Instructions:

6 Southside Road Danvers, MA 01923

Phone 1-800-231-5409, 978-762-8307 Fax 978-750-3639

Employee/PCA Registration Form 1. Employee/PCA should not start working until the hiring process is complete. 2. Write the consumer number at the top of each form and complete all forms in this package. 3. The consumer, surrogate or legal guardian may sign as the employer. 4. Once complete; fax, mail, or drop off the paperwork to our office. 5. We will contact you if there is a problem with the paperwork and call you when the Employee/PCA becomes

active in our system (approximately 5 business days). 6. Once the Employee/PCA is active, please begin submitting timesheets. Timesheets received before this time

cannot be processed and will be mailed back to you. Reminder: Masshealth , SCO or One Care consumers cannot hire his/her spouse, parent (if consumer is a minor), surrogate, foster parent, or legally responsible relative.

 CONSUMER’S INFORMATION

 

Name: Consumer#:  

Street: Phone #:  

City: State: Zip:  

Employee/PCA Start Date: (The date the Employee/PCA began or will begin working for you)  

Check One: Masshealth SCO Self-Direct One-Care    

SURROGATE’S INFORMATION (if applicable):  

Name:  

Street: Phone#:  

City: State: Zip:  

  

EMPLOYEE/PCA’S INFORMATION  Name: Birth Date:  Street:

City: State: Zip:_______________

Home Phone #: Cell Phone #:

Email Address: Social Security#:  

Union#: (For FI use only) Rev. 7/21/14

 

        

Instrucciones:

6 Southside Road Danvers, MA 01923

Teléfono 1-800-231-5409, 978-762-8307 Fax 978-750-3639

Formulario de Registración del Empleado/PCA 1. El Empleado/PCA no debe de empezar a trabajar antes de que se complete el proceso de contratación. 2. Marque el número de consumidor en la parte de arriba de cada uno de los formularios que complete. 3. Sólo el consumidor, Sustituto o el Guardián Legal puede firmar como el Empleador. 4. Cuando estén completos los documentos, lo puede faxear, mandar por correo o entregarlo en nuestra oficina. 5. Nosotros le contactaremos si hay algún problema con los documentos y le llamaremos cuando su Empleado/PCA

este activo en nuestro sistema. (Aproximadamente 5 días laborables). 6. Cuando el Empleado/ PCA este activo, puede comenzar a mandar sus hojas de tiempo. Hojas de tiempo recibidas

antes de este tiempo no podrán ser procesadas y serán devueltas a usted por correo. Recordatorio: Un consumidor con cobertura de Masshealth , SCO o One Care no puede contratar a su Esposo/Esposa, Padre/Madre (si el consumidor es menor), Sustituto, Padres Foster, o cualquier relativo legalmente responsable de él.

 

INFORMACION DEL CONSUMIDOR  

Nombre: #de Consumidor:  

Calle: # Telefónico:  

Ciudad: Estado: Zip:  

Primer día del Empleado/PCA: (La fecha en que el Empleado/PCA comenzara a trabajar para usted))  

Marque Uno: Masshealth SCO Self-Direct One-Care    

INFORMACION DEL SUSTITUTO (si aplica):  

Nombre:  

Calle: # Telefónico:  

Ciudad: Estado: Zip:  

  

INFORMACION DEL EMPLEADO/PCA  

Nombre: Fecha de Nacimiento:  

Calle:  

Ciudad: Estado: Zip:  

# Teléfono de casa: Teléfono Celular #:  

Dirección Electrónica: # Seguro Social:  

Union#: (For FI use only) Rev. 7/21/14

Employee/PCA Package Check List  

Consumer Number:   

Please complete () this list as you complete forms in this package. A copy of the form must be returned with the completed package

     For FI Use

only For FI Use only

FORM COMPLETED

BY CONSUMER ()

     

      Received Forms       Completed

Employee/PCA Registration Form         

Personal Care Attendant Signature Form          Did the PCA check the box which represents their relationship?

Did the PCA sign this form?Form W-4

        

Did the PCA complete Line 1 to 3? Did the PCA complete Line 4 if applicable? Did the PCA fill out line 5 or 7 for exemptions, not both?

Did the PCA fill out Line 6 if they wanted additional taxes taken out of their paycheck?

Did the PCA sign this form? Did you write in the consumer name and address on line 8?

Form M-4

        

(OPTIONAL- Complete if PCA wants to claim different state exemptions from federal exemptions W-4)

Did the PCA complete Line 4? Did the PCA complete line 5 or line 5D, not both? Did the PCA sign this form?

Form I-9 (This is a 2 page document)

        

PCA/EMPLOYEE must present original documents at the time of hire

It is consumer’s responsibility for ensuring this form is properly filled out

Did the PCA complete Section 1 and sign this form? Was ID information verified and documented in section 2? ID

title, number and expiration date, if applicable. (Check back of I-9 to view acceptable documents)

Did the consumer fill in the date of hire and sign the CertificationSection in Section 2?

The business address is the consumer’s address.Other Forms of Payment

        

(OPTIONAL-but highly recommended)

Direct Deposit Application

Did the PCA include a voided check or an official bank form?Debit Card Application

Work Permit – Needed if the PCA is under age 18. (Can be completed by your local high school or city hall)

        

 

REMINDERS: - You must notify Northeast Arc FI of your most current contact information including address, phone numbers, e-mail and bank account information. This will allow us to send you any live PTO check, FICA refund check and/or year end W-2.

Rev. 7/8/2014

Lista de chequeo del Paquete para el Empleado/PCA  

Número del Consumidor:  

Por favor, complete () esta lista de la forma en la que completa los formularios en este paquete. Una copia de este formulario debe ser retornada junto al paquete completo.

   COMPLETADO POR EL

For FI Use only

For FI Use only

FORMULARIO CONSUMIDOR ()         Received Forms       Completed Formulario de Registración del Empleado/PCA   

Formulario para la Firma Del Asistente de Cuidado Personal          El PCA marcó la casilla en la que establece su relación?

El PCA firmó este formulario?Formulario W-4

        

El PCA completó las Líneas 1 a la 3? El PCA completó la Línea 4 si aplica? El PCA completó las líneas 5 ó 7 de las excepciones, no

ambas? El PCA completó la Línea 6 si desea que impuestos

adicionales sean deducidos de sus cheques? El PCA firmó este formulario? Usted escribió el nombre y dirección del consumidor en la

Línea 8?Formulario M-4

        

(OPCIONAL- Complete si el PCA desea clamar excepciones estatales diferentes de las Federales especificadas en el W-4)

El PCA completó la Línea 4? El PCA completó la línea 5 o la línea 5D, pero no ambas? El PCA firmó este formulario?

