Public Partnerships, LLC (PPL) PPL’s FFissccaall IInntt er ......Submit time each visit or submit signed timesheets to PPL every 2 weeks Receive a paycheck from PPL, based on time

Dear Employee:

Welcome aboard! You have received this packet because you intend to provide services as a Personal Attendant to an individual receiving support and funding through the Indiana Family and Social Services Administration (FSSA) Self-Directed Care Program.

FSSA has contracted with Public Partnerships, LLC (PPL), a Fiscal Intermediary (FI), to make all payments on behalf of waiver program participants who utilize Personal Attendants. The FI will track all hours worked and pay for services on behalf of your Employer. The FI will also administer the required background checks on all Personal Attendants.

PPL asks that you sign and return the enclosed forms as soon as possible. You must complete a separate packet for each Employer who employs you, even if you are hired by two people in the same household. PPL cannot pay any claims until a completed packet is received for your work with each Employer. PPL will issue your paychecks to you based on either telephonic or signed physical timesheets. These paychecks will reflect tax withholdings. If you have any questions, please call or email Public Partnerships at (866) 264- 2296 or [email protected].

Thank you.

How do I complete the forms? Is there an easy way to tell which ones apply to me?

PPL has enclosed an instruction page for each form to help you complete the appropriate paperwork. We also have enclosed a checklist of all forms you need to return to PPL. Please use this to help you identify which forms to return to us.

What should I expect as an Employee?

Before you are eligible to provide services on your new job you must:

Pass a statewide criminal history check

Meet with your Employer to complete an employment contract and verify the information youhave provided on your USCIS Form I-9

Complete the enclosed tax forms and submit to PPL for processing Report to your Employer about job performance and scheduling requests

After you start your new job you will:

Submit time each visit or submit signed timesheets to PPL every 2 weeks Receive a paycheck from PPL, based on time submitted to PPL, every 2 weeks Receive W-2 Wage Statement from PPL, on behalf of your Employer, every year

PPPPLL’’ss FFiissccaall IInntteerrmmeeddiiaarryy SSeerrvviiccee Employee Instructions to Create a Payroll Account

Public Partnerships, LLC (PPL) IN FSSA Fiscal Intermediary 7776 S Pointe Pkwy W Ste. 150 Phoenix, AZ 85044 Phone: (866) 264-2296 Customer Service Email: [email protected] Phone: (800) 360-5899 Business Fax: (866) 799-9381 Time Sheet Fax: (866) 874-0478

Who is responsible for submitting timesheets to PPL?

It is the responsibility of the Employee to call the TIPS telephonic timesheet system to log in and out. If the Employee is submitting paper timesheets, it is the responsibility of the Employer to collect all timesheets from their Personal Attendants for a paycheck cycle and submit them to PPL together. If Personal Attendant timesheets for a single Employer are not submitted together, payments may be delayed or even denied.

What is the US Citizenship and Immigration Service (USCIS) Form I-9?

The USCIS Form I-9 is your employment eligibility verification. You must bring this form, and the documents listed on page 3 of the I-9, to your Employer. Your Employer will review the documents, confirm your identity and verify your identity under penalty of perjury by signing this form. Federal law requires that all Employers and Employees complete this form.

What taxes will be withheld and how will my paycheck stub change?

PPL will withhold Social Security, Medicare (FICA), and state and federal income taxes from your paycheck. A summary of all tax withholdings will appear on your paycheck stub throughout the calendar year. PPL also will mail you a W-2 form in January. You will need this W-2 form to file your individual tax return by April. Your Employer will receive regular reports from PPL about your total year to date wages and taxes paid.

When do I need to complete and return tax forms to Public Partnerships?

You must complete and return the required forms to PPL once you are hired by an Employer. Delays which go beyond the scheduled timeframe may result in payment delay, or inaccurate tax withholding for services you provide to your Employer.

Are there other forms I need to review?

Yes. PPL has enclosed the following forms for your review.

PPL Timesheet and Payment Calendar. A signed timesheet will authorize PPL to issue a paycheck. A timesheet can be completed online, faxed or mailed, but must to be legible, signed and for authorized service dates and hours. Paychecks are issued every other week. See the enclosed Payment Schedule for more information about processing days and deadlines. Please feel free to make copies of the Timesheet form to record Employee hours.

Thank you On behalf of your new Employer and FSSA, PPL would like to thank you for your commitment to individuals and families enrolled in the FI program. PPL encourages you to call or email us at 1-866-264-2296 or [email protected] if you have any questions regarding this new requirement or theprocess in general. PPL staff is available to help walk you through the forms over the phone. Thanks for your attention to this matter.

Sincerely,

PPL Fiscal Intermediary

STEP ONE – MEET WITH YOUR EMPLOYER TO FILL OUT FORMS

USCIS Form I-9 (Filled out by you, Section 2 signed by your employer)

Employment Terms and Conditions

Federal Tax Exemption Information Form

STEP TWO – MAIL FORMS TO PPL

USCIS Form I-9. US Citizenship and Immigration Services (USCIS)

IRS W-4 Form. Employee’s Withholding Allowance Certificate

Form WH-4. Employee’s Withholding Exemption and County Status Certificate

Employment Terms and Conditions

Employee Data Form

Employee Training Checklist

Federal Tax Exemption Information Form

All forms must be signed and returned to PPL prior to issuing paychecks to employees.

