Participant Hired Worker Packet · 2020-02-04 · enroll with Outreach, The checklist can be used as a guide to make sure no forms are forgotten. IRIS Participant Hired Worker Set-Up

Participant Hired Worker

Packet

Date of Completion: ______________(Filling in this date will populate in the packet)

Estimated Start Date: ______________

(xx/xx/xxxx)

Participant Hired Worker Packet Forms and Form Explanations

This packet is automated. If completing the packet on a computer,simply fill out ALL Sections on the Information Form.

The information is used to populate the rest of the packet.Signatures will still be needed.

FORM PURPOSE

Start Up Checklist This form lists all of the forms that must be completed to enroll with Outreach, The checklist can be used as a guide to make sure no forms are forgotten.

IRIS Participant Hired Worker Set-Up

This form is to be filled out by employee and participant it is required under the IRIS program.

I-9 Form This form documents that you are eligible to work in the United States. You must complete section 1 of this form. The participant completes section 2 by examining your supporting documents from either list A or lists B and C. Please attach the supporting documents

W4 Form This form is for tax purposes and taxes are taken out based on claim. If claiming any exemptions from W4 please fill out the WT-4 form available on Outreach website.

IRIS Participant Hired Worker Relationship Disclosure Identification

Please fill this form out based on your relationship with participant. This is used for exemptions in payroll taxes if related to participant.

Direct Deposit Authorization This form is intended to be used on how the PHW would like be paid

Money Network Application/Deposit Agreement

Fill out this form only for if they are applying for the pay card.

IRIS Supportive Home Care/Self Directed Personal Care/Respite Care Training Verification

This form is to be completed by employee and participant. Training materials available at Outreach website and in this packet.

Background Information Disclosure Addendum – IRIS

This is required by IRIS program to be filled out. It is for completion of the background check.

Background Information Disclosure (BID)

This form will need to be filled out using employee information and will be used to complete background check on each employee. All employees will need to be cleared in order to start work.

WI Medicaid Program Provider Agreement

This form is used to acknowledge the terms under IRIS for working with the participant

Participant Hired Worker Agreement

By Signing this form, you understand that the participant is the employer and you will provide care based on IRIS plan.

Please return all accurate and completedforms to Outreach for processing.

ParticipantHiredWorker(PHW)

EnrollmentPacketChecklist

_______________________________________ _____________________________________First Last First Last

PrintParticipantName PrintNameofEmployee

Thischecklistisusedasaguidetomakesureallformsarecompleted.PleaseinitialbyeachitemwhentheformiscompleteandreturnwiththeEnrollmentPacket.

Ifyouhaveanyquestionspleasecalltollfree1-877901-5826.

Participant PHW

1. StartUpChecklist _________ _________

2. FormF-01201IRISParticipant-HiredWorkerSet-Up _________ _________

3. FormI-9EmploymentEligibilityVerification _________ _________

4. FormW-4 _________ _________

5. Participant-HiredWorkerRelationshipIdentification _________ _________

6. DirectDepositAuthorization _________ _________

7. MoneyNetworkApplication/DepositAgreement _________ _________

8. IRISSupportiveHomeCare/SelfDirectedPersonal _________ _________Care/RespiteCareTrainingVerification

9. BackgroundInformationDisclosureAddendum _________ _________

10. BackgroundInformationDisclosure(BID) _________ _________

11. WisconsinMedicaidProgramProviderAgreement _________ _________

12. ParticipantEmployer/ParticipantHired-WorkerAgreement _________ _________

Mysignatureindicatesthatthefollowingformshavebeenexplainedtome.

_____________________________________ _____________________________________

Participant/LegalGuardianSignatureDate PHWSignature Date

DEPARTMENT OF HEALTH SERVICES

Division of Long Term Care F-01201 (05/2015)

STATE OF WISCONSIN

IRIS PARTICIPANT- HIRED WORKER SET- UP

INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. A participant-hired worker may not begin working for a participant before the IRIS start date, indicated in the participant’s start date letter.

Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose.

Completed forms should be submitted to the participant’s Fiscal Employer Agent.

SECTION I – PARTICIPANT-HIRED WORKER DEMOGRAPHICS (all fields must be filled) Name – Participant-Hired Worker (Last, First, MI) Gender

Male Female

Date of Birth

Mailing Address City Phone Number PHW Social Security Number

State Zip Email Address

SECTION II – PARTICIPANT EMPLOYER DEMOGRAPHICS (all fields must be filled) Name – Participant Employer (Last, First, MI) Date of Birth Master Client Index (MCI)

Mailing Address City Phone Number

State Zip Email Address

By signing below, I (we) agree the information on this form is accurate and I (we) have all supporting documentation in my possession. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. Both signers also acknowledge that no hours worked prior to a passed background check will be authorized.

