PPL One Cabot Rd, STE 102Medford, MA 02155

Phone: 1- 888-623-5688 Admin Fax: 1-866-457-7276 TTY: 1-800-360-5899

Dear Employee:

You are receiving this Employment Packet because you intend to provide services as a

In Home employee to a child participating in the

Services (DDS) DESE Program.

will serve as your Employer and

processing services. The enclosed paperwork must be completed and returned to PPL

immediately. As a newly hired employee you must

before you can begin work.

Certain forms are required for

the enclosed Employee Packet Checklist.

properly completed Employee

If you need a new form, you can call PPL

Web site, go to: www.publicpartnerships.com, click on “Program Login”

corner, select “Massachusetts

PPL will issue paychecks to you based on properly submitted timesheets. These paychecks will

reflect tax withholdings based upon federal and state law and the information you provide to

us on the tax documents within this pa

to properly complete and submit a timesheet. PPL provides

method using the PPL Web Portal for timesheet submission.

If you have any questions regarding this process,

Service at 1-888-623-5688. We

Please fax all required forms to our Administrative Fax line:

EE

You are receiving this Employment Packet because you intend to provide services as a

ild participating in the Massachusetts Department of Developmental

. The parent/caregiver for the child that you provide services for

Employer and Supervisor, while PPL is responsible for all tax and payroll

processing services. The enclosed paperwork must be completed and returned to PPL

hired employee you must pass a criminal background check

required for each child you work for. These requirements are identified on

Packet Checklist. PPL cannot pay for any services provided until a

ee Packet is received.

If you need a new form, you can call PPL or print a copy from PPL’s Web site. To print from

Web site, go to: www.publicpartnerships.com, click on “Program Login” in the upper

Massachusetts” from the drop-down menu, click on the “ ESE

mades

PPL will issue paychecks to you based on properly submitted timesheets. These paychecks will

reflect tax withholdings based upon federal and state law and the information you provide to

us on the tax documents within this packet. The Employee Packet provides instructions on how

to properly complete and submit a timesheet. PPL provides the option of a

method using the PPL Web Portal for timesheet submission.

If you have any questions regarding this process, please feel free to contact PPL

. We are more than happy to assist you!

all required forms to our Administrative Fax line: 1-866

Please mail all required forms to:

Public Partnerships, LLC

Attn. MA DESE

One Cabot Rd, STE 102Medford, MA 02155

EEmmppllooyyeeee PPaacckkeett

You are receiving this Employment Packet because you intend to provide services as a Respite-

Massachusetts Department of Developmental

for the child that you provide services for

responsible for all tax and payroll

processing services. The enclosed paperwork must be completed and returned to PPL

criminal background check (CORI)

child you work for. These requirements are identified on

PPL cannot pay for any services provided until a

s Web site. To print from the

in the upper-right

DESE” link.

PPL will issue paychecks to you based on properly submitted timesheets. These paychecks will

reflect tax withholdings based upon federal and state law and the information you provide to

Packet provides instructions on how

the option of a convenient online

lease feel free to contact PPL Customer

66-457-7276 or

1

I n f o r m a t i o n a l

Employee Packet Forms Checklist

Forms Required for Each Child Served

- Employee Information and Attestation Form: This form is the standard application for employment for a potential employee under the DESE program. It provides PPL with all

necessary demographic information. It also includes the Employment Agreement Form, which

identifies the terms of employment. By signing this form, you are agreeing to all language in the

Employment Agreement, and Guidelines for Tax Exemptions forms and certify that all

information provided is accurate. ___page 3

- USCIS Form I-9: Department of Homeland Security - Employment Eligibility Verification. This form is used to confirm your immigration and US citizenship information. The form contains

instructions developed by the USCIS. Your employer must certify and sign Section 2 of the I-9

Form in order to hire you as his/her employee. Copies of the documents used for verification

must be verified by your employer but do not need to be submitted to PPL. Documents that

verify your identity are your Driver’s License, Passport, Birth Certificate, along with many

others. ___page 12

- IRS Form W-4: Employee’s Withholding Allowance Certificate. This form is used to calculate your federal tax withholding. The form contains instructions developed by the

