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
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Employee/PCA Registration Form REGISTRATION...Instructions: 6 Southside Road Danvers, MA 01923 Phone 1-800-231-5409, 978-762-8307 Fax 978-750-3639 Employee/PCA Registration Form 1.
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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:
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
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www.ne-arc.org
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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
nsarc28
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For FI Use: Paychoice____________ OIG________________ SS_______________
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Rev 03/17/2015
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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 (2016)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, 2017. 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 2016. 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 $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . G
H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H
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
20161 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 2016, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 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 (2016)
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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:
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
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Cons#________
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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
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Cons #______________
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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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REV. 7/21/14
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Payc
hekP
LU
S!
Sele
ct® M
ast
erC
ard
® P
repaid
Card
Te
rms
of
Use
Com
eric
a B
ank
(“w
e”,
“us”
and
“B
ank”
) is
pro
vidi
ng y
ou w
ith t
hese
ter
ms
(“Te
rms”
) an
d th
e en
clos
ed M
aste
rCar
d® (
“Car
d”).
You
may
acc
ept
cert
ain
one-
time
or r
ecur
ring
pa
ymen
ts f
rom
you
r em
ploy
er(s
), c
erta
in a
genc
ies
or o
ther
Ser
vice
Pro
vide
rs (
each
a
“Pay
or”)
to
by m
eans
of
the
Car
d. T
his
agre
emen
t de
scri
bes
your
rig
hts
and
oblig
atio
ns
with
res
pect
to
the
Car
d. I
f yo
u ha
ve q
uest
ions
, or
do
not
agre
e w
ith t
hese
Ter
ms,
you
sh
ould
not
act
ivat
e th
e C
ard.
You
can
des
troy
it b
y cu
tting
it in
hal
f.
YO
U C
AN
NO
T U
SE
THE
ENC
LOS
ED C
AR
D U
NTI
L Y
OU
AC
TIV
ATE
THE
CA
RD
AN
D
SEL
ECT
YO
UR
PER
SO
NA
L ID
ENTI
FIC
ATIO
N N
UM
BER
(P
IN).
Vis
it w
ww
.pay
chek
plus
.com
or
ca
ll us
at
1-
877-
380-
0978
to
ac
tivat
e yo
ur
card
. B
y se
lect
ing
your
P
IN an
d ac
tivat
ing
the
Car
d in
ac
cord
ance
w
ith th
e in
stru
ctio
ns
acco
mpa
nyin
g th
is f
orm
, yo
u w
ill b
e ag
reei
ng t
o ab
ide
by t
hese
Ter
ms.
You
r us
e of
the
C
ard
will
furt
her
atte
st to
you
r ag
reem
ent t
o ab
ide
by th
ese
Term
s.
1.
Paym
ents
to Y
ou.
An
acco
unt h
as b
een
esta
blis
hed
with
us
to fu
nd p
aym
ents
to y
ou.
We
will
mak
e fu
nds
avai
labl
e to
you
in th
e am
ount
s de
sign
ated
by
the
Pay
or, a
nd y
ou w
ill
be a
ble
to a
cces
s th
ose
fund
s w
ith th
e C
ard.
TH
E O
NLY
FED
ERA
L P
AYM
ENTS
TH
AT M
AY
BE
DEP
OS
ITED
TO
TH
IS C
AR
D A
RE
FED
ERA
L P
AYM
ENTS
FO
R Y
OU
R B
ENEF
IT.
The
max
imum
val
ue o
f pay
men
ts to
you
r C
ard
that
we
will
per
mit
each
day
is $
5,00
0, a
nd th
e m
axim
um b
alan
ce a
llow
able
on
your
car
d is
$10
,000
.
2.
Pers
onal
Identi
fica
tion N
um
ber
(PIN
). T
he C
ard
cann
ot b
e us
ed a
t au
tom
ated
te
ller
mac
hine
s (“
ATM
s”)
and
som
e po
int-
of-s
ale
(“P
OS
”) te
rmin
als
with
out t
he P
IN. Y
ou
may
be
aske
d to
sig
n a
sale
s sl
ip o
r pr
ovid
e id
entif
icat
ion,
rat
her
than
ent
er y
our
PIN
, fo
r ce
rtai
n P
OS
tra
nsac
tions
. A
t so
me
mer
chan
ts,
such
as
gas
stat
ions
, yo
u m
ay n
ot b
e re
quir
ed to
sig
n yo
ur n
ame
or e
nter
you
r P
IN.