If you have any questions, please call PPL at (866) 264-2296 or email PPL at [email protected]

CCHHEECCKK LLIISSTT PPPPLL’’ss FFiissccaall IInntteerrmmeeddiiaarryy SSeerrvviiccee

Public Partnerships, LLC (PPL) IN FSSA Fiscal Intermediary 7776 S Pointe Pkwy W Ste. 150 Phoenix, AZ 85044 Phone: (866) 264-2296 Customer Service Email: [email protected] Phone: (800) 360-5899 Business Fax: (866) 799-9381 Time Sheet Fax: (866) 874-0478

WHERE TO SEND FORMS:Fax: 1-866-799-9381 Mail: Public Partnerships, LLC

ATTN: IN FSSA 776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044

Email: [email protected]

EMPLOYER NAME:

EMPLOYEE DATA FORM

PERSONAL INFORMATION

NAME:

PHONE:

ADDRESS:

SS#

OPTIONAL - SEX:

MALE

FEMALE

EMPLOYER NAME:

CITY: STATE: ZIP:

D.O.B.

OPTIONAL - RACE:

BLACK

HISPANIC

ASIAN/ PAC. ISLAND

NAT. AMER. OR ALASKAN

WHITE

OTHER

OPTIONAL - VETERAN STATUS:

SPECIAL DISABLED VETERAN

* Please check one that describes your veteran status.

*Means (A) a veteran who is entitled to compensation (or who, but for the receipt of military retired pay, would beentitled to compensation) under laws administered by the Department of Veteran Affairs for a disability rateof 10-20% in the case of a veteran who has been determined to have a serious employment disability

or (B) a person who was discharged or released from active duty because of a service connected disability.

VIETNAM ERA VETERAN*Means a veteran, any part of whose active military, naval or air service, was during the period August 5, 1964 through

May 7, 1975 who (1) served on active military duty for a period of more than 180 days and was discharged or releasedthere from with other than a dishonorable discharge, or (2) was discharged or released from active dutybecause of a service-connected disability. No veteran can be considered to be a veteran of the

Vietnam era under this paragraph after December 31, 1994.

OPTIONAL - FAMILY INFORMATION

SPOUSE: CHILD: CHILD: CHILD:

* Additional children may be listed on the back of this form.

OPTIONAL - EMERGENCY CONTACTS

CONTACT RELATIONSHIP

D.O.B.M / F D.O.B. M / F D.O.B. M / F D.O.B.

DAYTIME PHONE

*Information provided on this form is confidential and is treated as such. Completion of this data is voluntary and willnot affect your employment status. Identification can be declared at any time prior to, or if applicable, after hire.

CONSUMER NAME:

Employment Terms and Conditions Agreement Page 1 of 3

EMPLOYMENT TERMS AND CONDITIONS AGREEMENT

LETTER OF ACCEPTANCE

The following terms stated in this agreement apply to the following individuals: (please print)

Name of Employer: ______________________________________________

Name of Employee: ______________________________________________

Name of Waiver Program Participant: ______________________________________________

Certain unemployment tax exemptions exist for employers who hire family members. Is there a

family relationship between the Employee and Employer? If so, what is this relationship?

_____________________________________________________________________________

WHEREAS, the State of Indiana, Family and Social Services Administration (FSSA) has designated Public

Partnerships, LLC (PPL) as a Fiscal Intermediary (FI) to provide agent of the employer services on behalf of the

employer stated above, which shall include processing paychecks, performing state and federal withholdings and

reporting, and procuring unemployment insurance, and

WHEREAS, the employer has selected the employee to provide certain services and supports consistent with the

above named Employer’s Service Authorization, and

WHEREAS, the employer will 1) direct the employee on how to deliver services, 2) utilize the individual’s FSSA

funding allocation to support all aspects of the employee’s service, and 3) ensure compliance with the State of Indiana

Program Rules

THEREFORE, the employer and employee hereby agree as follows:

Offer: The employer is pleased to offer the employee a position to provide personal

attendant services to the waiver program participant. The employer believes

there is a good fit between the employee’s skills and interests, and the

individual’s needs.

Expected Start Date:

________/ ________/ _______. This date is contingent on the employee

agreeing to an annual, statewide criminal background check and submitting the

required documents to PPL. Once this information is received, PPL will

conduct the background check and report results to FSSA and the Employer.

Employee must not begin work until informed by PPL that they have been

certified to start.

Wage: $9.80 per hour. The employee will be paid on a bi-weekly schedule per

submission (telephonic, mail or fax) of timesheets to Public Partnerships, LLC,

agent of the employer. A valid timesheet must be signed and dated by the


Benefits:

Supervision:

Registry:

Criminal History:

Transportation:

Termination:

Form I-9:

employee and employer. PPL will withhold appropriate taxes and issue tax

statements based on tax forms filed by the employee and employer, respectively.

The employee is not eligible to receive benefits under this agreement, or

participate in any state pension or retirement plan.

Continued employment will be determined by the FSSA, Division of Aging and

the employer. Employment eligibility is based on satisfactory employee

performance, the employee remaining in good standing with their criminal

background, the employer’s needs, and the availability of State Program funding

for the waiver program participant.

