you or have you been a Certified Nursing Assistant (CNA)? [ ] Y or [ I N Do you have a valid driver's license? [ ] Y or [ 1 N If yes, License# State Exp Date Do you have a car available to you? [ ] Y or [ ] N Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ 1 Y or [ ] N If yes, please explain: Would you be willing to? (Please check all that apply) [I Cook []Clean [ ] Drive [ I Shop [ ] Help with Hygiene [ ] Emergency work (if needed) Monday Friday Hours Available: from to Hours Available: from to Tuesday Saturday Hours Available: from to Hours Available: from to Wednesday Sunday Hours Available: from to Hours Available: from to Thursday Hours Available: from to If hired, on what date can you start working? _1_ 1_ Signature Date. _ Mail to: PO Box 2128 South Portland, ME Fax: Tel: (v/tty)

4 Form W-4 (2015) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3. 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, See Pub. 505, Tax Withholding and Estimated Tax. Not e. 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 1ncome (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. A B c 0 E F G H 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 worl<sheets 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 worl<sheets 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 f~guring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Alowances Worl<sheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Personal Allowances Worksheet (Keep for your records.) Enter "1" for yourself if no one else can claim you as a dependent. Enter "1" if: { You are single and have only one job; or } You are married, have only one job, and your spous e does not work; or Your wages from a second job or your spouse's wages (or the t otal of both) are $1,500 or less. 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 worl<ing 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 13g2, 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) wim be posted at Enter "1" for your spouse. B ut, 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.). Enter number of dependents (other than your spouse or yourseiq you will claim on your tax return. Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit (Note. Do not include child support payments. See Pub. 503, Child and Depend ent Care Expenses, for details.) C hild Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($1 00,000 if married), enter "2" for each eligible child; then less "1" if you have two to four eligible children or less "2" if you have five or more eligible children. If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. G 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 I If you plan to itemize or claim adjustments to income and want to reduce your w ithholding, see the Deductions Fo r accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one j ob or are married and you and your spouse both w ork and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Mult iple Jobs W orksheet on page 2 to that apply. avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below Separate here and give For m W-4 to your employer. Keep the top part for your recor ds Form W-4 Employee's Withholding Allowance Certificate OMB No Department of the Treasury.,. Whether you are entitled to claim a certain number of allowances or exemption from withholding is 1 5 Internal Revenue Service subject to review by the IRS. Your employer may be required to send a c opy of this form to the IRS. 1 Your first name and middle initial I Last name Home address (number and street or rural route) City or town, state, and ZIP code 12 A B c 0 E F Your social security number 3 0 Single 0 Married 0 Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the "Single" box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card., Total number of allowances you are claiming (from line H above o r from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck 6 $ 7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write " Exempt" here Under penalties of perjury, I declare that I have exammed thrs certrfrcate and, to the best of my knowledge and behef, rt IS true, correct, and complete. Employee's signature (This form is not valid unless you sign it.).,. 8 Employer's name and address (Employer: Complete lines 8 and 1 0 only if sending to the IRS.) 9 Office code (optionaq 10 Employer identification number (EIN) Da te.,. For Privacy Act and Pap erwork R eduction Ac t Not ice, see p age 2. Cat. No Form W-4 (2015)

5 Form W-4 (2015) 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 2015 itemized deductions. These include qualifying home mortgage interest, char~able contributions, state and local taxes, medical expenses in excess of 10% (7.5% if ehher you or your spouse was bom before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details 1 $ { $12,600 if married filing jointly or qualifying widow(er) 2 Enter: $9,250 if head of household } 2 $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter "-0-" 3 $ 4 Enter an estimate of your 2015 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 2015 Form W-4 worksheet in Pub. 505.). 5 $ 6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7 $ 8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction 8 9 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 "3" 2 3 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. 3 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 4 5 Enter the number from line 1 of this worksheet 5 6 Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $ 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 Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on paying job are- line 2 above paying job are- line 2 above paying job are- line 7 above paying job are- line 7 above $0 $6,000 0 $0 - $8,000 0 $0 - $75,000 $600 $0 - $38,000 $600 6,001-13, ,001-17, , ,000 1,000 38,001-83,000 1,000 13, , ,001-26, , ,000 1,120 83, ,000 1,120 24,001 26, ,001 34, , ,000 1, , ,000 1,320 26,001 34, ,001-44, , ,000 1, ,001 and over 1,580 34,001 44, ,001-75, ,001 and over 1,580 44,001 50, ,001-85, ,001 65, , , ,001 75, , , ,001-80, , , , , ,001 and over , , , , , , , , ,001 and over 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(1){2) and 6109 and the~ regulations require you to provide this information; your employer uses ~ to determine your federal income tax w~hhold ing. Failure to provide a properly completed form wiu resun in your being treated as a single person who claims no w~hholding 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 lit1gation; to crties, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Heanh and Human Services for use 1n the National Directory of New Hires. We may also disclose this information to other countries under a lax treaty, lo federal and state agencies to enlorce federal nontax criminal laws, or to federal law enforcement and intenigence agenc1es to combat terrorism. You are not required to provide the inlormation 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 mak1ng this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