Formulario I-9 (Este es un documento de 2 páginas)

        

El PCA/EMPLEADO debe presentar documentos originales al momento de la contratación. Es la responsabilidad del consumidor de asegurarse que este formulario este completado apropiadamente. El PCA completó la Sección 1 y firmó este formulario? Está la información de la identificación verificada y documentada en la sección 2? Título de la identificación ID, número y fecha de expiración, si aplica. (Vea la parte de atrás del I-9 para revisar la lista de documentos aceptables) El consumidor completó la fecha de contratación y firmó la Certificación en la Sección 2?OTRAS FORMAS DE PAGO

        

(OPCIONAL-Pero muy recomendado) Aplicación para Depósito Directo

· El PCA incluyó un cheque cancelado o una carta oficial del banco?

Aplicación para Tarjeta de Débito Permiso de Trabajo – Necesario si el PCA es menor de 18 años de edad. (Puede ser completado por su Escuela secundaria local o Alcaldía)

        

 

RECORDATORIOS: - Usted debe mantener informado al Northeast Arc de su más actualizada información de contacto, incluyendo su dirección, teléfono, e-mail e información de su cuenta bancaria. Esto nos permitirá enviarle cualquier cheque de PTO, cheque de compensación de FICA o su W-2 a fin de año.

Rev. 7/8/2014

PCA-S (Rev. 06/11)  

Signature Form Personal Care Attendant

THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services

 

   

Northeast Arc Consumer # Name of fiscal intermediary (FI)

 ● All PCAs hired by a PCA consumer must fill out and sign

this form and give it to their employer (the PCA consumer). ● The PCA’s employer (the PCA consumer) must submit this

form to the FI, along with all other paperwork required by the FI and MassHealth.

● The FI cannot pay a PCA until all required paperwork is received and complete.

● MassHealth and the FI cannot pay a PCA to work o when the PCA consumer is in an inpatient facility, such

as a hospital or nursing facility; or o when the amount of time that has been authorized by

MassHealth has been exhausted or is insufficient. ● The PCA must read the rest of this form and sign below

before receiving payment from the FI.

 I agree to accept the position of personal care attendant (PCA) for (name of PCA consumer).

 I understand that my employer is the PCA consumer. My employer is responsible for hiring, firing, training and scheduling PCAs. My employer may select another person (a surrogate) to help manage his or her PCA ser vices. I must notify my employer and the surrogate (if any), of any changes in my circumstances that would affect my ability to perform my duties as a PCA. I must complete and provide accurate Activity Forms (time sheets) to my employer or the FI as soon as I can.The FI will process payroll for my employer. My employer is responsible for giving the check to me (unless I requested that my check be deposited directly into my bank account). I must provide proof of my identity to my employer to complete the Employment Eligibility Verification form (Form I-9), which the Depar tment of Homeland Security requires all employees to complete. (The FI will give my employer this form.)

 I understand that the MassHealth PCA program pays for personal care ser vices provided by a PCA only when the PCA provides physical assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to an eligible PCA consumer who has obtained prior authorization from MassHealth for PCA ser vices. PCA ser vices must be provided in accordance with the PCA consumer’s authorized PCA evaluation or reevaluation, ser vice agreement, and MassHealth regulations at 130 CMR 422.410.

 I understand that ADLs include physically assisting the PCA consumer with transferring, walking, using medical equipment, taking medications, bathing and grooming, dressing and undressing, passive range-of-motion exercises, eating, and toileting. I understand that IADLs include household ser vices that are essential to the PCA consumer’s care such as laundr y, shopping, housekeeping, meal preparation and cleanup, transpor tation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiv- ing personal care ser vices, and other activities approved by MassHealth as being instrumental to the health care needs of the PCA consumer.

 I understand that my employer (the PCA consumer) will tell me which of these ser vices require me to provide physical assistance.

 I understand that I cannot be paid as a PCA if I am a spouse, parent (if the PCA consumer is a minor child), surrogate, foster parent, or legally responsible relative of the PCA consumer.

 The following describes my relationship to my employer (the PCA consumer). (Please check one.)

 

adult child (18 yrs. or older) of member daughter–in-law of member son-in–law of member parent of adult (18 yrs. or older) member other relative (describe)________ nonrelative (describe)_______

 

I cer tify under pains and penalties of perjur y that the information on this signature form, and any accompanying statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete to the best of my knowledge. I also cer tify that I understand my duties, rights, and responsibilities as a PCA and that all the information I have provided to my employer (the PCA consumer), to the fiscal intermediar y, to the personal care management agency, or to MassHealth is true and accurate to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.

  

Print PCA Name Date

 PCA signature

PCA-S (Rev. 06/11)  

Ayudante de atención individual Formulario para la firma

   THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

 

  

Nombre del intermediario fiscal (FI, por sus siglas en inglés): Northeast Arc Consumer #  ● Todos los Ayudantes de atención individual (PCA, por sus siglas en

inglés) contratados por un usuario de PCA deberán llenar y firmar este formulario y entregárselo a su empleador (el usuario de PCA).

● El empleador de PCA (el usuario de PCA) deberá enviarle este formulario al intermediario fiscal, junto con toda la document- ación adicional que exijan el intermediario y MassHealth.

● El FI no podrá realizarle pagos a un PCA hasta que se haya recibido toda la documentación requerida y esta esté completa.

● MassHealth y el FI no podrán pagarle a un PCA por trabajar : o cuando el usuario de PCA esté internado en un hospital o

centro de enfermería; o o cuando la cantidad de tiempo que MassHealth haya autorizado

se haya agotado o no sea suficiente. ● El PCA deberá leer el resto de este formulario y firmar en el

espacio siguiente antes de recibir pagos del IF.

 Estoy de acuerdo en aceptar el puesto de ayudante de atención individual (PCA, por sus siglas en inglés) para

(nombre del usuario de PCA).  

Entiendo que mi empleador es el usuario de PCA. Mi empleador está a cargo de contratar, despedir, capacitar y elaborar los horarios de los PCA. Mi empleador puede escoger a otra persona (un sustituto) que le ayude a manejar los servicios de PCA. Debo notificarles a mi empleador y al sustituto (si lo hubiera) cualquier cambio en mi situación que afecte mi capacidad para desempeñar mis labores de PCA. Debo llenar y entregarle a mi empleador o al sustituto Formularios de actividad (planillas de control de horas) exactos tan pronto como pueda. El FI procesará los pagos que deba realizarme mi empleador. Mi empleador tendrá la responsabilidad de entregarme el cheque (a menos que yo haya solicitado que mi cheque se deposite directamente en mi cuenta bancaria).Tendré que proporcionarle a mi empleador prueba de mi identidad para llenar el Formulario de verificación de cumplimiento de los requisitos de empleo (Formulario I-9), que el Depar tamento de Seguridad Nacional (Depar tment of Homeland Security) requiere a todos los empleados. (El FI le entregará a mi empleador este formulario.)