The employee will be listed in a web-based provider registry as an approved

provider available for hire by other waiver program participants. If you do not want to be include in the provider registry please check the opt-out box below:

By signing this agreement, the employee signals his or her understanding that he

or she will be subject to a statewide limited criminal history and the result of the

history may determine employment eligibility.

Also, by signing this agreement, you acknowledge the following federal

regulation that may affect employment: The United States Department of Health

and Human Services-Office of the Inspector General (HHS-OIG) maintains a

List of Excluded Individuals/Entities (LEIE), which includes persons with

convictions for program-related fraud, patient abuse, or licensing board actions.

Medicaid payments cannot be made for services furnished by an excluded person

who is on the LEIE. PPL, in coordination with EverCare Select, is screening

prospective and current attendants monthly to assure compliance with this

federal law.

If the employee is providing transportation to the employer, the employee must

provide a copy of his or her valid driver’s license and proof of insurance. If

there are any changes to an employee’s driving history, the employee is

obligated to update the employer and Fiscal Intermediary.

Either party may terminate this agreement by notifying the other party and PPL,

in writing by submitting the “Notice of Termination” form 5 days prior to formal

separation of employment.

Employer is responsible for proper execution of USCIS Form I-9, as defined in

Instructions for Employment Eligibility Verification, Department of Homeland

Security. Employer must retain original Form I-9. PPL will only provide Form

I-9 in employment packets and retain a forwarded copy in PPL maintained

employee files.

Opt-out


Confidentiality

Upon receipt of information relating to the waiver program participant, the employee will become

a holder of confidential data. The employee agrees to use confidential data solely for carrying out

his/her responsibilities under this agreement.

Indemnification The employee agrees to indemnify and hold PPL and PPL’s principals, agents, employees and

subcontractors harmless for all claims, losses, expenses, fees, including attorney fees, costs and

judgments that may be asserted against PPL based on any acts or omissions of the employee and/or

employer in carrying out their individual responsibilities under this agreement.

Accepted:

__________________________ _________________________________

Employer Signature/Date Employee Signature/Date

Send Signed Agreement to PPL to Finalize EmploymentPlease return one signed copy of this agreement to PPL and keep copies for the employer and employee

records. Upon receipt by PPL, this agreement will be executed. An executed agreement will authorize PPL

to issue paychecks to the employee on behalf of the employer using FSSA funds awarded to the participant.

Public Partnerships, LLC

Fiscal Intermediary

7776 Pointe Pkwy W Ste. 150

(866) 799-9381 Fax

(866) 264-2296 Phone [email protected] Email

Phoenix, AZ 85044

Attendant/Employee Training Checklist

As a participant in the Indiana Self-Directed Attendant Care Program, I, the undersigned, affirm that I have received training in how to fulfill my role in the program and am presently in good understanding of how the program will work and what my responsibilities will be:

• I will complete all necessary paperwork required to become and employee.• I will report my time accurately and appropriately in accordance with the program’s

outlined timekeeping procedures.• I understand that Worker’s Compensation will not be provided by my employer, the fiscal

intermediary (PPL), or the State of Indiana and that I am responsible for my own negligentacts. As such, I will not take on responsibility for services that are outside the range of thejob description, specifically medically-related services.

• I will be treated with dignity and respect, which includes respect of my privacy andconfidentiality, and I will extend this respect to my employer.

• I will report abuse or fraud promptly to the specified authorities.

My signature below affirms that I have read and understood these responsibilities and willdo my best to discharge them.

_____________________________ _________________________ Signature Date

NEED HELP? CALL TOLL FREE 1-866-264-2296

Consumer and Employee Relationship Form

What is the purpose of this form?

Our contract with IN FSSA has specific guidelines as to who is allowed to provide services to our consumers. Please complete this form with your employer.

I ____________________________________ provide services to the (Print Employee’s Name)

Participant/Consumer _____________________________. My relationship to the consumer is (Check One): (Print Participant’s Name)

I hereby certify that the information presented above is correct to the best of my knowledge.

Employer Signature: _______________________________

Employee Signature: _________________________________

I am his/her Spouse

I am his/her Parent

I am his/her Legal Guardian

I am his/her Power of Attorney (POA); or his/her Health Care Representative (HCR); or the person directing care for the consumer (EOR)

I am None of the Above

Public Partnerships, LLC IN FSSA Financial Administrator 7776 S Pointe Pkwy W Ste. 150 Phoenix, AZ 85044

Revised: 6/1/12 PCG Public Partnerships, LLC

Form TE 20 Financial Administrator 7776 Pointe Pkwy W Ste. 150 Phoenix, AZ 85044

Application for Tax Exemptions Based on Age, Student Status, and Family Relationship

State Worked: _____________________________________ Program: _____________________________________

Participant Name: _____________________________ Employer Name: _____________________________________

Employee Name: _____________________________ Employee Date of Birth: ______ /______ /____________

Employees providing domestic services, such as personal assistance, may be exempt from paying certain federal and state taxes based on the employee’s age, student status, or family relationship to the employer. In some cases, the employer may also be exempt based on the employee’s status. If you and your employer qualify for these exemptions you must take them. PCG Public Partnerships will determine the tax exemptions that apply to you and to your employer (see enclosed guidelines). Employee – Please answer all the following questions based on your age, student status, and relationship to the employer:

1. Are you a non-resident alien temporarily in the United States on an F-1, J-1, M-1, or Q-1 visa admitted to the USfor the purpose of providing domestic services?