6 FORM W-4ME MAINE Employee's Withholding Allowance Certificate 1 Type or print your first name M.l. Last name Home address (number and street or rural route) l 2. Your social sectty r umrer I I I I - 3. D Single D -I I I I Married Filing Joint Married, but withholding at higher single rate City or town State ZIP code D : (See Instructions) 4. Total number of allowances you are claiming from line C of the personal allowances worksheet below Additional amount, if any, you want withheld from your paycheck s 6. If you do not want a ny state income tax withheld, check the appropriate box that applies to you (you must qualify- see instructions below). By signing below, you certify that you qualify for the exemption that you select: a. You claimed ' Exempt" on line 7 of your federal Form W a 0 b. You completed federal Form W-4P and checked the box on line b. c. You are a resident employee with no Maine tax liability in prior or current year c. d. e. You are a recipient of periodic retirement payments with no tax liability in prior or current year d. Your spouse is a member of the military assigned to a location in Maine and you qualify for exemption under the Military Spouse's Residency Relief Act. You must attach supporting documents. See instructions e. Under penalties of perjury, I certify that I am entitled to the number of withholding allowances or the exemption claimed on this certificate. EMPLOYEE'S/PAYEE'S SIGNATURE (Form is not valid unless you sign it.) ~ Date ~ D D D D I TO BE COMPLETED BY EMPLOYER/PAYER (see Instructions) 7 Employer/Payer Name and Address (Emo/oyer!payer: Complete lines 7, 8, 9, and 10 only If sending to Maine Revenue Services) 8. Identification Number 9. Employer/Payer Contact Person: 10. Contact Person's Phone Number Cut here and give the certificate above to your employer. Keep the part below for your records Personal Allowances Worksheet - for line 4 above Note: Because the personal exemption amount for 2013 is $3,900 (an increase of $1,050 over the 2012 personal exemption amount), you should determine the number of allowances for 2013 carefully. A Number of federal allowances claimed (see instructions for line 4)....A. B. Less: Number of allowances claimed on federal Form W-4 Personal Allowances Worksheet, line G for the Child Tax Credit B. _ C. Maximum number of allowances for Maine purposes (line A minus line B). Enter here and on line 4 above. See line 4 instructions below if you want to claim fewer allowances or more allowances than claimed for federal purposes C. Employee/Payee Instructions Purp ose: Complete Form W-4ME so your employer/payer can withhold the ~ You may check this box if you claimed "Exempt" on line 7 of your correct Maine income tax from your pay. Because your tax situation may federal Form W-4. Do not check this box if you want Maine income taxes change, you may want to recalculate your withholding each year. withheld even though you are exempt from federal withholding. Line 4. If you qualify for one of the Maine exemptions from withholding, please complete lines 1, 2. 3 and 6, and sign the form. Othervvise. complete the Personal Allowances worksheet above. Enter on line A the number of allowances you claimed on federal Form W-4, line 5 or Form W-4P, line 2. If you are a spouse in a same-sex marriage, enter the number of allowances that would be allowed if you had completed federal Form W-4 or W-4P as a married person. You may claim fewer allowances than you are entitled to, but you must obtain special permission from the State Tax Assessor if you want to claim more allowances than claimed on your federal Form W-4. Box 3. Select the manta/ status that applies to you. You must select the single box if you are single. married but legally separated. or you or your spouse are a nonresident alien. Married individuals have the option of selecting either the married filing joint or married but withholding at higher single rate box. Line 6. Exemptions from w ithholding: J..i.n.lL6.Q. You may check this box if you completed federal Form W-4P and put a check in the box on line 1 Do not check this box if you want Maine income taxes withheld even though you are exempt from federal withholding. ~ You may elect this exemption if you are an employee receiving wages and you meet both of the following conditions: 1. You had no Maine income tax liability last year, a nd 2. You reasonably expect to have no Maine income tax liability this year. This exemption will expire at the end of the year and you must complete a new Form W-4ME for next year or you will be subject to Maine withholding at the maximum rate. ~ You may elect this exemption if you receive periodic retirement payments pursuant to IRC 3405, you had no Maine income tax liability in the prior year and you reasonably expect you will have no Maine income tax liability this year. instructions continued on next page