 Entiendo que el programa PCA de MassHealth solamente paga por los ser vicios de atención individual que preste un PCA cuando éste proporcione asistencia física para realizar actividades de la vida diaria (ADLs, por sus siglas en inglés) o actividades instrumentales de la vida diaria (IADLs, por sus siglas en inglés) a un usuario de PCA elegible que haya obtenido autorización previa de MassHealth para recibir ser vicios de PCA. Los servicios de PCA deberán prestarse de conformidad con la evaluación o reevaluación autorizada del usuario de PCA, con el contrato de ser vicios y las regulaciones de MassHealth en 130 CMR 422.410.

 Entiendo que las ADLs comprenden asistir físicamente al usuario con las actividades cotidianas comprende ayudarle a trasladarse, a caminar, a utilizar aparatos médicos, a tomar medicamentos, a bañarse y arreglarse, a vestirse y desvestirse, a realizar ejercicios pasivos para mejorar la amplitud de movimientos, a comer y a ir al baño. Entiendo que las IADLs comprenden ser vicios domésticos esenciales para la atención del usuario, tales como lavar la ropa, hacer las compras, mantener la casa ordenada, preparar las comidas y recoger los platos, llevarlo a citas médicas, realizar el mantenimiento de sillas de ruedas u otros equipos médicos, llenar los documentos requeridos para recibir los ser vicios de atención individual y otras actividades que MassHealth haya aprobado por ser instrumentales para satisfacer las necesidades relativas al cuidado de la salud del usuario de PCA. Entiendo que mi empleador (el usuario de PCA) me informará en cuáles de estos ser vicios se requiere que yo le preste asistencia física.

 Entiendo que no me podrán pagar como un PCA si soy el cónyuge, el padre/la madre (si el usuario de PCA es un hijo menor de edad), el sustituto, el padre/la madre de crianza o el pariente legalmente responsable del usuario de PCA.

 La siguiente es mi relación con mi empleador (el usuario de PCA). (Por favor marque una opción.)

 

Hijo adulto (de 18 años o más) del afiliado Nuera del afiliado Yerno del afiliado Padre/madre del afiliado adulto (18 años o más) Otro pariente (describa)_____ No soy pariente (describa)______

Cer tifico bajo los castigos y penas de perjurio que la información que contiene este formulario para la firma y toda declaración adjunta que yo haya suministrado, han sido revisadas y firmadas por mí y son verdaderas, exactas y completas a mi mejor entender.También cer tifico que entiendo mis deberes, derechos y responsabilidades como PCA y que toda la información que he proporcionado a mi empleador (el usuario de PCA), al intermediario fiscal, a la agencia de administración de atención individual o a MassHealth es verdadera y exacta a mi mejor entender. Entiendo que yo podría ser objeto de sanciones de carácter civil o de denuncia penal por cualquier falsificación, omisión u ocultación de cualquier hecho fundamental incluido en este documento.

 Nombre del PCA en imprenta: Firma del PCA y fecha:

 Firma del PCA:

Form W-4 (2015)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, 2016. See Pub. 505, Tax Withholding and Estimated Tax.Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2015. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . . G

H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20151 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

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

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

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)

 

 

 

N

P E U

  

FORM M-4

MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/ 12

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

 Employee: File this form or Form W-4 with your employer. Otherwise, Massachusetts Income Taxes will be withheld from your wages without exemptions.

 

Employer: Keep this certificate with your records. If the employee is believed to have claimed excessive exemptions, the Massachusetts Department of Revenue should be so advised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . . . . . . . . . .

2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will

be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Additional withholding per pay period under agreement with employer $

A. Check if you will file as head of household on your tax return.

B. Check if you are blind. C. Check if spouse is blind and not subject to withholding.

D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income will not exceed $8,000.

EMPLOYER: DO NOT withhold if Box D is checked.  

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.  

Date . . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THIS FORM MAY BE REPRODUCED            

 THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE

 A. Number. If you claim more than the correct number of exemptions, civil and criminal penalties may be imposed. You may claim a smaller number of exemptions. If you do not file a certificate, your employer must withhold on the basis of no exemptions.

 

If you expect to owe more income tax than will be withheld, you may either claim a smaller number of exemptions or enter into an agreement with your employer to have additional amounts withheld.

 

You should claim the total number of exemptions to which you are entitled to prevent excessive overwithholding, unless you have a significant amount of other income.

 

If you work for more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer.

 

If you are married and if your spouse is subject to withholding, each may claim a personal exemption.

 

B. Changes. You may file a new certificate at any time if the number of exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son’s income indicates that you will not provide over half of his support for the year, you must file a new certificate.

 C. Spouse. If your spouse is not working or if she or he is working but not claiming the personal exemption or the age 65 or over exemption, general- ly you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemp- tions for your spouse or for any dependents that will not be claimed on your annual tax return.  

If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding system adjustment for the $4,400 exemption for a spouse.  

D. Dependent(s). You may claim an exemption in line 3 for each individual who qualifies as a dependent under the Federal Income Tax Law. In addition, if one or more of your dependents will be under age 12 at year end, add “1” to your dependents total for line 3.  

You are not allowed to claim “federal withholding deductions and adjustments” under the Massachusetts withholding system.  

If you have income not subject to withholding, you are urged to have additional amounts withheld to cover your tax liability on such income. See line 5.

 IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

 

Consumer #________________________ 

 

 

Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services

USCIS Form 1-9

OMB No. 1615-0047 Expires 03/3112016

..,.START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any)

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

Date of Birth (mm/ddlyyyy) I r· ]~[j~[ Numbj E-mail Address Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following): D A citizen of the United States

D A noncitizen national of the United States (See instructions)

D A lawful permanent resident (Alien Registration Number/USCIS Number): -----------

0 An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) _______ . Some aliens may write "N/A" in this field. (See instructions)

For aliens authorized to work, provide your Alien Registration Number!USCIS Number OR Form 1-94 Admission Number:

1. Alien Registration Number/USCIS Number: __________ _

OR 3-D Barcode

Do Not Write in This Space 2. Form 1-94 Admission Number:---------------

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:

Foreign Passport Number:----------------------

Country of Issuance: ------------------------

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

I Signature of Employee: I Date (mmldd/yYW):

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator: I Date (mmlddlyyyy):

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

Address (Street Number and Name) 'City or Town I State I Zip Code

Employer Completes Next Page

Form 1-9 03/08/13 N Page 7 of9

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List 8 and one document from List C as listed on the "Lists of Acceptable Documents• on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.)