IRS. ___ page 21

- Form M-4 (optional): Massachusetts Employee’s Withholding Exemption Certificate. This form is used to calculate your state tax withholding and is optional if you claim the same

number of exemptions for Massachusetts and US Income taxes. ___page 23

- CORI Request Form: Criminal Background Check Request Form. You must pass a criminal background check before you begin working with a consumer in the program. ___page 10

Informational Forms

� Guide to Tax Exemptions Based on Age, Student Status, and Family Relationship:

Employees providing domestic services may be exempt from paying certain federal and

state taxes based on the employee’s age, student status or family relationship to the

employer. Please review and keep this form for your records. ___page 24

� Timesheet Instructions and Copy of a Timesheet ___page 26

� Payroll Schedule: Follow this schedule to complete timesheets and submit them to PPL

biweekly. Properly completed and approved timesheets must be received by the

payroll deadline in order for you to be paid according to the payroll schedule.

___page 29�

EFT Instructions: This document provides instructions for setting up Direct Deposit with

PPL. Direct Deposit is highly recommended because it is the most dependable and

quickest way to receive pay checks. ___page 30

2

EEmmppllooyyeeee EEmmppllooyymmeenntt IInnffoorrmmaattiioonn && AAtttteessttaattiioonn FFoorrmm

In order to process your service payments Public Partnerships, LLC (PPL) needs to collect all of the information below. Please complete, sign and date this four (4) page Employment Information & Attestation Form in its entirety and submit it to PPL.

Consumer First Name: Consumer Last Name:

Employee First Name: M.I. Employee Last Name:

Employee Maiden/Alias Name(s)

Contact Information

Physical Address

Physical Address 2 (apt, number etc…)

City State and Zip Code

County

Mailing Address (leave blank if same as physical address)

Mailing Address 2 (apt, number etc…) (leave blank if same as physical address)

City (leave blank if same as physical address) State and Zip Code (leave blank if same as physical address)

County (leave blank if same as physical address)

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Primary Phone No./Extension Cell Phone No.

Alternate Phone No. Fax No.

Email Address

Tax Identification No. / Social Security Number

___-___-___ ___-___ ___-___-___-___

Date of Birth

___ ___/___ ___/___ ___ ___ ___ Gender

____ Male ____ Female

Marital Status

____ Single ____ Married

Employee Pay Rate (This information is necessary in order to process your timesheets)

Service Rate per Hour Effective Date

Senior Behavioral Therapist – PhD

Senior Behavioral Therapist – MA

In-Home Behavioral Therapist

Speech Therapy

Physical Therapy

Occupational Therapy

Skills Trainer

4

Account Detail Information (This information is necessary to process your payment via direct deposit or paper check. Only complete one)

___ I still want to receive a paper check, please send paper remittance advice.

For Direct Deposit Setup: Please include a copy of a blank check or a letter from your bank confirming the bank routing and bank account number. Financial Institution Name (only for Direct Deposit)

Account Type (please check one-only for Direct Deposit)

____ Checking ____ Savings ____ Debit

5

___ I still want to receive a paper remittance of my direct deposit instead of viewing my remittance online. To "Go Green" leave this check-box blank.

Relationship Status Note – The Employer is the person hiring you, evaluating your work and signing off on your

timesheets. The Employer is not the child you are providing services to. (This information is necessary so that we can determine if you are eligible for tax withholding exemptions)

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

_____ Yes, That description fits my status ____No, that description does not fit my status

2. Are you the child of the employer (includes adopted children)?

____ Yes, my employer is my parent (mother or father) _____No, my employer is not my parent

3. Are you the spouse of the employer?

____ Yes, my employer is my spouse (husband or wife) ____ No, my employer is not my spouse

4. Are you the parent of the employer (includes adopted children)?

___ Yes, my employer is my child (son or daughter) ____ No, my employer is not my child 5. If you answered “Yes” to Question 4, check any of the following that apply. If you answered “No”,

proceed to Question 6.___ Yes, I also provide care for my grandchild or step-grandchild in my child’s home.

___ Yes, my grandchild or step-grandchild is under 18, or has a physical or mental condition that requires personal care of an adult for at least four continuous weeks during the calendar quarter in which services are performed.