SIGNATURE – Participant Hired-Worker Date Signed

SIGNATURE – Participant Employer Date Signed

Please pay close attention tothe following Federal form.

This form is detailed and needs yourclose attention to complete correctly.

Incomplete forms may result in penalties.

Call for assistance if needed. We are here to help!

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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 boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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 a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

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 Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll 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

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

75-2382997Outreach Health, 251 Renner Pkwy, Richardson TX 75080

Form W-4 {2020) Page3

Step 2{b)-Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1 Two jobs. If you have two jobs or you're married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the "Higher Paying Job" row and the "Lower Paying Job" column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.

a Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the "Higher Paying Job" row and the annual wages for your next highest paying job in the "Lower Paying Job" column. Find the value at the intersection of the two household salaries

1 $ -------

and enter that value on line 2a . 2a $

b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the "Higher Paying Job" row and use the annual wages for your third job in the "Lower Paying Job" column to find the amount from the appropriate table on page 4 and enter this amount

-------

on line 2b 2b $ --'--------

c Add the amounts from lines 2a and 2b and enter the result on line 2c 2c $ --'--------

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc.

4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional

3

amount you want withheld) . 4 $

Step 4{b)-Deductions Worksheet (Keep for your records.)

1 Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1 040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes {up to $10,000), and medical expenses in excess of 10% of your income 1 $ --'--------

2 Enter: ( • $24,800 if you're married filing jointly or qualifying widow(er) • $18,650 if you're head of household• $12,400 if you're single or married filing separately l 2 $

3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter "-0-" 3 $ --'--------

4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4 _$ _____ _

5 Add lines 3 and 4. Enter the result here and in Step 4{b) of Form W-4 . 5 $

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 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 with no other entries on the form; 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.

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 0MB 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 6103.

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.

EMPLOYER INSTRUCTIONS for Department of Revenue:• If you do not have a Federal Employer Identification Number (FEIN), contact

the Internal Revenue Service to obtain a FEIN.• If the Employee has claimed more than 10 exemptions OR has claimed

complete exemption from withholding and earns more than $200.00 a weekor is believed to have claimed more exemptions than he or she is entitled to, mail a copy of this certificate to: Wisconsin Department of Revenue, AuditBureau, PO Box 8906, Madison WI 53708 or fax (608) 267‑0834.

• Keepacopyofthiscertificatewithyourrecords.IfyouhavequestionsabouttheDepartmentofRevenuerequirements,call(608)266‑2772or(608)266‑2776.

EMPLOYER INSTRUCTIONS for New Hire Reporting:• This report contains the required information for reporting a New Hire to

Wisconsin. If you are reporting new hires electronically, you do not need toforward a copy of this report to the Department of Workforce Development.Visit https://dwd.wi.gov/uinh/ to report new hires.

• If you do not report new hires electronically, mail the original form to the Depart‑mentofWorkforceDevelopment,NewHireReporting,POBox14431,MadisonWI 53708‑0431 or fax toll free to 1‑800‑277‑8075.

• IfyouhavequestionsaboutNewHirerequirements,calltollfree(888)300‑HIRE(888‑300‑4473). Visit dwd.wi.gov/uinh/ for more information.

Employee’s Wisconsin Withholding Exemption Certificate/New Hire Reporting WT-4

W‑204 (R. 10‑19) Wisconsin Department of Revenue

EMPLOYEE INSTRUCTIONS:

• WHO MUST COMPLETE:Effective on or after January 1, 2020, every newly‑hired employee isrequiredtoprovideacompletedFormWT‑4toeachofhisorheremploy‑ers. Form WT‑4 will be used by your employer to determine the amountof Wisconsin income tax to be withheld from your paychecks. If youhave more than one employer, you should claim a smaller number or noexemptions on each Form WT‑4 provided to employers other than yourprincipal employer so that the total amount withheld will be closer to your actual income tax liability.You must complete and provide your employer a new Form WT‑4 within10 days if the number of exemptions previously claimed DECREASES.You may complete and provide to your employer a new form WT‑4 at anytime if the number of your exemptions INCREASES.Youremployermayalsorequireyoutocompletethisformtoreportyourhiring to the Department of Workforce Development.

• UNDER WITHHOLDING:If sufficient tax is not withheld from your wages, you may incur additionalinterest charges under the tax laws. In general, 90% of the net tax shown on your income tax return should be withheld.

• OVER WITHHOLDING:If you are using Form WT‑4 to claim the maximum number of exemptionsto which you are entitled and your withholding exceeds your expectedincome tax liability, you may use Form WT‑4A to minimize the overwithholding.