Employee Last Name, First Name and Middle Initial from Section 1:

List A Identity and Employment Authorization

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mmlddlyyyy):

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mmlddlyyyy):

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mmlddlyyyy):

Certification

OR List B Identity

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mmlddlyyyy):

AND ListC Employment Authorization

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mmldd/yyyy):

3-D Barcode Do Not Write in This Space

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

Signature of Employer or Authorized Representative I Date (mmldd/yyyy) I Title of Employer or Authorized Representative

Last Name (Family Name) First Name (Given Name) I Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) I City or Town I State I 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 I B. Date of Rehire (if applicable) (mmlddlyyyy):

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below.

Document Title: I Document Number: Expiration Date (if any)(mmldd/yyyy):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative: Date (mmlddlyyyy): Print Name of Employer or Authorized Representative:

Form 1-9 03/08/13 N Page 8 of9

1.

2.

3.

4.

5.

6.

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A LIST B LISTC

Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization

Employment Authorization OR AND

U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number

Permanent Resident Card or Alien li>·.· State or outlying possession of the card, unless the card includes one of

Registration Receipt Card (Form 1-551) United States provided it contains a the following restrictions: photograph or information such as (1) NOT VALID FOR EMPLOYMENT

Foreign passport that contains a name, date of birth, gender, height, eye

(2) VALID FOR WORK ONLY WITH temporary 1-551 stamp or temporary

color, and address INS AUTHORIZATION

1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION

Employment Authorization Document provided it contains a photograph or information such as name, date of birth, 2. Certification of Birth Abroad issued

that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545)

3. SchooiiD card with a photograph 3. Certification of Report of Birth For a nonimmigrant alien authorized to work for a specific employer 4. Voter's registration card issued by the Department of State because of his or her status: (Form DS-1350)

5. U.S. Military card or draft record Original or certified copy of birth a. Foreign passport; and 4.

b. Form 1-94 or Form I-94A that has 6. Military dependent's ID card certificate issued by a State,

the following: 7. U.S. Coast Guard Merchant Mariner county, municipal authority, or territory of the United States

(1) The same name as the passport; Card bearing an official seal and

8. Native American tribal document (2) An endorsement of the alien's 5. Native American tribal document

nonimmigrant status as long as 9. Driver's license issued by a Canadian 6. U.S. Citizen ID Card (Form 1-197) that period of endorsement has government authority not yet expired and the ..... ·' 7 . Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or ·,· unable to present a document States (Form 1-179) limitations identified on the form. 1• listed above:

8. Employment authorization Passport from the Federated States of I•. 10. School record or report card document issued by the Micronesia (FSM) or the Republic of Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Form I-9 03/08/13 N Page 9 of9

Rev. 4/9/2014  

6 Southside Road, Danvers, MA 01923

978-762-8307 – Fax 978-750-3639  

Direct Deposit Application  

 

Consumer #:  

Employee/PCA’s Name:  

Bank Name:  

Routing#: Account#:  

 

Checking Account – Please attach a copy of a voided check. This check must show your name and address pre-printed on it and contains a valid bank routing number and checking account number.

     

Please tape or glue a voided check here  

         

Savings Account – Please attach an official bank form from your bank indicating your name, bank routing number, and savings account number. This document must be signed by a Bank Representative and the account information must be typed not handwritten.

 

  

I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize the Bank to accept and to credit any credit entries indicated by the Company to my account. In the event the Company deposits funds erroneously to my account, I authorize the Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until the Company and the Bank have received written notice from me of its termination in such time and such manner as to afford the Company and the Bank reasonable opportunity to act on it.

 

 Employee/PCA’s Signature: Date:

 

PLEASE NOTE THAT A DIRECT DEPOSIT ACTIVATION MAY TAKE UP TO 10 BUSINESS DAYS. YOUR FIRST PAYMENT MAY BE A PAPER CHECK.

Rev. 4/9/2014  

6 Southside Road, Danvers, MA 01923

978-762-8307 – Fax 978-750-3639  

Aplicación para Depósito Directo  

 

Número de Consumidor:  

Empleado/Nombre del PCA:  

Nombre del Banco:  

Numero de Ruta: Numero de cuenta:  

 

Cuenta de cheques – Por favor agregue una copia de un cheque cancelado. Este cheque debe mostrar su nombre y dirección -impreso y debe contener una cuenta de banco y numero de ruta validos.

     

Por favor, pegue el cheque cancelado aquí con cinta adhesiva o con otro material adhesivo.         

Cuenta de Ahorros – Por favor agregue una carta o formulario oficial de su banco indicando su nombre, numero de cuenta y de ruta de su cuenta de ahorros. Este documento debe estar firmado por un representante de su banco y la información de su cuenta debe estar impresa y no escrita a mano.

 

  

Yo autorizo a mi empleador (de aquí en adelante “La Compañía”) a depositar cualquier cantidad que se me deba iniciando entradas de crédito a mi cuenta en la institución financiera (de aquí en adelante “El Banco”) indicado en este formulario. Además, yo autorizo que el Banco acepte y acredite cualquier entrada de crédito indicada por La Compañía a mi cuenta. En el caso de que la Compañía deposite fondos erróneamente en mi cuenta, yo autorizo a la Compañía a que debite mi cuenta por el monto que no sobrepase la cantidad depositada por error. Esta autorización se mantendrá en efecto hasta que La Compañía y El Banco hayan recibido notificación por escrito de mi parte para terminación a su debido tiempo y de una manera que ambos puedan actuar a tiempo.

 

 Firma del PCA/Empleado: Fecha:

 

POR FAVOR, NOTE QUE LA ACTIVACION DEL DEPOSITO DIRECTOR PUEDE TOMAS HASTA 10 DIAS LABORABLES. SU PRIMER PAGO SERA UN CHEQUE FISICO.

 

 

PaychekPLUS! Select® MasterCard® Prepaid Card Enrollment Form  

FISCAL INTERMEDIARY: Northeast ARC   Thank you  for your  interest  in using the PaychekPLUS! Select MasterCard Prepaid Card (“PaychekPLUS! Select Card”) to receive your pay. By completing this form you will be applying for a PaychekPLUS! Select Card. Use of this card  is subject to the terms, conditions and fees outlined in the Cardholder Agreement included with this enrollment form. If you have any  concerns about  the  terms and  conditions  for  the  card, please  contact  the  Fiscal  Intermediary named above before you submit this form. 

 

The PaychekPLUS! Select Card  is  issued by Comerica Bank pursuant to a  license with MasterCard International, Inc. To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to  identify you. We may also ask to see your driver's license or other identifying documents. We may also use other records to validate your identity. 

Applicant Information:  

*Full Name 

*Home Address  (PO Box is not permitted) 

*Street: 

 

*City:  *State: *ZIP: 

Mailing address (if different than Home Address) 

Street: 

 

City:  State: ZIP: 

*SSN  *Date of Birth (MM/DD/YYYY) *Phone Number: 

* These fields are required. 