___ Yes, my child (son or daughter) is widowed and divorced and not remarried, or living with a spouse who has a mental or physical condition which prohibits the spouse from caring for my grandchild for at least four continuous weeks during the calendar quarter in which services are performed. 6. Are you under the age of 18 or do you turn 18 this calendar year?

___ Yes, I am under 18 or turning 18 this calendar year. ____ No, I am over 18.

If you answered “Yes” to Question 6, answer the following question. If you answered, “No” skip the questions below.

Is this job of performing household services (respite or nursing) your principal occupation? Note: Do not answer “Yes” if you are a student.

___ Yes ___ No

6

EMPLOYMENT AGREEMENT

The employee is hired and supervised directly by the employer. The employee must comply with the policies outlined below. This document must be signed and a copy maintained by the employer and employee and a copy must be included in the employment packet that is sent to PPL.

The Employee attests that he or she meets the minimum qualifications for employment in the MA DESE Program and hereby agrees to the duties and policies as specified below. Qualifications, duties and policies of the Employee include, but are not limited to, the following:

1. Employee is 18 years of age or older.

2. Employee has received a satisfactory result from the CORI process.

3. Employee has the required skills to perform Employee care services as specified in theDESE individual service plan.

4. Employee possesses a valid Social Security Number and is authorized to work in theUnited States.

5. Employee can demonstrate the capability to perform health maintenance activitiesrequired by the Employer or specified in the child’s DESE individual service plan, or bewilling to receive training in performance of the specified health maintenance activities.

6. Employee agrees that Federal Income, Medicare, Social Security and MassachusettsIncome Tax (as applicable) shall be withheld from Employee wages per IRS Form W-4and Massachusetts Form M-4 as completed by the Employee.

7. PPL will verify that the Employee does not appear on the Office of Inspector General’s(OIG) List of Excluded Individuals/Entities (LEIE). In the event the Employee appearson this list, he or she will not be permitted to work or be paid in this program.

8. Employee acknowledges and understands that funds available for payment are authorizedby the Commonwealth of Massachusetts, Department of Developmental Services inadvance of work performed. Payment to the Employee shall only be made as authorizedby the Commonwealth of Massachusetts Department of Development Services.Employees shall only perform work within the authorized hour amount as they will notbe compensated by the Commonwealth of Massachusetts, Department of DevelopmentalServices for work performed in excess of the authorized amount. Overtime (time inexcess of 8 hours per day or 40 hours per week) is not permitted in this program and ifthe Employer and Employee allow work to occur beyond the approved, authorized hours,the Employer shall accept responsibility for compensating the provider for any servicesperformed in excess of the amount authorized in the Individual Service Plan/ServiceAuthorization.

9. The Employee will not be paid for services not performed or time not worked and willnot be paid for services when the consumer is hospitalized.

7

10. Timesheets must be properly completed and signed by both the Employer and theEmployee. Hours recorded on timesheets cannot exceed the authorized number of hours.Timesheets are due to PPL within two business days from the end of the pay period.Timesheets received after two days will be paid within the next payroll cycle. Incorrecttimesheets will be returned and no paycheck will be issued. Timesheets must besubmitted by the consumer or Employee in accordance with the payroll scheduleprovided in this packet. Timesheets must be received within 30 days of when the servicesare provided, timesheets received after 30 days cannot be guaranteed payment.

11. All documents required by the Employment Packet, must be completed by the Employeeand submitted to PPL prior to performing work. The Employee must not begin work untilinformed by PPL that they have been certified to start.

12. All paychecks are mailed directly to the Employee’s home or are sent by direct deposit.

13. Payment of Employee wages are from Federal and State funds. Any false claims,statements, documents or concealment of material facts will be prosecuted underapplicable Federal and State laws.

14. Employee agrees to assist the family by providing the services and performing theactivities specified in the DESE individual service plan.

15. Employee agrees to provide Employee Services as specified in the DESE individualservice plan on a schedule mutually agreed upon between the Employer and theEmployee. Occasional variations in the Employee tasks and in the schedule may occur,based on mutual Agreement of the parties.