Yes, that description fits my status. No, that description does not fit my status.

2. Are you the child of the employer (includes adopted children)? Yes, my employer is my parent (mother or father). No, my employer is not my parent.

3. Are you the spouse of the employer? Yes, my employer is my spouse (husband, wife). No, my employer is not my spouse.

4. Are you the parent of the employer (includes adopted children)? Yes, my employer is my child (son or daughter). No, my employer is not my child.

5. If you answered “Yes” to Question 4, check any of the following that apply. If you answered “No”, proceed toQuestion 6.

Yes, I also provide care for my grandchild or step-grandchild in my child’s home. Yes, my grandchild or step-grandchild is under age 18, or has a physical or mental condition that requires

personal care of an adult for at least four continuous weeks during the calendar quarter in which services are performed.

Yes, my child (son or daughter) is widowed or divorced and not remarried, or living with a spouse who has a mental or physical condition which prohibits the spouse from caring for my grandchild for at least four continuous weeks during the calendar quarter in which services are performed.

6. Are you under the age of 18 or do you turn 18 this calendar year? Yes, I am under 18 or am turning 18 this calendar year. No, I am over 18.

If you answered “Yes” to Question 6, answer the following question. If you answered “No”, skip this section. Is the job of performing household services (personal assistance) your principal occupation? Note: Do not answer “Yes” if you are a student.

Yes, performing household services is my principal occupation. No, performing household services is not my principle occupation, or I am a student.

IMPORTANT: You must notify PCG Public Partnerships if your status changes. Employee Signature: ______________________________________ Date: ______/______/__________

Submit to:



Guide to Tax Exemptions Based on Age, Student Status, and Family Relationship Employee Copy – Keep for your records

Employees providing domestic services such as personal assistance may be exempt from paying certain federal and state taxes based on the employee’s age, student status or family relationship to the employer. In some cases, the employer may also be exempt from paying certain taxes based on the employee’s status. IMPORTANT: Please see IRS Publication: #926 – Household Employer’s Tax Guide, and IRS website article: “Foreign Student Liability for Social Security and Medicare Taxes” for additional information.

IMPORTANT:

These exemptions are not optional. If the employee and employer qualify for these tax exemptions they mustbe taken.

If the employee’s earnings are exempt from these taxes, the employee may not qualify for the related benefits,such as retirement benefits and unemployment compensation.

The questions regarding family relationship refer to the relationship between the employee and the employer ofrecord (common law employer). In some cases, the program participant is the employer of record. In othercases, the employer of record may be someone other than the program participant. Check program rules.

Program rules may prohibit some types of employees. For example, most Medicaid-funded programs do notpermit a spouse to be paid as an employee for providing services to a spouse. Check program rules.

PCG Public Partnerships will determine the tax exemptions that apply to the employee and employer based onthe information provided by the employee. PCG Public Partnerships cannot provide tax advice.

Tax Exemptions for Non-Resident Students

For a non-resident student in the United States on an F-1, J-1, M-1, or Q-1 visa admitted to the US for the purpose of providing domestic services, the employer and employee are exempt from paying FICA (Social Security and Medicare taxes) and the employer is exempt from paying FUTA (Federal Unemployment Tax) on wages paid to this employee. The employer may also be exempt from paying State Unemployment Insurance, depending on the rules in the state.

Tax Exemptions for Children Employed by Parent

For a child under 21 employed by his or her parent, the employer and employee are exempt from paying FICA (Social Security and Medicare taxes) and the employer is exempt from paying FUTA (Federal Unemployment Tax) on wages paid to this employee until the child (employee) turns 21 years of age. The employer may also be exempt from paying State Unemployment Insurance, depending on the rules in the state.

Tax Exemptions for Spouses Employed Spouses

For a spouse (husband, wife, or domestic partner in some states) employed by his or her spouse, the employer and employee are exempt from paying FICA (Social Security and Medicare taxes) and the employer is exempt from paying FUTA (Federal Unemployment Tax) on wages paid to this employee. The employer may also be exempt from paying State Unemployment Insurance, depending on the rules in the state.



Tax Exemptions for Parents Employed by Children

For a parent employed by his or her child and answering “No” to any of the additional questions under Question #6 regarding caring for a grandchild or step grandchild, the employer and employee are exempt from paying FICA (Social Security and Medicare taxes) and the employer is exempt from paying FUTA (Federal Unemployment Tax) on wages paid to this employee. The employer may also be exempt from paying Stat e Unemployment Insurance, depending on the rules in the state.

For a parent employed by his or her child and answering “Yes” to all of the additional questions regarding caring for a grandchild or step grandchild, the employer is exempt from paying Federal Unemployment Tax (FUTA) on wages paid to this employee. The employer may also be exempt from paying State Unemployment Insurance, depending on the rules in the state.