7 This election will remain in effect until you complete a new Form W-4ME. ~ If you are the spouse of a member of the military, you may claim exemption from Maine withholding if you meet the following requirements: 1. Your spouse is a member of the military located in Maine in compliance with military orders. 2. You are in Maine solely to be with your spouse. 3. You and your spouse have the same domicile in a state other than Maine. 4. You attach a copy of your spouse's latest Leave and Earning Statement reflecting an assignment location in Maine. 5. You present your military ID to your employer. The ID must identify you as a military spouse. Your exemption will expire at the end of the calendar year during which you submit Form W-4ME claiming the exemption, at which time you must complete and submit a new Maine Form W-4ME for the new year. ~ You may be subject to penalty if you do not have sufficient withholding to meet your Maine income tax liability. General Instructions for Employers and Other Payers Maine law requires employers and other persons to withhold money from certain payments. most commonly wages, retirement payments and gambling winnings. and remit to Maine Revenue Services for application against the Maine income tax liability of employees and other payees. The amount of withholding must be calculated according to the provisions of Rule No. 803 (See and must constitute a reasonable estimate of Maine income tax due on the receipt of the payment. Amounts withheld must be paid over to Maine Revenue Services on a periodic basis as provided by Title 36 M.R.S.A. Chapter 827 ( B) and Rule No. 803 ( CMR 803). Maine withholding for an employee who is a spouse in a same-sex marriage is computed in the same manner as for an employee in an opposite-sex marriage. The Maine taxable wages may differ from the federal wages because of the treatment of fringe benefits affecting the employee's spouse. For the purpose of treating a cafeteria plan payment as pre-tax or imputing income from an employer-paid benefit, the federal rules for the payment are applied for Maine withholding purposes in the same manner to all married employees. Employer/Payer Information for Completing Form W-4ME Missing or invalid Forms W-4, W-4P orw-4me. lfanyofthe circumstances below occur, the employer or payer must withhold as if the employee or payee were single and claiming no allowances. Maine income tax must be withheld at this rate until such time that the employee or payee provides a valid Form W4-ME. (1) The employee/payee has not provided a valid, signed Form W-4ME; (2) The employee's/payee's Form W-4 or W-4P is determined to be invalid for purposes of federal withholding; (3) The Assessor notifies the employer/payer that the employee's/payee's Form W-4ME is invalid; or (4) The employee's/payee's Personal Withholding Allowance Variance Certificate has expired, a new variance certificate has not been approved and submitted to the employer/payer and lhe payee has not provided the payer with a valid Form W-4ME. Exemptions from withholding Form W-4ME, line 6. Generally, employers/payers must withhold from payments subject to Maine income tax unless an exemption is claimed on line 6. Federal exemption from withholding (see lines 6a and 6b). An employee/payee who is exempt from federal income tax withholding is also exempt from Maine income tax withholding. This includes recipients of periodic retirement payments who are exempt from federal income tax withholding. The employee/payee must check the applicable box on line 6 An employee/payee exempt from federal withholding that wants Maine withholding must leave line 6 blank. Resident employee exemption from Maine withholding (see line 6c). A resident employee who is subject to federal income tax withholding is exempt from Maine income tax withholding if the employee had no Maine tax liability for the prior year and expects to have no Maine tax liability for the current year. The exemption on line 6c expires at the end of each year. If the employee fails to submit a new Form W-4ME for the next calendar year, the employer must begin withholding at the single rate with no allowances. Withholding from payments to nonresident employees. An employee who is exempt from Maine income tax because of the nontaxable thresholds applicable to nonresidents is not required to complete and submit Form W-4ME; however. an employee becomes subject to Maine income tax withholding immediately upon exceeding a threshold at any time during the year. Because all income earned in Maine is taxable by Maine once a threshold is exceeded, employers should work with affected employees to ensure that Maine withholding is adequate to cover Maine income tax liability for the year. This may require the employee submitting a new Form W-4ME with the employer. Withholding exemption for periodic retirement payments (see line 6d). Recipients of periodic retirement payments as defined by IRC 3405 that are subject to federal income tax withholding are exempt from Maine income tax withholding if the recipient certifies (by checking the box on line 6c) that he or she had no Maine income tax liability for the prior year and expects to have no Maine income tax liability for the current year. The exemption remains in effect until the recipient submits an updated Form W-4ME. Exemptions under the Military Spouse's Residency Relief Act (MSRRA). If the box on line 6e is checked, the employer must: (1) Ensure that a copy of the military member's Leave and Earnings Statement (LES) is attached, and verify that the assignment location entered on the LES is a location in Maine; and (2) Review the employee's military ID to ensure that the date on the ID is not more than four years prior to the date on the employee's Form W-4ME, and that the ID denotes the employee as a current military spouse. An exemption claimed on line 6e expires at the end of the calendar year. If the employee does not submit a new Maine Form W-4ME, the employer must begin withholding for the first pay period in the following year at the maximum rate (single with one allowance). See the employee instructions for line 6e above for more information about this exemption. An employer/payer is required to submit a copy of Form W-4ME, along with a copy of any supporting information provided by the employee/payee, to Maine Revenue Services if A. The employer/payer is required to submit a copy of federal Form W-4 to the Internal Revenue Service either by written notice or by published guidance as required by federal regulation 26 CFR (f)(2)-1(g); or B. An employee performing personal services in Maine furnishes a Form W-4ME to the employer containing a non-maine address and, for any reason, claims no Maine income tax is to be withheld. This submission is not required if the employer reasonably expects that the employee will earn annual Maine-source income of less than 53,000 or if the employee is a nonresident working in Maine for no more than 12 days for the calendar year and is, therefore. exempt from Maine income tax withholding pursuant to MRS Rule 803 Section 04.C 1 Submit copies of Form W-4ME directly to the MRS Withholding Unit separately from any other tax filing. Employers/Payers must complete lines 7 through 10 only if required to submit a copy of Form W-4ME to Maine Revenue Services "' Line 7 Enter employer/payer name and business address. "' Line 8 Enter employer/payer federal identification number (EIN and/or SSN). "' Line 9 Enter employer/payer contact person who can answer questions about withholding (i.e. human resources person, company officer, accountant, etc ) "' Line 10 Enter employer/payer contact person's phone number. Rev. 01 / 13