WT-4 Instructions – Provide your information in the employee section.• LINE 1:

(a)‑(c) Number of exemptions – Do not claim more than the correct numberof exemptions. If you expect to owe more income tax for the year than will

be withheld if you claim every exemption to which you are entitled, you may increase your withholding by claiming a smaller number of exemptions on lines 1(a)‑(c) or you may enter into an agreement with your employer to have additional amounts withheld (see instruction for line 2).(c) Dependents–Thosepersonswhoqualifyasyourdependentsforfederalincome tax purposes may also be claimed as dependents for Wisconsinpurposes. The term “dependents” does not include you or your spouse.Indicate the number of dependents that you are claiming in the space provided.

• LINE 2:Additional withholding – If you have claimed “zero” exemptions on line 1, butstill expect to have a balance due on your tax return for the year, you maywishtorequestyouremployertowithholdanadditionalamountoftaxforeachpay period. If your employer agrees to this additional withholding, enter theadditional amount you want deducted from each of your paychecks on line 2.

• LINE 3:Exemption from withholding – You may claim exemption from withholding ofWisconsin income tax if you had no liability for income tax for last year, andyou expect to incur no liability for income tax for this year. You may not claimexemption if your return shows tax liability before the allowance of any creditfor income tax withheld. If you are exempt, your employer will not withholdWisconsin income tax from your wages.You must revoke this exemption (1) within 10 days from the time you expectto incur income tax liability for the year or (2) on or before December 1 if youexpect to incur Wisconsin income tax liabilities for the next year. If you want to stoporarerequiredtorevokethisexemption,youmustcompleteandprovidea new Form WT‑4 to your employer showing the number of withholding exemp‑tions you are entitled to claim. This certificate for exemption from withholdingwill expire on April 30 of next year unless a new Form WT‑4 is completed andprovided to your employer before that date.

Signature Date Signed ,

FIGURE YOUR TOTAL WITHHOLDING EXEMPTIONS BELOWComplete Lines 1 through 3

1. (a) Exemption for yourself – enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) Exemption for your spouse – enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) Exemption(s) for dependent(s) – you are entitled to claim an exemption for each dependent . . . . . . . .

(d) Total – add lines (a) through (c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Additional amount per pay period you want deducted (if your employer agrees) . . . . . . . . . . . . . . . . . . . . . .

3. I claim complete exemption from withholding (see instructions). Enter “Exempt” . . . . . . . . . . . . . . . . . . . . .ICERTIFYthatthenumberofwithholdingexemptionsclaimedonthiscertificatedoesnotexceedthenumbertowhichIamentitled.Ifclaimingcompleteexemptionfromwithholding, I certify that I incurred no liability for Wisconsin income tax for last year and that I anticipate that I will incur no liability for Wisconsin income tax for this year.

Employer’s Section

Employer’s payroll address (number and street) City State Zip code

Completed by Title Phone number Email

Employer’s name Federal Employer ID Number

( )

Employee’s Section (Print clearly)

City State Zip code Date of hire

Employee’s legal name (first name, middle initial, last name) Social security number

Employee’s address (number and street) Date of birth

Single

Married

Married, but withhold at higher Single rate.Note: If married, but legally separated, check the Single box.

https://dwd.wi.gov/uinh/

https://dwd.wi.gov/uinh/

DEPARTMENT OF HEALTH SERVICESDivision of Medicaid ServicesF-01201A (11/2017)

STATE OF WISCONSIN

IRIS PARTICIPANT-HIRED WORKER RELATIONSHIP IDENTIFICATION

INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is anIRIS program requirement. Both the participant-hired worker and the participant employer must sign and date thebottom in order to be considered complete. Participant-hired worker may not begin working for participant employeruntil they have received a mailed start date letter.

Completed forms should be submitted to the participant’s fiscal employer agent.Name – Participant-Hired Worker (Last, First) Name – Participant Employer (Last, First)

Date of Birth – Participant-Hired Worker

Check your legal relationship to the participant. For example, if the participant is your grandmother, you are the participant’sgrandchild. Check one.

RELATIVE (BIOLOGICAL)RELATIVE (BY

MARRIAGE/PARTNERSHIP) NON-RELATED RELATIONSHIPSParent * ± Spouse * ± FriendSon/Daughter (over 21) * Domestic Partner * Ŧ NeighborSon/Daughter (under 21) * ± Step Parent * WorkerAdopted Child * Step Child * Ex-Husband / Ex-WifeGrandparent * Step GrandchildGrandchild * Step Brother / Step SisterBrother / Sister Parent-in-LawUncle / Aunt Child-in-LawNephew / Niece Brother-in-Law / Sister-in-LawCousin

* Due to your relationship with theparticipant and current legislation, you are exempt from payroll taxes for unemployment insurance (SUTA). If your employment with the participant is terminated, you will not receive

unemployment benefits. Any applicableexemptions cannot be waived.