Authorization:  

•  By signing below, you direct the Fiscal Intermediary identified above to load your pay to your PaychekPLUS! Select Card. You specifically authorize the Fiscal Intermediary to initiate credit entries to, and if necessary, to initiate debit entries to correct a previous credit error to your PaychekPLUS! Select Card. This authorization will remain  in effect until the Fiscal  Intermediary receives written notice from you terminating your consent and Fiscal Intermediary has a reasonable opportunity to act on that notice. 

 

•  You also understand and agree that to process this application and  load your pay to the PaychekPLUS! Select Card, certain personally identifiable  information about  you  and  your PaychekPLUS!  Select Card  account will be  collected by  and  shared between  the  Fiscal Intermediary and Comerica. Information shared by and with the Fiscal Intermediary and Comerica Bank may include, without limitation, your name, address, social security number, date of birth, prepaid card account status, and direct deposit information for your prepaid card account. By providing a telephone number, I expressly consent to receiving calls regarding my card account at this number, including auto‐dialed calls and prerecorded or artificial voice message calls. Calls to a mobile number may incur fees from my cellular provider. By signing below, you consent to the Fiscal Intermediary and Comerica Bank sharing this and other information for the purpose of opening, maintaining and loading the requested prepaid account. 

  

Employee Signature  Date  

 Information below this line will be used by the Fiscal Intermediary only. 

 To assist the Fiscal Intermediary in processing your pay, please provide information about the individual to whom you provide Services (your “Client”): Client Name:  Client

Address Street:

Apt/Suite

Client No.:  City: ZIP:

Consumer#_________ 

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sact

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uld

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otic

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you

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rror

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ified

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ay b

e au

tom

atic

ally

ded

ucte

d fr

om fu

ture

pay

men

ts to

you

r ac

coun

t as

desc

ribe

d

in S

ectio

n 9

of th

is d

ocum

ent.

Your

Car

d m

ust n

ot b

e us

ed fo

r an

y un

law

ful p

urpo

se (

for

exam

ple,

to

faci

litat

e In

tern

et g

ambl

ing)

. Yo

u ag

ree

not

to u

se y

our

Car

d or

fun

ds f

or

any

tran

sact

ion

that

is

illeg

al. W

e re

serv

e th

e ri

ght to

den

y tr

ansa

ctio

ns o

r au

thor

izat

ions

fr

om m

erch

ants

app

aren

tly e

ngag

ing

in t

he I

nter

net

gam

blin

g bu

sine

ss o

r id

entif

ying

th

emse

lves

thr

ough

tra

nsac

tion

reco

rds

or o

ther

wis

e as

eng

aged

in

such

bus

ines

s. Y

ou

may

als

o st

op p

aym

ent

on a

pre

auth

oriz

ed r

ecur

ring

pay

men

t by

eith

er c

allin

g us

or

wri

ting

us a

t lea

st th

ree

busi

ness

day

s be

fore

the

date

of t

he p

aym

ent.

Ple

ase

be

advi

sed t

hat

you m

ay e

xper

ience

diff

iculti

es u

sing t

he

Car

d a

t: unat

tended

ve

ndin

g m

achin

es a

nd k

iosk

s; g

as s

tatio

n p

um

ps

(you m

ay g

o in

side

to p

ay);

and c

erta

in

oth

er m

erch

ants

, su

ch a

s re

nta

l ca

r co

mpan

ies,

wher

e a

pre

auth

ori

zed a

mount

may

be

hel

d u

ntil

a fi

nal

bill

is r

ender

ed.

4.

Card

and P

IN S

ecu

rity

. Yo

u ag

ree

not

to g

ive

or o

ther

wis

e m

ake

the

Car

d or

PIN

av

aila

ble

to o

ther

s. F

or s

ecur

ity r

easo

ns,

you

agre

e no

t to

wri

te y

our

PIN

on

the

Car

d or

ke

ep i

t in

the

sam

e lo

catio

n as

the

Car

d. T

he C

ard

is o

ur p

rope

rty

and

mus

t be

ret

urne

d

to u

s up

on r

eque

st.

5.

Transa

ctio

n L

imit

ati

ons.

We

may

ref

use

to a

utho

rize

a C

ard

tran

sact

ion

if: (

a) i

t w

ould

exc

eed

the

amou

nt a

vaila

ble

for

your

use

; (b

) th

e C

ard

is r

epor

ted

lost

or

stol

en;

(c)

we

belie

ve t

he C

ard

is c

ount

erfe

it; o

r (d

) w

e ar

e un

cert

ain

whe

ther

the

tra

nsac

tion

is

auth

oriz

ed b

y yo

u or

per

mitt

ed b

y la

w. W

e m

ay te

mpo

rari

ly “

free

ze”

the

Car

d an

d at

tem

pt

to c

onta

ct y

ou if

we

note

tran

sact

ions

that

are

unu

sual

or

appe

ar s

uspi

ciou

s.

For

secu

rity

rea

sons

, we

limit

the

amou

nt a

nd n

umbe

r of

tran

sact

ions

you

can

mak

e w

ith

your

Car

d. F

or e

xam

ple,

com

mon

tran

sact

ions

are

lim

ited

as fo

llow

s:

Transa

ctio

n T

ype

Maxi

mum

Am

ount

per

Transa

ctio

n

Tota

l

Maxi

mum

A

mount

per

Day

Maxi

mum

N

um

ber

of

Transa

ctio

ns

per

Day

ATM

Wit

hdra

wals

$500

$500

3

Purc

hase

s (P

OS

Tr

ansa

ctio

ns)

$252

5$2

525

20

Tell

er

Ass

iste

d C

ash

W

ithdra

wals

$252

5$2

525

4

Transf

ers

(to

a c

ard

or

to

a b

ank

acc

ount)

$950

$950

2

6.

Fore

ign C

urr

ency

Tra

nsa

ctio

ns.

If

you

obta

in c

ash

or p

erfo

rm a

n AT

M o

r P

OS

tr

ansa

ctio

n in

a c

urre

ncy

othe

r th

an U

.S.

dolla

rs,

the

mer

chan

t or

Mas

terC

ard®

will

co

nver

t th

e am

ount

of

the

tran

sact

ion

into

U.S

. do

llars

to

be c

harg

ed t

o yo

ur C

ard.