3.
Card
Tra
nsa
ctio
ns.
You
can
use
you
r C
ard
to m
ake
purc
hase
s at
PO
S te
rmin
als,
and
m
erch
ant
loca
tions
tha
t ac
cept
Mas
terC
ard
debi
t ca
rds.
With
you
r P
IN,
you
may
use
you
r C
ard
to o
btai
n ca
sh fr
om a
ny A
TM o
r any
PO
S d
evic
e, a
s pe
rmis
sibl
e by
mer
chan
t, th
at b
ears
th
e M
aste
rCar
d®,
Mae
stro
®,
Cir
rus®
, A
CC
EL®
, A
llpoi
nt®
, or
Com
eric
a B
ank
Acc
epta
nce
Mar
k. W
hen
you
use
the
Car
d to
initi
ate
a tr
ansa
ctio
n at
cer
tain
mer
chan
ts, s
uch
as h
otel
s, a
ho
ld m
ay b
e pl
aced
on
your
ava
ilabl
e C
ard
fund
s fo
r an
am
ount
equ
al to
or in
exc
ess
of y
our
ultim
ate
tran
sact
ion.
The
hel
d fu
nds
will
not
be
avai
labl
e to
you
for
any
othe
r pu
rpos
e. A
ny
exce
ss w
ill b
e re
leas
ed fo
r yo
ur u
se w
hen
the
tran
sact
ion
is fi
nally
set
tled.
Cas
h re
fund
s w
ill n
ot b
e m
ade
to y
ou fo
r P
OS
pur
chas
es. I
f a m
erch
ant g
ives
you
a c
redi
t fo
r m
erch
andi
se r
etur
ns o
r ad
just
men
ts, it
may
do
so b
y pr
oces
sing
a c
redi
t ad
just
men
t, w
hich
we
will
app
ly a
s a
cred
it to
you
r C
ard
acco
unt.
You
may
not
use
the
Car
d to
per
form
tran
sact
ions
that
exc
eed
the
amou
nt o
f fun
ds m
ade
avai
labl
e to
you
. Th
ere
may
be
occa
sion
s w
hen
depo
sits
are
pos
ted
to y
our
acco
unt
in
erro
r, or
fun
ds a
dded
tha
t do
not
bel
ong
to y
ou.
You
are
not
auth
oriz
ed t
o sp
end
thes
e fu
nds
beca
use
the
Pay
or h
as n
ot a
utho
rize
d us
to
mak
e th
ese
fund
s av
aila
ble
thro
ugh
the
Car
d. I
n su
ch e
vent
s, t
his
erro
r w
ill b
e co
rrec
ted
once
dis
cove
red
and
fund
s w
ill
be a
djus
ted
in y
our
acco
unt.
Sho
uld
the
adju
stm
ent
resu
lt in
you
r ac
coun
t be
com
ing
nega
tive,
a n
otic
e le
tter
will
be
sent
to
you
expl
aini
ng t
he e
rror
and
the
rea
son
for
the
adju
stm
ent.
If yo
u ha
ve s
pent
the
fun
ds b
efor
e th
e er
ror
is i
dent
ified
, th
e am
ount
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 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
espi
te r
easo
nabl
e pr
ecau
tions
take
n by
us;
prob
lem
whe
n yo
u st
arte
d th
e tr
ansa
ctio
n;
avai
labl
e fo
r w
ithdr
awal
; or
13.
Lim
itati
on of
Tim
e to
S
ue.
An
actio
n or
pro
ceed
ing
by y
ou t
o en
forc
e an
0326
3304
17
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.
c. AtimesheetmaynotbesubmittedelectronicallyiftheConsumerandthePersonalCareAttendanthavenotbothsignedandagreedtousetheElectronicTimesheetsSubmissionInterfaceviathisAgreement.
i. IftheConsumerapprovestheirSurrogatetousethesystem,thentheSurrogatemustalsosignthisAgreement.
d. AnindividualElectronicTimesheetsAgreementisrequiredforeachConsumer/PersonalCareAttendantrelationshipthatchoosestousetheElectronicTimesheetsSubmissionInterface.ThisistrueeveniftheConsumerorPersonalCareAttendantisalreadyusingtheElectronicTimesheetsSubmissionInterfaceinanotherConsumer/PersonalCareAttendantrelationship.
MAILTO:NortheastArcFI,6SouthsideRd,Danvers, MA 01923
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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.