± Due to your relationship with theparticipant and current legislation, you are exempt from payroll taxes for Social Security and Medicare (FICA). By not paying into Social Security and Medicare (FICA), it means you are not earning Social Security work credits. Anyapplicable exemptions cannot be waived.

Ŧ Per Wis. Statute 770.05, Domestic Partnership means you and your samesex partner have filed for DomesticPartnership, and have a certified copy ofyour Declaration of DomesticPartnership.

Yes No The participant receiving nonmedical care lives in the participant-hired worker’s home.

NOTE: It is the participant-hired worker’s responsibility to notify the participant’s fiscal employer agent should their living situationchange.

By signing below, you agree the information on this form is accurate and you have all supporting documentation in your possession.

SIGNATURE – Participant-Hired Worker Date Signed


kw0404

OUTREACH HEALTH SERVICES DIRECT DEPOSIT AUTHORIZATION – CDS

In lieu of delivering payroll payments directly to the undersigned, I hereby authorize Outreach Health Services, and all Subsidiaries, to initiate credit entries to the account indicated below (the "ACCOUNT") and the depository named below (the "DEPOSITORY") to credit such payments to the ACCOUNT.

In the event of overpayment to the ACCOUNT, the undersigned grants Outreach Health Services and the DEPOSITORY the right to make an adjusting debit entry to the ACCOUNT, not in excess of the amount of such overpayment. NOTE: Upon receipt of this form, the first payroll cycle will be pre-noted and you will receive a live check until the bank information provided is verified through your banking institution.

I decline the pre-note process: ______ (if declined, a voided check or bank issued document must be attached for routing/account verification)

Primary Depository (BANK): Branch:

Address:

City: State: Zip: Phone:

Account in the name of: Acct.#:

Checking Acct.: or Savings Acct.: Bank Routing #:

Indicate if your financial institution is a Credit Union: or Savings & Loan:

This authority may be terminated upon thirty day's prior written notice thereof from the undersigned to the OHC Payroll Department.

Name: Social Security #:

Signature: Date:

Signature: Date: (Spouse or other Authorized Signatory)

ALL account holders MUST sign and date this form or it will not be accepted.

Secondary Depository (BANK): Branch:

Address:

City: State: Zip: Phone:

Account in the name of: Acct.#:

Checking Acct.: or Savings Acct.: Bank Routing #:

Indicate if your financial institution is a Credit Union: or Savings & Loan:

Amount to Secondary Account: All funds above this amount will be deposited to your primary account. Attach additional forms for multiple secondary accounts. Each form must be signed and dated by all account holders.

PLEASE ATTACH A VOIDED CHECK OR BANK ISSUED DOCUMENT FOR EACH ACCOUNT

First Last

First Last

Money Network Payroll Debit Card:

The Money Network Payroll Debit Card (“Card”) provides a dependable, safe, optional, and convenient way to receive and access my pay on and after each payday morning with the following features: (i) eliminates the need to pick up my paycheck, wait for it to be mailed, or pay for it to be cashed; (ii) immediate, worldwide access wherever the Card is accepted for ATM cash withdrawals, bank branch withdrawals, and store purchases (including “cash back”); (iii) money transfers to a personal or joint checking account; and (iv) free balance inquiries by phone or online. There is no monthly service charge for the Card as long as I am employed by Employer.Many Card transactions are free (and I need never incur a fee to access 100% of my wages,to the penny, using the Money NetworkService), but there are fees for other transactions. The Terms and Conditions, fee schedule, and other disclosures related to the MoneyNetwork Service are included in the Money Network Service’s Welcome Packet. Once I have consented to those terms and contractedfor the Money Network Service by activating my Money Network Service account by following the instructions in the Welcome Packet,I may begin to use the Money Network Service. Money Network™ Check: The Money Network Check (“Check”) is a paycheck thatI can easily complete on or after each payday morning wherever I am, eliminating the need to pick up my paycheck, wait for it to bemailed, or pay for it to be cashed. The Check can be deposited into my personal bank account or cashed for free at Money Networkcheck-cashing partners.

“In lieu of delivering payroll payments directly to the undersigned, I hereby authorize Outreach Health Services, and all Subsidiariesto initiate credit entries to the account indicated above (the “ACCOUNT”) and the depository named above the (the “DEPOSITORY”)to credit such payments to the ACCOUNT. In the event of overpayment to the ACCOUNT, the undersigned grants Outreach HealthServices and the DEPOSITORY the right to make an adjusting debit entry to the ACCOUNT, not in excess of the amount of theoverpayment. Additionally, in the event that I do not pass the required banking security verification, additional identification will berequired. I authorize Outreach Health Services to provide that identification from my personnel file immediately in order to avoid any delay in the availability of my debit card funds.”