U

nder

the

cur

renc

y co

nver

sion

pro

cedu

re t

hat

Mas

terC

ard®

use

s, t

he n

on-U

.S.

dolla

r tr

ansa

ctio

n am

ount

is m

ultip

lied

by a

cur

renc

y co

nver

sion

rat

e to

det

erm

ine

its e

quiv

alen

t in

U.S

. do

llars

. Th

e cu

rren

cy c

onve

rsio

n ra

te t

hat

Mas

terC

ard®

typ

ical

ly u

ses

is e

ither

a

gove

rnm

ent-

man

date

d ra

te,

or a

rat

e se

lect

ed f

rom

a r

ange

of

rate

s av

aila

ble

in t

he

who

lesa

le c

urre

ncy

mar

kets

(N

OTE

: th

is r

ate

may

be

diffe

rent

fro

m t

he r

ate

Mas

terC

ard

®

itsel

f re

ceiv

es).

The

con

vers

ion

rate

may

be

diffe

rent

fro

m t

he r

ate

in e

ffect

on

the

date

of

your

tran

sact

ion

and

the

date

it is

pos

ted

to y

our

Car

d.

7.

Reco

rd o

f Your

Ava

ilable

Funds

and T

ransa

ctio

ns.

You

can

get

a r

ecei

pt a

t the

tim

e yo

u pe

rfor

m a

tra

nsac

tion

at a

n AT

M o

r P

OS

ter

min

al.

You

may

obt

ain

info

rmat

ion

ab

out

the

amou

nt o

f fu

nds

avai

labl

e th

roug

h th

e C

ard

by c

allin

g th

e C

usto

mer

Ser

vice

C

ente

r to

ll fr

ee a

t 1-

877-

380-

0978

or

by v

isiti

ng w

ww

.pay

chek

plus

.com

. Fr

om t

he w

eb

site

you

can

sel

ect

and

prin

t m

onth

ly s

tate

men

ts f

or t

rack

ing

the

tran

sact

ions

pos

ted

to

your

Car

d ac

coun

t. Yo

u al

so h

ave

the

righ

t to

rece

ive

a w

ritte

n su

mm

ary

of tr

ansa

ctio

ns fo

r th

e 60

day

s pr

eced

ing

your

req

uest

by

calli

ng u

s at

1-8

77-3

80-0

978.

8.

Lost

or

Sto

len C

ard

/PIN

. If

you

belie

ve t

he C

ard

or P

IN h

as b

een

lost

or

stol

en o

r th

at s

omeo

ne h

as tr

ansf

erre

d or

may

tran

sfer

mon

ey fr

om y

our

Car

d ac

coun

t with

out y

our

perm

issi

on,

call

us a

t 1-

877-

380-

0978

, or

wri

te t

o us

at

Car

dhol

der

Ser

vice

s, P

O B

ox

5516

17, J

acks

onvi

lle, F

L 32

255

with

det

ails

.

9.

Adju

stm

ents

to Y

our

Acc

ount

Bala

nce

. Th

ere

are

occa

sion

s w

hen

adju

stm

ents

w

ill b

e m

ade

to y

our a

ccou

nt to

refle

ct a

mer

chan

t adj

ustm

ent,

reso

lve

a ca

rdho

lder

dis

pute

re

gard

ing

a tr

ansa

ctio

n po

sted

to

your

acc

ount

, or

to

adju

st e

ntri

es o

r de

posi

ts p

oste

d in

er

ror.

Thes

e pr

oces

sing

ent

ries

cou

ld c

ause

you

r ac

coun

t to

have

a n

egat

ive

bala

nce.

If s

o,

you

agre

e to

rep

ay u

s th

e am

ount

of

any

tran

sact

ions

tha

t ex

ceed

the

aut

hori

zed

amou

nt

or c

ause

you

r ac

coun

t to

go

nega

tive,

eith

er f

rom

fut

ure

depo

sits

pos

ted

to y

our

acco

unt

or b

y pe

rson

al c

heck

or

mon

ey o

rder

. Unl

ess

paid

by

pers

onal

che

ck o

r m

oney

ord

er, t

he

amou

nt to

be

repa

id m

ay b

e au

tom

atic

ally

ded

ucte

d fr

om fu

ture

pay

men

ts to

you

r ac

coun

t.

10.

In C

ase

of Err

ors

or

Quest

ions

about Your

Transa

ctio

ns.

If y

ou th

ink

an e

rror

ha

s oc

curr

ed in

con

nect

ion

with

you

r C

ard

acco

unt,

call

us a

t 1-8

77-3

80-0

978

or w

rite

us

at th

e ad

dres

s de

scri

bed

abov

e as

soo

n as

you

can

.

We

mus

t al

low

you

to

repo

rt a

n er

ror

until

60

days

afte

r th

e ea

rlie

r of

the

dat

e yo

u

elec

tron

ical

ly ac

cess

yo

ur ac

coun

t, if

the

erro

r co

uld

be vi

ewed

in

yo

ur el

ectr

onic

hi

stor

y, o

r th

e da

te w

e se

nt t

he F

IRS

T w

ritte

n hi

stor

y on

whi

ch t

he e

rror

app

eare

d. I

f el

ectr

onic

acc

ess

to y

our

Car

d ac

coun

t is

not

ava

ilabl

e or

if

you

have

not

rec

eive

d

a w

ritte

n st

atem

ent,

we

mus

t he

ar f

rom

you

with

in 1

20 d

ays

the

tran

sfer

was

cre

dite

d

or d

ebite

d fr

om y

our

acco

unt.

You

may

req

uest

a w

ritte

n hi

stor

y of

you

r tr

ansa

ctio

ns

at a

ny t

ime

by c

allin

g us

at

1-87

7-38

0-09

78 o

r w

ritin

g us

at

Car

dhol

der

Ser

vice

s,

P O

Box

551

617,

Jac

kson

ville

, FL

3225

5. Yo

u w

ill n

eed

to te

ll us

:1.

You

r na

me,

add

ress

, tel

epho

ne n

umbe

r an

d C

ard

num

ber.

2. W

hy y

ou b

elie

ve th

ere

is a

n er

ror,

and

the

dolla

r am

ount

invo

lved

. 3.

App

roxi

mat

ely

whe

n th

e er

ror

took

pla

ce.

Ple

ase

prov

ide

us w

ith y

our

addr

ess

and

tele

phon

e nu

mbe

r, as

wel

l, so

tha

t w

e ca

n

com

mun

icat

e w

ith y

ou. I

f the

err

or c

anno

t be

reso

lved

ove

r th

e ph

one,

we

will

mai

l you

a

Req

uest

for

Inve

stig

atio

n fo

rm to

com

plet

e an

d re

turn

. You

mus

t ret

urn

the

form

with

in 1

0

days

to C

ardh

olde

r S

ervi

ces,

P O

Box

551

617,

Jac

kson

ville

, FL

3225

5.

We

will

det

erm

ine

whe

ther

an

erro

r oc

curr

ed w

ithin

10

busi

ness

day

s af

ter

we

hear

fro

m

you

and

will

cor

rect

any

err

or p

rom

ptly

. If w

e ne

ed m

ore

time,

how

ever

, we

may

take

up

to

45 d

ays

to i

nves

tigat

e yo

ur c

ompl

aint

or

ques

tion.