16. In the event of illness, emergency, or incident preventing Employee from providingscheduled service to the Employer, the Employee agrees to notify the Employer as soonas possible so that the Employer can obtain assistance from someone else.

17. Employee agrees to confidentially maintain all information regarding the Employer andto respect the Employer’s privacy.

18. Employee understands that the Employee is employed by the Employer not by PublicPartnerships, LLC or the Commonwealth of Massachusetts.

19. Employer’s property is not to be used for the Employee’s personal use, unless mutuallyagreed upon by both parties prior to use of property. All private matters discussed duringworking times shall be kept confidential.

20. Employees are to be punctual and respectful of all family members. All instructions as tocare shall be carried out carefully. The Employer's telephone may be used only withpermission.

21. Misrepresentation of time, services, individuals and/or other information is not permittedin MA DESE Program’s Fiscal Agent program. If the Employer or Employee sign atimesheet that is determined to misrepresent information, the consumer may lose theoption of consumer-direction.

22. The Employee agrees to follow the policies and procedures of the program and to holdharmless, release, and forever discharge DDS and Public Partnerships, LLC (PPL) from

8

any claims and/or damages that might arise out of any action or omissions by the Employee, Employer of Record, or Consumer.

23. Employer agrees to orient, train, and direct the Employee in providing the Employeeservices that are described and authorized by the DESE individual service plan or that arerequested by the Employer.

24. Employer agrees to establish a mutually agreeable schedule for the Employee’s services,either orally or in writing.

25. Employer agrees to provide adequate notice of changes in the Employee’s work schedulein the event of unforeseen circumstances or emergencies, but such notice cannot beguaranteed.

26. In consideration of Employee’s satisfactory job performance, the Employer agrees toauthorize completed Employee timesheets on a regular and timely basis according to thepredetermined Payroll Schedule. Net wages will include gross earnings calculatedaccording to the Employee’s pay rate minus payroll deductions for Employee’s share ofapplicable state and federal payroll withholdings.

27. Misrepresentation of time, services, individuals and/or other information is not permittedin the Department of Developmental Services DESE Fiscal Agent program. If theEmployer or Employee signs a timesheet that is determined to misrepresent information,the consumer may lose the program services.

28. The Employer agrees to follow the policies and procedures of the program and to holdharmless, release, and forever discharge DDS and Public Partnerships, LLC (PPL) fromany claims and/or damages that might arise out of any action or omissions by theEmployee, Employer of Record, or Consumer.

29. The Employer is responsible for proper execution of USCIS Form I-9, as defined inInstructions for Employment Eligibility Verification, Department of Homeland Security.The Employer must retain original Form I-9. PPL will only provide Form I-9 inemployment packets and retain a forwarded copy in PPL maintained employee files.

9

PUBPAEOHHS

COMPANY LETTERHEAD (The above code must remain visible)

CORI REQUEST FORM

Public Partnerships, LLC has been certified by the Criminal History Systems Board for access toconviction and pending criminal case data. As an applicant/employee for , Iunderstand that a criminal record check will be conducted for conviction and pending criminalcase information only and that it will not necessarily disqualify me. The information below iscorrect to the best of my knowledge.

Applicant/Employee Signature

APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT)

LAST NAME FIRST NAME MIDDLE NAME

MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH

DATE OF BIRTH *ID Theft Index PIN - -

SOCIAL SECURITY NUMBER (last 6 digits required) (if applicable)

MOTHER'S MAIDEN NAME

CURRENT AND FORMER ADDRESSES:

SEX: HEIGHT: ft. in. WEIGHT: EYE COLOR:

STATE DRIVER'S LICENSE NUMBER:(include state of issue)

***THE INFORMATION WAS VERIFIED WITH THE FOLLOWING FORM OFGOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION:

REQUESTED BY: SIGNATURE OF CORI AUTHORIZED EMPLOYEE

*The CHSB Identify Theft Index PIN Number is to be completed by those applicants that have beenissued an Identity Theft Index PIN Number by the CHSB. Certified agencies are required to provide allapplicants the opportunity to include this information to ensure the accuracy of the CORI requestprocess. All CORI request forms that include this field are required to be submitted to the CHSB via mailor by fax to 617-660-4614.