Employee Signature: _________________________________ Date: _________________

Employee Printed Name: ____________________________________________________________

State: __________________________________________________________________

CARD HOLDER INFORMATION

Social Security Number: ____________________ Date of Birth: __________________________

First Name: ___________________________ Last Name: ____________________________

Address: __________________________________________________________________________

City: __________________________________ State: ______________ Zip: _________________

Phone: _________________________ Account Number: _________________________________

Money Network Applicationand Deposit Agreement

(No PO Boxes - Physical Addresses Only)

(* Account number is NOT the card number, pleaseuse account number included with packet)

SPENDING MONEY MNAccount

PortableAccount

ATM Withdrawals (see below for ATM balance inquiry and decline fees) / U.S In-Network ATMsTo find participating In-Network ATMs, use the Money Network mobile app (available at the App StoreTM and Google PlayTM), visit moneynetwork.com or call Customer Service. An additional surcharge may be separately charged by an owner or operator of an ATM.

$0.00 $0.00

ATM Withdrawals (see below for ATM balance inquiry and decline fees) / U.S Out-of-Network ATMsAn additional surcharge may be separately charged by an owner or operator of an ATM. $1.75 $1.75

ATM Withdrawals (see below for ATM balance inquiry and decline fees) / Non-U.S. ATMsAn additional surcharge may be separately charged by an owner or operator of an ATM. A foreigntransaction conversion fee of 2% will apply to non-U.S. transactions. A Cross Border Transaction Feeof 0.8% will also apply. See “Foreign Transaction Fees” in your Account Holder Agreement for details.

$2.50 $2.50

Bank Teller Over-the-Counter Cash Withdrawal (at any bank that displays the logo shown on your card) $0.00 $0.00

Money NetworkTM Check (use, order, or stop payment; cash at participating check-cashing locations)To find participating locations, use the Money Network mobile app (available at the App StoreTM and Google PlayTM), visit moneynetwork.com or call Customer Service.

$0.00 $0.00

Signature Point-of-Sale Transactions (for purchases, declines and returns) / U.S. and Non-U.S.A foreign transaction conversion fee of 2% will apply to non-U.S. transactions. A Cross Border Transaction Fee of 0.8% will also apply. See “Foreign Transaction Fees” in your Account Holder Agreement for details.

$0.00 $0.00

PIN Point-of-Sale Transactions - with or without Cash Back (for purchases, declines and returns) / U.S and Non-U.S.A foreign transaction conversion fee of 2% will apply to non-U.S. transactions. A Cross Border Transaction Fee of 0.8% will also apply. See “Foreign Transaction Fees” in your Account Holder Agreement for details.

$0.00 $0.00

Transfer Funds to a U.S. Bank Account (ACH transfer) $0.00 $0.00

Transfer Funds from your Account to a Secondary Card $0.00 $0.00

MANAGING MONEY MNAccount

PortableAccount

Monthly Account Maintenance Fee (applies only to Portable Accounts) N/A $2.95

Balance Inquiries and Alerts / via Mobile App, Automated Phone System, Customer Service, Online Access, or Notifications (push, email or text)Your wireless carrier’s standard messaging and data rates may apply.

$0.00 $0.00

Balance Inquiries and Declines at ATM I U.S. ATMs (In-Network and Out-of-Network)An additional surcharge may be separately charged by an owner or operator of an ATM. $1.75 $1.75

Balance Inquiries and Declines at ATM I Non-U.S. ATMsAn additional surcharge may be separately charged by an owner or operator of an ATM. $2.50 $2.50

Customer Service 24/7 $0.00 $0.00

Replacement Card with Standard Delivery $6.00 $6.00

Replacement Card: - Additional Fee for Expedited -Delivery $13.00 $13.00

Monthly Paper Statement by MailYou may view statements online at no charge. You may also call to request transaction information or aprinted 60-day history at no charge.

$2.95 $2.95

Request a secondary card for a Family Member, Dependant or Caregiver $2.00 $2.00

Money Network Card Fee Schedule

1 Your Money Network Account will automatically convert to a Portable Account upon termination of your employment with the employer through whom you initially enrolled to receive your Money Network Card in accordance with your Account Holder Agreement. In the event of an automatic conversion, you may avoid the Monthly Account Maintenance Fee for the Portable Account by withdrawing or spending the funds in your Money Network Account.