Tax Exemptions for Employee under Age 18

For employees under the age of 18 or turning 18 in the calendar year: If the employee is a student, domestic services are deemed not to be the employee’s principle occupation and the employer and employee are exempt from paying FICA (Social Security and Medicare taxes) .

Employment Relationship Status

Federal Insurance Contributions Act - Social Security and

Medicare Taxes

Federal Unemployment Tax Act

State Unemployment Insurance

(FICA) (FUTA) (SUI)

Foreign Student on VISA in US for Purpose of Providing Domestic Service

FICA exempt FUTA exempt See footnote (1)

Child Employed by Parent FICA exempt only until 21st birthday

FUTA exempt only until 21st birthday

See footnote (2)

Spouse Employed by Spouse FICA exempt FUTA exempt SUI exempt (3)

Parent Employed by Child FICA exempt only if not also caring for dependent child of the

employer (employee’s grandchild)

FUTA exempt SUI exempt except in NY and WA. See footnote (4)

Employee Under 18 or Turning Age 18 in Calendar Year

FICA exempt through year of 18th birthday only if enrolled as a full-

time student

Not Applicable Not Applicable

(1) Foreign student in the United States on F-1/J-1 VISA is exempt from SUI in the following states: PA, WA.

(2) Child under 18 employed by parent is SUI exempt in the following states: CA, IL, MA, ME, NJ, NV, OH, OR, PA, SC, TN, WA, WV.Child under 21 employed by parent is SUI exempt in the following states: AZ, GA, IN, KS, NY, OK, VA, WY, and District ofColumbia.

(3) For California only, a registered domestic partner employed by his/her re gistered domestic partner is SUI exempt.

(4) Parent employed by child is SUI exempt in all states and the District of Columbia with the exception of N Y and WA.

Public Partnerships, LLC Attention: IN FSSA 7776 S Pointe Pkwy W Suite 150 Phoenix, AZ 85044

Paperwork Reminder: Form I-9

Please note that Federal rules require employees and employers to complete the relevant sections of the Form I-9. Employers must examine identity documents and record the employment eligibility of each employee they wish to hire.

As a reminder, third parties such as PPL are not permitted to complete this form on behalf of you or your employees. It is the responsibility of employers and employees to complete Form I-9 themselves.

PPL provides Employers with an enrollment package with a number of forms, including the Form I-9 and instructions for completing this form. Employers must:

Direct employees they wish to hire to properly and fully complete the I-9 Ensure that the employee completes and signs Section 1 of the I-9 Verify I-9 documentation and complete Section 2 of the I-9 Complete and sign as the employer in the Certification section of the I-9 Forward a copy of the completed I-9, along with all other completed enrollment forms, to PPL for record-keeping purposes

As the employer, you should retain the original Form I-9 for your own records.

PPL will maintain its copy, along with the other enrollment forms, per the records retention terms of the IN FSSA Program.

As always, we are here to assist you. If you have any questions or need further information, please contact PPL Customer Service at 866-264-2296.

What is it for?

This form tells the USCIS that you – the employee - are eligible for employment in the United States.

Who needs to sign?

Two people need to sign it – 1) the employee and 2) the employer.

Why does the employer need to sign this?

The IRS holds both the employer and the employee responsible for an individual’s legal status and eligibility for employment.

I have a temporary work authorization that needs to be renewed at a later date. Can I still work?

Yes. If you are eligible to work now, you can complete this form. It is important that you keep your work authorizations up-to-date. Your employer will need to verify your status again once your temporary authorization has expired.

Do I need to do anything more than sign the I-9?

Yes. You need to show proof that you are legally eligible to work. There are 10 types of documents that verify work eligibility listed on page 2. Show these documents to your employer when he/she certifies the I-9.

USCIS FORM I-9 Employment Eligibility Verification

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.

What is it for?

This form tells the IRS about the withholding allowances for which the employee is eligible.

Who needs to sign?

Every employee working with an employer who is using the FI.

What if an employee does not want to sign this tax form?

The FI needs this form completed and signed in order to withhold taxes with the employee’s desired allowances. In order to pay an employee, the FI must have a completed and signed form on file.

How should I complete the W-4 worksheet?

The FI cannot give advice about what allowances you should claim. If you have questions about what allowances you should claim, contact your tax professional.

IRS FORM W-4 Employee’s Withholding Allowing Certificate

Form W-42020

Employee’s Withholding Certificate

Department of the Treasury Internal Revenue Service

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Give Form W-4 to your employer.

Your withholding is subject to review by the IRS.

OMB No. 1545-0074

Step 1:

Enter

Personal

Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

(c) Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:

Multiple Jobs

or Spouse

Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:

Claim

Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 $

Multiply the number of other dependents by $500 . . . . $

Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $

Step 4

(optional):

Other

Adjustments

(a)

Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $

(b)

Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $

Step 5:

Sign

Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) Date

Employers

Only

Employer’s name and address First date of employment

Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)

Form W-4 (2020) Page 2

General Instructions

Future Developments

For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505.

Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.

Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).

When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:

1. Expect to work only part of the year;

2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax;

3. Have self-employment income (see below); or

4. Prefer the most accurate withholding for multiple job situations.

Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.

Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

!CAUTION

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.