If

we

deci

de t

o do

thi

s, w

e w

ill c

redi

t yo

ur C

ard

with

in 1

0 bu

sine

ss d

ays

for

the

amou

nt y

ou t

hink

is

in e

rror

, so

tha

t yo

u w

ill

have

use

of

the

mon

ey d

urin

g th

e tim

e it

take

s us

to

com

plet

e ou

r in

vest

igat

ion.

If

we

ask

you

to p

ut y

our

com

plai

nt o

r qu

estio

n in

wri

ting

and

we

do n

ot r

ecei

ve i

t w

ithin

10

busi

ness

day

s, w

e m

ay n

ot c

redi

t you

r C

ard.

For

err

ors

invo

lvin

g P

OS

or

fore

ign-

initi

ated

tr

ansa

ctio

ns, w

e m

ay ta

ke u

p to

90

days

to in

vest

igat

e yo

ur c

ompl

aint

or

ques

tion.

We

will

tell

you

the

resu

lts w

ithin

thre

e bu

sine

ss d

ays

afte

r co

mpl

etin

g ou

r in

vest

igat

ion.

If

we

deci

de th

at th

ere

was

no

erro

r, w

e w

ill s

end

you

a w

ritte

n ex

plan

atio

n. Y

ou m

ay a

sk fo

r co

pies

of t

he d

ocum

ents

that

we

used

in o

ur in

vest

igat

ion.

If

you

need

mor

e in

form

atio

n ab

out

our

erro

r-re

solu

tion

proc

edur

es,

call

us t

oll-

free

at

1-87

7-38

0-09

78.

11.

Your

Lia

bil

ity.

Tel

l us

AT

ON

CE

if yo

u be

lieve

you

r C

ard

or P

IN h

as b

een

lost

or

stol

en. T

elep

honi

ng is

the

best

way

of k

eepi

ng y

our

poss

ible

loss

es d

own.

You

cou

ld lo

se

all t

he m

oney

ass

ocia

ted

with

you

r C

ard.

If y

ou te

ll us

with

in tw

o bu

sine

ss d

ays,

you

can

lo

se n

o m

ore

than

$50

if s

omeo

ne u

sed

your

Car

d or

PIN

with

out y

our

perm

issi

on. I

f you

do

NO

T te

ll us

with

in tw

o bu

sine

ss d

ays

afte

r yo

u le

arn

of th

e lo

ss o

r th

eft o

f you

r C

ard

or

PIN

, and

we

can

prov

e th

at w

e co

uld

have

sto

pped

som

eone

from

usi

ng y

our

Car

d or

PIN

w

ithou

t you

r pe

rmis

sion

if y

ou h

ad to

ld u

s, y

ou c

ould

lose

as

muc

h as

$50

0.

Note

: Yo

u w

ill n

ot b

e lia

ble

for

the

$50

or $

500

amou

nts

stat

ed a

bove

for

tra

nsac

tions

w

here

you

r P

IN i

s no

t us

ed t

o ve

rify

you

r id

entit

y if

you

have

not

rep

orte

d tw

o or

mor

e in

cide

nts

of u

naut

hori

zed

use

in t

he i

mm

edia

tely

pre

cedi

ng 1

2 m

onth

s, y

our

Car

d is

in

go

od s

tand

ing,

and

you

hav

e ex

erci

sed

reas

onab

le c

are

in s

afeg

uard

ing

your

Car

d fr

om

risk

of l

oss

or th

eft.

Als

o, i

f th

e w

ritte

n tr

ansa

ctio

n hi

stor

y or

oth

er C

ard

tran

sact

ion

info

rmat

ion

prov

ided

to

yo

u sh

ows

tran

sfer

s th

at y

ou d

id n

ot m

ake,

tel

l us

at on

ce. If

you

do n

ot tel

l us

with

in 6

0

days

afte

r th

e tr

ansm

ittal

of

such

inf

orm

atio

n, y

ou m

ay n

ot g

et b

ack

any

mon

ey y

ou l

ost

afte

r th

e 60

day

s if

we

can

prov

e th

at w

e co

uld

have

sto

pped

som

eone

fro

m t

akin

g th

e m

oney

if yo

u ha

d to

ld u

s in

tim

e. If a

good

rea

son

(suc

h as

a lon

g tr

ip o

r a

hosp

ital st

ay)

kept

you

from

not

ifyin

g us

, we

will

ext

end

the

time

peri

ods.

We

will

can

cel

your

Car

d if

it is

rep

orte

d to

us

as l

ost,

stol

en o

r de

stro

yed.

Onc

e yo

ur

Car

d is

can

cele

d, y

ou w

ill h

ave

no l

iabi

lity

for

furt

her

tran

sact

ions

inv

olvi

ng t

he u

se o

f th

e ca

ncel

ed C

ard.

12.

Our

Lia

bil

ity.

If w

e do

not

com

plet

e an

ele

ctro

nic

fund

tran

sfer

to o

r fr

om th

e C

ard

on

tim

e or

in th

e co

rrec

t am

ount

acc

ordi

ng to

thes

e Te

rms,

we

may

be

liabl

e fo

r you

r los

ses

or d

amag

es. T

here

are

som

e ex

cept

ions

, how

ever

. We

will

not

be

liabl

e, fo

r in

stan

ce, i

f:

perf

orm

the

tran

sact

ion;

stri

ke,

labo

r di

sput

e, c

ompu

ter

brea

kdow

n, t

elep

hone

lin

e di

srup

tion,

or

a na

tura

l di

sast

er)

prev

ents

or

dela

ys th

e tr

ansf

er, d

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REV.3‐31‐14

I. AboutTheElectronicTimesheetsModule

a. TheElectronicTimesheetsModuleisaweb‐basedinterfacethroughwhichConsumers,Surrogates,PersonalCareAttendants,andFiscalIntermediarystaffcanrespectivelyviewrelevanttimesheetinformation.Additionally,ConsumersandtheirSurrogates,butnotPersonalCareAttendants,willbeabletoviewtheirPriorAuthorizationamountsandutilization.

b. Consumers,SurrogatesandPersonalCareAttendantswillbeabletousethesystemtobothsubmitandapprovetimesheetselectronicallyforpaymentbytheFiscalIntermediary.

c. AConsumerisnotrequiredtohaveaSurrogateinordertousethesystem.ButincaseswhereaConsumerdoeshaveaSurrogateandtheConsumerapprovestheSurrogatetohaveaccesstotheElectronicTimesheetsSubmissionInterface,boththeConsumerandhis/herSurrogatewillhaveidenticalabilitiestoenterandapprovetimesheetsforpayment.IftheConsumerdoesnotfeelcomfortablewiththeelectronicinterface,theSurrogatehastheabilitytohandlealloftheConsumer’stimesheetsubmissionandapprovalresponsibilities.