ADDING MONEY MNAccount

PortableAccount

Payroll Direct Deposit $0.00 $0.00

Direct Deposit of Other Funds (for example: tax refunds, child support, etc.) $0.00 $0.00

Load Cash at Participating Reload Locations (fee set by each reload location)use the Money Network mobile app (available at the App StoreTM and Google PlayTM), visit moneynetwork.com or call Customer Service.

VARIES VARIES

TRANSACTION LIMIT SCHEDULE

ATM Withdrawal Limit $600 per transaction and per day (ATM owner may have lower limits)

Transactions at Point-of-Sale (POS) $3,000 per transaction and per day

Money Network Check Limit $9,999.99 per check (some check-cashing locations may have lower limits)

Bank Teller Over the Counter Cash Withdrawal $8,000 per transaction and per day (bank may have lower limits)

Non-Payroll ACH Loads (Tax Refunds and Others) $4,000 per day; $8,000 per calendar month

Retail or Reload Agent Loads $2,500 per transaction and per day; $5,000 per calendar month

Portable Account Balance / Maximum Allowed $8,000 at any time (no limit for employer payroll loads

ACH Transfer to a Bank Account $8,000 per transaction

Transfer to Secondary Card $1,000 per transaction

DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01201B (02/2017)

STATE OF WISCONSIN

IRIS SUPPORTIVE HOME CARE / SELF-DIRECTED PERSONAL CARE / RESPITE CARE TRAINING VERIFICATION

INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. Participant-hired worker may not begin working for participant employer until they have received a mailed start date letter.

Please fill out the appropriate section(s) based on services that will be provided.


SECTION I – PARTICIPANT-HIRED WORKER DEMOGRAPHICS (all fields must be filled)

Name – Participant-Hired Worker (Last, First) Name – Participant Employer (Last, First)

Date of Birth – Participant-Hired Worker Anticipated Employment Start Date

SECTION II – SUPPORTIVE HOME CARE REQUIRED TRAINING

Employee is oriented to participant’s place of care. Employee safely performs cares and duties. Employee knows what to do in an emergency situation*. Employee works effectively with participants and respects their choices.

Employee is familiar with homemaking/household services. Employee uses gloves as appropriate while assisting with participant’s cares.

Employee understands participant’s disability, diagnosis and related needs.

Employee is familiar with participant’s daily schedule, needs, and duties.

Employee is aware of the participant’s back-up plan.

Required training completed on:

SECTION III – SELF-DIRECTED PERSONAL CARE REQUIRED TRAINING


Employee uses gloves as appropriate while assisting with participant’s cares.





SECTION IV – RESPITE CARE REQUIRED TRAINING


Employee uses gloves as appropriate while assisting with participant’s cares.





*Emergency Response: employee knows how to evacuate the participant in an emergency, and knows how to respond toemergencies related to the participant’s health and safety.

F-01201B Page 2 of 2

By signing below, you agree the information on this form is accurate. Both signers also acknowledge that no hours worked prior to a passed background check will be authorized.

SIGNATURE – Employee Date Signed

SIGNATURE – Participant Date Signed

DEPARTMENT OF HEALTH SERVICES

Division of Medicaid Services F-01246 (02/2017)

STATE OF WISCONSIN

Wisconsin Statutes § 48.685 and 50.065

Administrative RuleDHS 12.05(4)

BACKGROUND INFORMATION DISCLOSURE ADDENDUM—IRIS

INSTRUCTIONS: Completion of this form is required under the provisions of Chapters 48.685 and 50.065 Wis. Stats. Failure to comply may result in a denial or termination of your employment.

Personally identifiable information on this form is collected to verify your identity and that the form is complete.

SECTION I – APPLICANT INFORMATION

Name – (Last, First, MI) Date of Birth

Please list all the cities and states in which you have lived in the past three years, and the name by which you were known (if different from your name now). Please indicate the number of years you lived there.

Address – (Address, City, State, Zip Code) Years at Residence

Any Other Names By Which You Have Been Known (Including Maiden Name)

SECTION II – ADDITIONAL APPLICANT INFORMATION

Completion of this section is only required for applicants who have lived outside the state of Wisconsin in the past three years.

Current Address City State Zip Code County

Previous Address City State Zip Code County



Mother’s Maiden Name Mother’s Current Name – (Last, First, MI)

Father’s Name – (Last, First, MI)

I acknowledge that the information on this form is accurate to the best of my knowledge. By signing below, I agree to have a background check run.

I further acknowledge that an out-of-state background check may increase processing time, if applicable.