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 onejob, 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 . . . . . . . . . . . . . . . . . . . . . 1 $

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 jobin the “Lower Paying Job” column. Find the value at the intersection of the two household salaries 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 paysweekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

4

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter thisamount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additionalamount 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 1040-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 7.5% 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

} . . . . . . . . 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 Part II of 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(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person 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 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 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.


Married Filing Jointly or Qualifying Widow(er)

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870

$10,000 - 19,999 220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070

$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900

$30,000 - 39,999 900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100

$40,000 - 49,999 1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220

$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220

$60,000 - 69,999 1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220

$70,000 - 79,999 1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240

$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460

$100,000 - 149,999 1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180

$150,000 - 239,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250

$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170

$260,000 - 279,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770

$280,000 - 299,999 2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370

$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970

$320,000 - 364,999 2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840

$365,000 - 524,999 2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280

$525,000 and over 3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650

Single or Married Filing Separately

Higher Paying Job

Annual Taxable

Wage & Salary


$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040

$10,000 - 19,999 940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830

$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110

$30,000 - 39,999 1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310

$40,000 - 59,999 1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080

$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060

$80,000 - 99,999 2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060

$100,000 - 124,999 2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620

$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370

$150,000 - 174,999 2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120

$175,000 - 199,999 2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230

$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$250,000 - 399,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$400,000 - 449,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540

$450,000 and over 3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300

Head of Household

Higher Paying Job

Annual Taxable

Wage & Salary


$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040

$10,000 - 19,999 830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440

$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850

$30,000 - 39,999 1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140

$40,000 - 59,999 1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360

$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380

$80,000 - 99,999 1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380

$100,000 - 124,999 2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870

$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620

$150,000 - 174,999 2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370

$175,000 - 199,999 2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980

$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$250,000 - 349,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$350,000 - 449,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200

$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240

FORM WH-4 Employee’s Withholding Exemption and County Status Certificate

What is it for?

This form tells your employer about the withholding allowances for which you are eligible.

Who needs to sign?

Every employee working with an employer who is using the FI.

What if an employee does not want to sign this tax form?

The FI needs this form completed and signed in order to withhold taxes with the employee’s desired allowances. If you do not submit this form to the FI, you will have the same federal and state tax exemptions..

How should I complete the WH-4 worksheet?

The FI cannot give advice about what allowances you should claim. If you have questions about what allowances you should claim, contact your tax professional.

State of IndianaEmployee’s Withholding Exemption and County Status Certificate

This form is for the employer’s records. Do not send this form to the Department of Revenue.The completed form should be returned to your employer.

Full Name _______________________________________________________ Social Security Number or ITIN __________________________

Home Address ________________________________ City _______________________ State ______ Zip Code ______________________

Indiana County of Residence as of January 1: ________________________________________ (See instructions)

Indiana County of Principal Employment as of January 1: _______________________________ (See instructions)

___________________________________________________________________________How to Claim Your Withholding Exemptions

1. You are entitled to one exemption. If you wish to claim the exemption, enter “1” .............................................................................. ___________ Nonresident aliens must skip lines 2 through 6. See instructions

2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1” ................................................... ___________3. You are allowed one (1) exemption for each dependent. Enter number claimed ............................................................................... ___________4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or

(b) if you and/or your spouse are legally blind. Check box(es) for additional exemptions: You are 65 or older □ or blind □ Spouse is 65 or older □ or blind □ Enter the total number of boxes checked ........................................................................................................................................... ___________

5. Add lines 1, 2, 3, and 4. Enter the total here ..................................................................................................................................... ►6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions) .................................................. ►

7. Enter the amount of additional state withholding (if any) you want withheld each pay period ........................................................... $ __________8. Enter the amount of additional county withholding (if any) you want withheld each pay period ......................................................... $ __________

I hereby declare that to the best of my knowledge the above statements are true. Signature: ______________________________________________________________________ Date: __________________________

Form WH-4State Form 48845 (R6 / 12-19)

Instructions for Completing Form WH-4This form should be completed by all resident and nonresident employees having income subject to Indiana state and/or county income tax.

Print or type your full name, Social Security number or ITIN and home address. Enter your Indiana county of residence and county of principal employment as of January 1 of the current year. If you neither lived nor worked in Indiana on January 1 of the current year, enter ‘not applicable’ on the line(s). If you move to (or work in) another county after January 1, your county status will not change until the next calendar tax year.

Nonresident alien limitation. A nonresident alien is allowed to claim only one exemption for withholding tax purposes. If you are a nonresident alien, enter “1” on line 1, then skip to line 7. You are considered to be a nonresident alien if you are not a citizen of the United States and do not meet the green card test and the substantial presence test (get Publication 519 from www.irs.gov for information about these tests).

All other employees should complete lines 1 through 7.

Lines 1 & 2 - You are allowed to claim one exemption for yourself and one for your spouse (if he/she does not claim the exemption for him/herself). If a parent or legal guardian claims you on their federal tax return, you may still claim an exemption for yourself for Indiana purposes. You cannot claim more than the correct number of exemptions; however, you are permitted to claim a lesser number of exemptions if you wish additional withholding to be deducted.