8 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USC IS Form 1-9 OMB No Expires 03/31 / START HERE. Read instructions carefully before completing this form. The instructions must be available during completion ofthis form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State Zip Code Date of Birth (mmldd/yyyy) I U.S. Social Security Number Address Telephone Number DD-1 I 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): 0 A citizen of the United States 0 A noncitizen national of the United States (See instructions) 0 A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USC/S Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS Number: OR 2. Form 1-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) 3-D Barcode Do Not Write in This Space Signature of Employee: Date (mmlddlyyyy): Pre parer 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: l Date (mmlddlyyyy): Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town I State I Zip Code Employer Completes Next Page Form /08/ 13 N Page 7 of9

9 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 employees first day of employment. You must physically examine one document from List A OR examine a combination of one document from Ust B and one document from Ust Cas listed on the "Lists of Acceptable Documents on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: List A Identity and Employment Authorization Document Title: OR Document Title: List B Identity AND Document Title: List C Employment Authorization I Issuing Authority: Document Number: Issuing Authority: Document Number: Issuing Authority: Document Number: Expiration Date (if any)(mm/ddlyyyy): Expiration Date (if any)(mmldd/yyyy): Expiration Date (if any)(mmldd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy): Document Title: 3-D Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any)(mm/ddlyyyy): 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 (mmldd/yyyy)" (See instructions for exemptions) Signature of Employer or Authorized Representative I Date (mmlddlyyyy) I Last Name (Family Name) First Name (Given Name) I Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) I City or Town I State 'Zip Code Title of Employer or Authorized Representative 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 t Date of Rehire (if applicable) (mmlddlyyyy): C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title: I Document Number: 'Expiration Date (if any)(mmlddlyyyy): 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 (mmldd/yyyy): Print Name of Employer or Authorized Representative: Form /08/ J 3 N Page 8 of9