10

Attestation

By signing below, I and my Employer attest that we have read and understand all program rules and responsibilities. I understand I must sign and return this form as a condition of employment in this program, and that I cannot begin working until this form is completed and returned to Public Partnerships. I further attest by signing below, that I understand what is being requested of me, and I agree to abide by these terms and conditions. I further understand and agree that violation of any of the terms and/or conditions may result in termination of this agreement and payment for employment to any Recipient of this program.

By signing below, I authorize PPL to process payments owed to me for services authorized by a MA DESE Program. Per my request, PPL or directly into my bank account using Automated Clearing House (ACH) transaction. I recognize that if I fail to provide complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously made. I certify I have read and agree to comply with PPL rules governing payments and electronic transfers. I authorize PPL to withdraw from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to PPL

Employer Signature ______________________________________________Date________

Employer Name (Please Print) ____________________________________ Date_________

Employee Signature _____________________________________________ Date ________

Employee Name (Please Print) ____________________________________ Date ________

11

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

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

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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's 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 boxes):

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

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

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

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

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

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

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

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

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

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

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

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

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

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

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

and(2) An endorsement of the alien's

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

a. Foreign passport; and

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

listed above:

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

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

5. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 11/14/2016 N

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

Refer to the instructions for more information about acceptable receipts.

Form W-4 (2017) The exceptions don't apply to supplemental wages greater than $1,000,000.

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.

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.

Basic instructions. If you aren't 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. 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.

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 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

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.

Note: If another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

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.

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

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Tax credits. You can take projected tax credits into

account in figuring your allowable number of withholding allowances. Credits for child or dependent

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 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married}. • Is age 65 or older,

• Is blind, or care expenses and the child tax credit may be claimed Future developments. Information about any future

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

using the Personal Allowances Worksheet below. developments affecting Form W-4 (such as See Pub. 505 for information on converting your other legislation enacted after we release it) will be posted credits into withholding allowances. at www.irs.gov/w4.

A

B

c

D E F

G

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

{ • You're single and have only one job; or }

Enter "1" if: • You're married, have only one job, and your spouse doesn't work; or

• Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.

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.) .

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return .

Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above)

Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

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.

A

B

c D

E F

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, I 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•4 Employee's Withholding Allowance Certificate OMB No. 1545-0074

Department of the Treasury ... Whether you are entitled to claim a certain number of allowances or exemption from withholding is ~@17 Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

1 Your first name and middle initial

I Last name

12 Your social security number

Home address (number and street or rural route) 30 Single D Married 0 Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single" box. City or town, state, and ZIP code 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 .... 0

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

7 I claim exemption from withholding for 2017, 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 . ... / 1 I . .

Under penalties of perjury, I declare that I have examined this cert1f1cate and, to the best of my knowledge and belief, 1t 1s 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. 102200 Form W-4 (2017)

Form W-4 (2017) Page2

Deductions and Adiustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you're married filing jointly or you're a qualifying widow(er); $287 ,650 if you're head of household; $261,500 if you're single, not head of household and not a qualifying widow(er); or $156,900 if you're

$ married filing separately. See Pub. 505 for details . 1

{ $12,700 if married filing jointly or qualifying widow(er)

} 2 Enter: $9,350 if head of household 2 $ $6,350 if single or married filing separately

3 Subtract line 2 from line 1. If zero or less, enter "-0-" 3 $ 4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . 5 $ 6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7 $ 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiole Jobs Worksheet (See Two earners or multiole iobs on paqe 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here.