Line 3 - Dependent Exemptions: You are allowed one exemption for each of your dependents based on state guidelines. To qualify as your dependent, a person must receive more than one-half of his/her support from you for the tax year and must have less than $4,200 gross income during the tax year (unless the person is your child and is under age 19 or under age 24 and a full-time student at least during 5 months of the tax year at a qualified educational institution).

Line 4 - Additional Exemptions. You are also allowed one exemption each for you and/or your spouse if either is 65 or older and/or blind.

Line 5 - Add the total of exemptions claimed on lines 1, 2, 3, and 4. Enter the total in the box provided.

Line 6 - Additional Dependent Exemptions. An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a son, stepson, daughter, stepdaughter, foster child, and/or child for whom you are a legal guardian.

Lines 7 & 8 - If you would like an additional amount to be withheld from your wages each pay period, enter the amount on the line provided. NOTE: An entry on this line does not obligate your employer to withhold the amount. You are still liable for any additional taxes due at the end of the tax year. If the employer does withhold the ad-ditional amount, it should be submitted along with the regular state and county tax withholding.

You may file a new Form WH-4 at any time if the number of exemptions increases. You must file a new Form WH-4 within 10 days if the number of exemptions previously claimed by you decreases for any of the following reasons:(a) you divorce (or are legally separated from) your spouse for whom you have been claiming an exemption or your spouse claims him/herself on a separate Form WH-4; or(b) someone else takes over the support of a dependent you claim or you no longer provide more than one-half of the person’s support for the tax year.

Penalties are imposed for willingly supplying false information or information which would reduce the withholding exemption.

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Phone: Administrative Fax: (866) 799‐9381 TTY: Timesheet Fax: (866) 874‐0478 Email:

(866)264‐2296(800)360‐5899 [email protected] Web: www.publicpartnerships.com

Direct Deposit, also known as Electronic Funds Transmission (EFT), is the fastest and safest way to receive your paycheck from PPL on behalf of your employer. Your payment can be deposited directly into your checking account, savings account, or to a pay card of your choice. To sign up, review the steps below and complete the Direct Deposit application.

1. Meet Direct Deposit RequirementsComplete the Direct Deposit Application.Agree to immediately notify PPL in writing if you change your bank, account number, accounttype, ABA routing number, or contact information. You may need to submit a new Direct DepositApplication form. Failure to comply with this may result in delay of payment.

2. Submit Direct Deposit Application to PPLOnce you have completed the Direct Deposit application, you must gather and submit account verification documents to PPL. This differs depending on where you want your funds to go: • Checking account: Submit a voided check or a letter from your bank that states the checking

account number where your funds should be deposited.

• Savings account: Submit a letter from your bank that states your savings account number whereyour funds should be deposited.

• Pay card/debit card: Submit documentation from the pay card’s enrollment process or the paycard’s financial entity that verifies the account and the routing numbers.

NOTE: If you choose this option, please note that PPL does not support any particular pay card/debit card financial institution and is not responsible for any fees established by the financial institution. PPL recommends you review all pertaining to your pay card prior to enrolling and activating it.

3. Await confirmation from PPLYour Direct Deposit account will become active after PPL verifies your account number with your bank or pay card. The whole process will take 1 to 2 pay cycles from the time we receive your completed and signed application.

If there is a change in bank account information, your PPL payment account will be taken off Direct Deposit status until the new bank account information is verified. Verification may take a few weeks. You will receive paper checks in the interim period.

The Direct Deposit payment is sent on the check date (see Payroll Schedule) and should be in your bank account 24‐48 hours afterwards. Please note that bank holidays may delay posting. After considering bank holidays, contact PPL if you don’t receive your payment on time.

That’s it! Once your Direct Deposit becomes active, you will receive a summary of your gross wages, tax withholding, etc. on a document called a “Remittance Advice” that is mailed to you. Thank you for signing up – we hope you enjoy having faster access to your payments!

Public Partnerships, LLC - Indiana FSSA Program FORM -EFT1

CREATE OR CHANGE PPL EFT ACCOUNT CLOSE EXISTING PPL EFT ACCOUNT

PAYEE INFORMATION

OR

3 Payee Name 4 Telephone Number

5 Payee Address

6 City 7 State 8 Zip

AUTHORIZATION FOR SET-UP, CHANGE OR CANCELLATIONI authorize PPL to stop making electronic transfers to my account without advance notice. I certify that I'm authorized to contract for entity receiving deposits per this agreement, & that all information provided is accurate.

9 Signature (Required) 10 Title 11 Date

ACCOUNT DETAIL INFORMATION

12 Financial Institution Name (My Bank's Name)

13 Bank Address

14 Bank Routing Number Checking Savings Debit

16 My Account Number

17 Bank City 18 Bank State 19 Bank Zip

CANCELLATION

Cancellation Reason

I do not have access to the PPL Web Portal, please send Remittance Advice

Staff Entry:Date:

PPL Use ONLY

15 Account Type

Sect

ion

5

EIN

SSN

DIRECT DEPOSIT APPLICATION

Sect

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4

MAIL WITH VOIDED CHECK TO: Indiana FSSA Program, Public Partnerships, LLC, 7776 S Pointe Pkwy W Ste. 150 Phoenix, AZ 85044

New Debit Card Set-up

Change Account Number

Change Account Type

Cancellation Request

Change Financial Institution

New Direct Deposit Set-up

Check the appropriate box below based on your request.