II. TermsandConditions

Bysigningbelow,youareagreeingtothefollowingTermsandConditions:a. TheConsumerand/orhis/herSurrogateandthePersonalCareAttendantmusthavevalide‐mail

addresseswhichtheyaccessfrequently.b. TheConsumer,his/herSurrogate(ifapplicable)andthePersonalCareAttendantagreetouse

theElectronicTimesheetsSubmissionInterfaceasamethodofsubmittingtimesheets.i. SigningthisAgreementdoesnotrequireyoutoonlyusetheElectronicTimesheets

SubmissionInterface.Othermethodsofsubmittingtime,suchasfaxingormailing,arestillacceptable.

c. AtimesheetmaynotbesubmittedelectronicallyiftheConsumerandthePersonalCareAttendanthavenotbothsignedandagreedtousetheElectronicTimesheetsSubmissionInterfaceviathisAgreement.

i. IftheConsumerapprovestheirSurrogatetousethesystem,thentheSurrogatemustalsosignthisAgreement.

d. AnindividualElectronicTimesheetsAgreementisrequiredforeachConsumer/PersonalCareAttendantrelationshipthatchoosestousetheElectronicTimesheetsSubmissionInterface.ThisistrueeveniftheConsumerorPersonalCareAttendantisalreadyusingtheElectronicTimesheetsSubmissionInterfaceinanotherConsumer/PersonalCareAttendantrelationship.

Pleasenote:MasshealthdoesnotpayforactivityperformedbyaPCAwhiletheconsumerisimpatientinahospitalornursinghome.ActivityperformedbyaPCAwhiletheconsumerisinahospitalornursinghomeisconsideredasfraudandwillbereferredtotheBureauofSpecialInvestigations.

ConsumerName:□□□□□□□□□□□□□□□Consumer#□□□□

ConsumerE‐mail:□□□□□□□□□□□□□□□□□□□□ConsumerSignature:_____________________________________________________Date:_________________

SurrogateName: □□□□□□□□□□□□□□□□□

SurrogateE‐mail:□□□□□□□□□□□□□□□□□□□□□

SurrogateSignature:______________________________________________________Date:_________________

PCAName:□□□□□□□□□□□□□□□□□

PCAE‐mail: □□□□□□□□□□□□□□□□□□□□□□ PCASignature:____________________________________________________________Date:_________________

ElectronicTimesheetsAgreementFAXTHISFORMTO978‐750‐3639OR

MAILTO:NortheastArcFI,6SouthsideRd,Danvers, MA 01923

REV.3‐31‐14

I. AcercadelsistemadeHojasdeTiempoElectrónicas

a. ElsistemadehojaselectrónicasesunasistemaqueseaccesaatravésdelInternetenelcualConsumidores,Sustitutos,AsistentesdecuidadopersonalyelPersonaldelIntermediariofiscalpodránverlainformaciónrelevantealainformacióndesushojasdetiempo.Adicionalmente,elconsumidorysusustituto,peronoelAsistentedecuidadopersona,podránverelbalancedesuaprobacióndelservicioysuutilización.

b. Consumidores,SustitutosylosAsistentesdeCuidadoPersonapodránusarestesistemaparasometeryaprobarhojasdetiempoconlashoraqueelPCAtrabajaparaqueseanpagadasporelIntermediarioFiscal.

c. NoesrequeridoqueelConsumidortengaunsustitutoparapoderusaresteNuevosistema.PeroencasosdondeelConsumidortengaunsustitutoyelconsumidorapruebealsustitutoparaquetengaaccesoaenviarlashojasdetiempoelectrónicas,ambosdebentenerhabilidadesidénticasparaentraryaprobarestashojasdetiempoparasupago.SielconsumidornosesientecómodoconesteNuevosistema,elsustitutodebetenerlahabilidadylaresponsabilidaddemanejaresteNuevoprocesodesometeryaprobarlashojasdetiempoelectrónicas.

II. TérminosyCondiciones:Alfirmardebajo,ustedacuerdaseguirlossiguientestérminosycondiciones:

a. Elconsumidory/osusustitutoyelAsistentedeCuidadoPersonaldebentenerunadireccióndecorreoelectrónicovalidaalacualaccesandemanerafrecuente.

b. Elconsumidor,suSustituto(siaplica)yelAsistentedeCuidadoPersonalestándeacuerdoenusarelSistemaelectrónicodeHojasdetiempocomométodoparasometerlashorasdetrabajodelPCA.

i. ElfirmaresteacuerdonorequierequesolopuedautilizarestemedioparasometerlashorastrabajadasporsuPCA.Otrosmétodoscomofaxearoenviarporcorreolahojadetiempodepapel,esaunaceptable.

c. UnahojadetiemponoserásometidaelectrónicamentesielconsumidorosuasistentedecuidadopersonalnohanfirmadoyacordadoelusodeHojasdetiempoelectrónicasatravésdeesteacuerdo.

ii. Sielconsumidorapruebaasusustitutoausarelsistema,entonceselsustitutodebetambiénfirmaresteacuerdo.

d. SeesrequeridounacuerdodeusodehojaselectrónicasparacadarelacióndeConsumidor/PCAquedeseenutilizarestemétodoparasometersushorastrabajadas.EstoescorrectoaunqueelconsumidoroelAsistentedecuidadopersonalyaesteusandoestesistemadehojaselectrónicasenotrarelacióndeconsumidor/Asistentedecuidadopersonal.

Recordatorio:MasshealthnopagaraportrabajohechoporunPCAmientraselconsumidoresteinternoenunhospitaloenunacasaderecuperación.TodotrabajohechoporelPCAmientraselconsumidorestuvointernoseráconsideradocomofraudeyseráreportadoalBureauofSpecialInvestigations.

NombredelConsumidor:□□□□□□□□□□□□ #DelConsumidor□□□□

CorreoElectrónicodelConsumidor:□□□□□□□□□□□□□□□□□□

FirmadelConsumidor:_____________________________________________________Fecha:_________________

NombredelSustituto:□□□□□□□□□□□□□□□□□CorreoElectrónicodelSustituto:□□□□□□□□□□□□□□□□□□FirmadelSustituto:__________________________________________________________Fecha:_________________

NombredelPCA:□□□□□□□□□□□□□□□□□CorreoElectrónicodelPCA:□□□□□□□□□□□□□□□□□□□FirmadelPCA:____________________________________________________________Fecha:_________________

AcuerdodeusodeHojasdeTiempoElectrónicasENVIEPORFAXAL978‐750‐3639O

PORCORREO:NortheastArcFI,6SouthsideRd,Danvers,MA01923