SIGNATURE – Applicant Date Signed

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-82064 (07/2018)

STATE OF WISCONSIN Wis. Stat. § 50.065

Wis. Admin. Code § DHS 12.05(4) Page 1 of 2

BACKGROUND INFORMATION DISCLOSURE (BID) • PENALTY: Knowingly providing false information or omitting information may result in a forfeiture of up to $1,000 and other

sanctions as provided in Wis. Admin. Code § DHS 12.05(4). • Completion of this form is required under the provisions of Wis. Stat. § 50.065. Failure to comply may result in a denial or revocation

of your license, certification, or registration, or denial or termination of your employment or contract. • Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to

prevent incorrect matches. • Refer to DQA form F-82064A, BID Instructions, for additional information. Check the box that applies to you.

Employee / Contractor (including new applicant) Household member (lives on premises, but is not a client)

Applicant for a license, certification, or registration (including continuation or renewal) Other – Specify:

NOTE: If you are an owner, operator, board member, or non-client resident of a facility regulated by the Division of Quality Assurance (DQA), complete the BID, F-82064 and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions. Full Legal Name – First

Middle

Last

Position Title (Complete only if a prospective or current employee or contractor.)

Birth Date (MM/dd/yyyy)

Sex Male Female

Any Other Names By Which You Have Been Known (Including Maiden Name) Race / Ethnicity (Check ONLY one.)

American Indian or Alaskan Native Asian or Pacific Islander Black White Unknown Social Security Number

Home Address

City

State

Zip Code

Business Name and Address – Employer or Care Provider (Entity)

A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval. Note: The areas below that are designated for responses are expandable.

SECTION A – ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION 1. Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts?

If Yes, list each charge, when it occurred or the date of the charge, and the city and state where the court is located. You may be asked to supply additional information, including a copy of the criminal complaint or any other relevant court or police documents.

Yes

No

2. Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts?

If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents.

Yes

No

3. IMPORTANT: Read before completing item 3.

Wis. Stat. § 48.981 Abused and neglected children and abused unborn children. (7)(a) CONFIDENTIALITY. “All reports made under this section, notices provided under sub. (3) (bm), and records maintained by an agency and other persons, officials, and institutions shall be confidential.” Reports and records may be disclosed only to the persons identified in this section.

If you are the employer or prospective employer of the person completing this form and are entitled to obtain this information per the above, check this box.

Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? If the above box has been checked, provide an explanation below, including when and where the incident(s) occurred.

Yes

No

F-82064 Page 2 of 2

4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any personor client?

If Yes, explain, including when and where it happened.

Yes No

5. Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly tookor used) the property of a person or client?


Yes No

6. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?


Yes No

7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care toclients?

If Yes, explain, including credential name, limitations or restrictions, and time period.

Yes No

SECTION B – OTHER REQUIRED INFORMATION 1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to

provide care, treatment, or educational services?


Yes No

2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premisesof a care providing facility?

If Yes, explain, including when and where it happened and the reason.

Yes No

3. Have you been discharged from a branch of the US Armed Forces, including any reserve component?

If Yes, indicate the year of discharge:

Attach a copy of your DD214, if you were discharged within the last three (3) years.

Yes No

4. Have you resided outside of Wisconsin in the last three (3) years?

If Yes, list each state and the dates you resided there.

Yes No

5. If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven(7) years?

If Yes, list each state and the dates you resided there.

Yes No

6. Have you had a caregiver background check done within the last four (4) years?

If Yes, list the date of each check, and the name, address, and phone number of the person, facility, or governmentagency that conducted each check.

Yes No

7. Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a countydepartment, a private child placing agency, school board, or DHS-designated tribe?

If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.

Yes No

Read and initial the following statement.

I have completed and reviewed this form (F-82064, BID) and affirm that the information is true and correct as of today’s date.

Name – Person Completing This Form Date Submitted

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Medicaid Services 42 CFR 431.107 & 42 CFR 438.602(b) F-00180C (07/2017)

WISCONSIN MEDICAID PROGRAM PROVIDER AGREEMENT AND ACKNOWLEDGEMENT OF TERMS OF PARTICIPATION

FOR WAIVER SERVICE PROVIDER AGENCIES OR INDIVIDUALS

Completion of this form is required under Federal Law by the Centers for Medicare & Medicaid Services, Department of Health and Human Services, under the Code of Federal Regulations 42 CFR 431.107.

Name of Provider (Typed or Printed—Must exactly match name used on all other documents) Phone Number

Address – Street City State Zip Code

The above-referenced provider of home and community-based waiver services under Wisconsin’s Medicaid program, hereinafter referred to as the provider, hereby agrees and acknowledges as follows:

1. To provide only the items or services authorized by the managed care organization or IRIS program.

2. To accept the payment issued by the managed care organization or IRIS program as payment in full for provideditems or services.