Sect

ion

1Se

ctio

n 2

Sect

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Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPL will use to file required information returns to IRS.

I authorize PPL to process payments owed to me for services authorized by a IN FSSA Program in the state of Indiana. Per my request, PPL will deposit

my payment directly to my bank account indicated below using Automated Clearing House (ACH) transaction. I recognize that if I fail to provide

complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously

made. I certify I have read and agree to comply with PPL rules governing payments and electronic transfers. I authorize PPL to withdraw from the

designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow withdrawal,

then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke

this authorization, I recognize that I must forward such notice to PPL.

1 Federal Employer Identification No. (EIN)

2 Social Security Number (SSN)

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Phone: Administrative Fax: (877) 818‐9787 TTY: Timesheet Fax: (866) 661‐0309 Email:

(866)896‐0040(800)360‐5899 [email protected] Web: www.publicpartnerships.com

1. Do I need a bank account to obtain a pay card?No, you do not need a bank account to obtain a pay card.

2. What is a pay card?A pay card is an easy way to have your money deposited each payday without having a bankaccount. You are able to use this pay card at any ATM or it can be used just like a debit card tomake purchases directly.

3. Where can I obtain a pay card?A pay card can be obtained at a local merchant store (Wal‐Mart, CVS, Walgreens, etc) for anominal fee or via the pay card company’s website.

4. Is a new pay card needed for each pay cycle?No, the same pay card is used every pay cycle and the pay amount is directly transferred ontothe card.

5. What if all the money on the pay card is not used before the next pay cycle?The remaining balance on your pay card will carry over with your next deposit.

6. How do I know the balance on my pay card?For many pay cards, there will be a customer service number for the financial institution on theback of your pay card that you can call to obtain your card balance. Simply follow the directionsprovided to obtain your balance. If there is not a phone number for balances indicated on yourcard, refer back to your pay card enrollment paperwork for more information.

7. Are there any fees with the pay card?Your particular pay card may have transaction fees. PPL is not responsible for any feesestablished by the pay card’s financial institution.

8. Can I use my pay card at an ATM and will there be surcharges?Pay cards are usually accepted at any ATM. If the ATM charges a surcharge, you will be notifiedbefore the transaction is completed. You can accept the charge or you will have the option ofcanceling the transaction if you do not want to pay the fee.

9. Can I use my pay card to make online purchases?Usually, your pay card can be used to make online purchases. Refer to your pay card enrollmentpaperwork for additional information.

There are many websites where you can get free general information and/or information regarding pay cards such as, www.consumer‐action.org or www.usapaycard.com.

What You Need to Know About Incident Reporting

It is a requirement for anyone with direct care responsibilities of a participant including employers of records, providers and case managers with knowledge of an incident that affects, or potentially affects, this participant’s health, safety, or welfare to submit an initial Incident Report. An incident involving:

A) abuse, neglect, or exploitation of a participant or the death of a participantmust be submitted within 24 hours of the incident

OR

B) an “unusual occurrence” affecting the participant’s health, safety and welfareare must be submitted within 48 hours of the time of the incident

• An unusual occurrence includes, but is not limited to:o Significant injury to the participanto A residential fire resulting in relocation, and/or property loss in the

participant’s homeo Threat to public safety caused by the participanto Participant becomes a missing persono Medication erroro Criminal activity

Please submit reports on the Incident Reporting Website: https://ddrsprovider.fssa.in.gov/IFUR/

Self-Directed Attendant Care Program

Spend-Down Policy

EFFECTIVE DATE: MAY 5, 2010

Individuals receiving services through the Aged and Disabled Waiver’s Self-Directed Attendant Care program may have a spend-down. Having a spend-down means that an individual must pay his or her provider(s) directly for a portion of the services he or she receives each month.

If the individual you provide services to has a spend-down, and that amount has not already been met through other incurred medical charges for a particular month, that amount will be deducted from your wages.

If PPL deducts money from your wages for spend-down, PPL will send you a statement with your paycheck listing the amount deducted for the spend-down. You will then need to collect the amount of the spend-down directly from your employer, who is responsible for paying you the amount of the spend-down.

Toll-Free Numbers Phone: 1-866-264-2296

E mail: [email protected] Timesheet Fax: 1-866-874-0478

Administrative Fax: 1-866-799-9381 TTY: 1-800-360-5899

Attention Provider

Legislation signed by the President on August 10, 2010 repeals the Advanced Earned Income

Tax Credit. Recipients will not be able to claim Advance EITC after December 31, 2010.

Due to this legislation, we are unable to process any requests for advanced EIC. Please note

that the Earned Income Credit still exists. It is just that you can no longer request this credit

in advance in your paycheck. It can be claimed on Form 1040 when you file your 2011

income tax paperwork.

IRS Publication 596 explains the Earned Income Credit in great detail. Please refer to this

document for additional guidance. If further clarification on this legislation is needed, please

contact a tax professional.

Thank you,

PPL

Public Partnerships, LLC 7776 Pointe Pkwy E Ste. 150 Phoenix, AZ 85044

617.426.2026 Phone 866-421-3309 Fax