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

11 0 A ttendant S ervices A Di1 isi011 o(a /JJ/w One Policies for Personal Support Specialists The PSS is hired and supervised directly by the surrogate. The PSS must comply with the following policies: 1. There is a probation period of 21 days from the date of hire. A Competency Certification Form must be submitted within the first 21 days of hire. 2. The relationship between the PSS and the surrogate is considered professional -- confidentiality is required. 3. W-4 Forms, W-4ME, Policies Form and 1-9 Form must be completed and sent to Attendant Services within three (3) days of hire. 4. Any change of address or marital status must be reported immediately, and new W-4's, W4-ME forms sent to Attendant Services. 5. Time sheets must be completed and signed by both the surrogate and the PSS(s). These timesheets can not exceed the authorized number of hours per week. It is the responsibility of the surrogate to submit timesheets. 6. Time sheets must be received by Attendant Services on or before 11 :00 AM on Thursday following the payroll period for any checks/direct deposits to be sent out on Friday. Timesheets that are not submitted by cutoff will be processed and paid the following week. 7. All direct deposits and checks will be mailed directly to the PSS's home. 8. Any PSS who has not submitted a valid timesheet for twelve (12) consecutive months will be considered inactive and will be terminated in our payroll system. Upon rehire, a new hiring packet will be required as well as proper identification. 9. PSS will not be paid if services are not required during any given week. For example, if the consumer is hospitalized the PSS can not bill for services. However, any PSS may apply to receive unemployment. 10. I am physically able to complete all tasks on my job description. For your protection all PSS's are covered by Worke~s Compensation. If an accident occurs that involves any PSS, your local Alpha One office must be notified immediately. 11. It is recommended that PSS's obtain Personal Liability Insurance. I understand that payment of PSS wages is from Government funds. Any false statements or concealment will be prosecuted under applicable Federal and! or State laws. I have read and understand the above policies: PSS's Signature Surrogater's Signature Date Mail to: PO Box 2128 South Portland ME Fax: Tel: 207 -() (v/tty)

12 ;\ A ttendant ~ S ervices I Di1 is ion ofa /p/111 On.: Smoking and Oxygen Use Policy Who: This form needs to be signed by both Personal Support Specialist (PSS) and surrogate whether or not bottle oxygen or oxygen units are used. Purpose: To create the safest possible working environment for all Personal Support Specialists (PSS) while in the workplace. Policy: Alpha One (Attendant Services) prohibits smoking and/or use of friendly fires (candles or other flames and sparks) in any location where bottled oxygen and/or oxygen units are stored or used. Procedure: The surrogate will manage their home environment to make sure policy is adhered to by everyone who may be present while bottled oxygen and/or oxygen units are being used on the premises. Personal Support Specialists (PSS) are not to occupy/work within a residence where the surrogate does not provide a safe work environment, especially when it comes to smoking and/or friendly fires (candles or other flames and sparks) while oxygen is being used. If Alpha One becomes aware that this safety policy is not being followed in a safe manner, Alpha one reserves the right to terminate the surrogate from this program immediately. I have read and understand the above policy and agree to adhere to the policy. Surrogate Signature. Date PSS Signature Date Mail to: PO Box 2128 South Portland, ME Fax: Tel: (v/tty)

13 i\ A ttendant ~ S ervices A Di1 ision of A {p/w One Direct Deposit Authorization Employees must attach a voided check or written notification from bank and signed by a banking representative to help verify their account numbers and bank routing numbers. Account type: [ ] Checking [ ] Savings Bank routing number (ABA number): Account number: Percentage or dollar amount to be deposited to this account: Please select one of the following: [ ] New Direct Deposit [ ] Replace an existing direct deposit (Original Account number being replaced) [ ] Cancel my direct deposit This authorizes Attendant Services to initiate electronic credit entries each pay period, and if necessary, debit entries and adjustments for any credit entries in error to my account(s) indicated above. This authorizes the financial institution holding the Account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable U.S. Law. This authorization will be in effect until Attendant Services receives a written termination notice from myself and has reasonable opportunity to act on it ACH Transfers require at least 48 hours from the time the transfer is initiated until the funds are deposited into your account PA Signature Date Print Name Consumer Signature. Date Print Name. Mail to: PO Box 2128 South Portland. ME Fax: Tel: (v/tty)