3. To make no additional claims or charges for provided items or services.

4. To refund any overpayment to the managed care organization or IRIS program.

5. To keep any records necessary to disclose the extent of services provided consistent with the provider’s businesstype.

6. To provide, upon request by the managed care organization, the IRIS program, or the Department of HealthServices (DHS) or its designee, information regarding the items or services provided.

7. To comply with all other applicable federal and state laws, regulations, and policies relating to providing homeand community-based waiver services under Wisconsin’s Medicaid program including the caregiver backgroundcheck law.

8. Medicaid Confidentiality Policies and Procedures: To maintain the confidentiality of all records or otherinformation relating to each participant’s status as a waiver participant and items or services the participantreceives from the Provider.

9. To respect and comply with the waiver participant’s right to refuse medication and treatment and other rightsgranted the participant under federal and state law.

10. Medicaid Fraud Prevention Policies and Procedures (including records retention): To keep records necessary todisclose the extent of services provided to waiver participants for a period of ten (10) years and to furnish uponrequest to the DHS, the federal Department of Health and Human Services, or the state Medicaid Fraud ControlUnit, any information regarding services provided and payments claimed by the Provider for furnishing servicesunder the Wisconsin Medicaid Program. This requirement includes retaining all records and documents accordingto the terms provided by Wis. Admin. Code § DHS 106.02(a)-(d); (f)-(g).

11. The provider agrees to comply with the disclosure requirements of 42 CFR Part 455, Subpart B, as now in effector as may be amended. To meet those requirements and address real or potential conflict of interest that mayinfluence service provision, among other things the provider shall furnish to the managed care organization andupon request, to the Department in writing:

a) The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers inwhich it has a controlling interest or ownership;

b) The names and addresses of all persons who have a controlling interest in the provider;

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Medicaid Services 42 CFR 431.107 & 42 CFR 438.602(b) F-00180C (07/2017)

c) Whether any of the persons named in compliance with (a) and (b) above are related to any owner or to aperson with a controlling interest as spouse, parent, child or sibling;

d) The names and addresses of any subcontractors who have had business transactions with the provider;e) The identity of any person named in compliance with (a) and (b) above, who has been convicted of a

criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or Title XXservices programs since the inception of those programs.

12. To provide to the DHS identifying information, including name, specialty, date of birth, Social Security number,national provider identifier, (NPI) (if eligible for an NPI), Federal taxpayer identification number, and Statelicense or certification for purposes of enrollment with the State Medicaid program.

13. To include its NPI (if eligible for an NPI) on all claims submitted under the Medicaid program.

14. To comply with the advance directives requirements specified in 42 CFR Part 489, Subpart I.

Modifications to this agreement cannot and will not be agreed to. Altering this agreement in any way voids the Department of Health Services’ signature. This agreement is not transferable or assignable.

Name – Provider (Typed or Printed)

SIGNATURE – Provider Date Signed

FOR DMS USE ONLY (DO NOT WRITE BELOW THIS LINE)

SIGNATURE – Department of Health Services Date Signed

8/14/17

DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01201C (02/2017)

STATE OF WISCONSIN

IRIS PARTICIPANT EMPLOYER / PARTICIPANT- HIRED WORKER AGREEMENT

INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. Participant-hired worker may not begin working for participant employer until they have received a mailed start date letter.

Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose.


Name – Participant-Hired Worker (Last, First) Name – Participant Employer (Last, First)

Date of Birth – Participant-Hired Worker

The participant employer requires the following tasks and duties to be performed by the participant-hired worker:

The participant employer agrees to provide/arrange for worker training as described below:

Participant-Hired Worker Schedule – Indicate Day(s) of the Week Participant-Hired Worker Will Provide Service(s)

Service Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Supportive Home Care (SHC)

Self-Directed Personal Care (SDPC)

Respite Care (R)

Other

Mileage

If “Other”, please explain:

Participant-Hired Worker Services – Indicate Which Service(s), Pay Rate(s), Unit Type(s) and Units Per Week the Participant-Hired Worker will Provide

Service Pay Rate Unit Type (per hour, per day, etc.) Units/Week

Supportive Home Care (SHC)

Self-Directed Personal Care (SDPC)

Respite Care (R)

Other

Mileage Indicate the rate and the number of miles per month the participant-hired worker is authorized to provide.

If “Other”, please explain:

� �

F-01201C Page 2

BY SIGNING BELOW:

I (We) understand that the services are provided under Medicaid regulations and that I (we) may not charge in excess of the amountauthorized on the participant employer’s plan. After the participant-hired worker has performed the service(s) per this agreement,time reports are due to the participant’s Fiscal Employer Agent.

Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above theauthorization may be rejected for payment.

SIGNATURE – Participant-Hired Worker Date Signed