1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than "3" 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter "-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . 3

Note: If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet 4

5 Enter the number from line 1 of this worksheet 5

6 Subtract line 5 from line 4 . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed 8 $ 9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1 Table 2

Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on paying job are- line 2 above paying job are- line 2 above paying job are- line 7 above paying job are- line 7 above

$0 - $7 ,000 0 $0 - $8,000 0 $0 - $75,000 $610 $0 - $38,000 $610 7,001 - 14,000 1 8,001 - 16,000 1 75,001 - 135,000 1,010 38,001 - 85,000 1,010

14,001 22,000 2 16,001 26,000 2 135,001 - 205,000 1,130 85,001 - 185,000 1,130 22,001 - 27,000 3 26,001 - 34,000 3 205,001 - 360,000 1,340 185,001 - 400,000 1,340 27,001 35,000 4 34,001 44,000 4 360,001 - 405,000 1,420 400,001 and over 1,600 35,001 44,000 5 44,001 70,000 5 405,001 and over 1,600 44,001 55,000 6 70,001 85,000 6 55,001 65,000 7 85,001 - 110,000 7 65,001 75,000 8 110,001 - 125,000 8 75,001 - 80,000 9 125,001 - 140,000 9 80,001 - 95,000 10 140,001 and over 10 95,001 115,000 11

115,001 130,000 12 130,001 140,000 13 140,001 150,000 14 150,001 and over 15

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(~(2) and 6109 and their regulations require you to provide this information; your employer uses It to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice tor civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Rev. 8/02

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

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

FORMM-4

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ASSACHUSETTS

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SP

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Employee:File this form or Form W-4 withyour employer. Otherwise,Massachusetts Income Taxeswill be withheld from yourwages without exemptions.

Employer:Keep this certificate with yourrecords. If the employee isbelieved to have claimedexcessive exemptions, theMassachusetts Departmentof Revenue should be soadvised.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS1. 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 “3.” If your spouse is age 65 or over or will

be before next year and if otherwise qualified, write “4.” 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 incomewill 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

IF YOU CLAIM THE SAME NUMBER OF EXEMPTIONS FOR MASSACHUSETTS AND U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

60M 1/01 CRP0101 printed on recycled paper

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

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

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

If you work for more than one employer at the same time, you mustnot claim any exemptions with employers other than your principalemployer.

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

B. Changes. You may file a new certificate at any time if the number of ex-emptions increases. You must file a new certificate within 10 days if the num-ber of exemptions previously claimed by you decreases. For example, if dur-ing the year your dependent son’s income indicates that you will not provideover 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 notclaiming the personal exemption or the age 65 or over exemption, generallyyou may claim those exemptions in line 2. However, if you are planning to fileseparate annual tax returns, you should not claim withholding exemptions foryour spouse or for any dependents that will not be claimed on your annual taxreturn.

If claiming a wife or husband, write “3” in line 2. Using “3” is the withholdingsystem adjustment for the $3,300 exemption for a spouse.

D. Dependent(s). You may claim an exemption in line 3 for each individualwho 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 ad-justments” under the Massachusetts withholding system.

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

23

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

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

IMPORTANT: • These exemptions are not optional. If the employee and employer qualify for these tax exemptions they must

be taken. • If the employee’s earnings are exempt from these taxes, the employee may not qualify for the related benefits,

such as retirement benefits and unemployment compensation. • The questions regarding family relationship refer to the relationship between the employee and the employer of

record (common law employer). In some cases, the program participant is the employer of record. In other cases, the employer of record may be someone other than the program participant. Check program rules.

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

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

Tax Exemptions for Non-Resident Students

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

Tax Exemptions for Children Employed by Parent

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

Tax Exemptions for Spouses Employed Spouses

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

24

Tax Exemptions for Parents Employed by Children

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

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

Tax Exemptions for Employee under Age 18

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

Employment Relationship Status

Federal Insurance Contributions Act - Social Security and

Medicare Taxes

Federal Unemployment Tax Act

State Unemployment Insurance

(FICA) (FUTA) (SUI) Foreign Student on VISA in US for Purpose of Providing Domestic Service

FICA exempt FUTA exempt See footnote (1)

Child Employed by Parent FICA exempt only until 21st birthday

FUTA exempt only until 21st birthday

See footnote (2)

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

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

employer (employee’s grandchild)

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

Employee Under 18 or Turning Age 18 in Calendar Year

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

time student

Not Applicable Not Applicable

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

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

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

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

25

Timesheet Instructions for MA DESE Providers Need Help? Call Customer Service Toll Free at 1-888-623-5688

DDS has contracted with PPL to provide Financial Management to improve services to you. Please do your part to correctly complete timesheets so that payment is not delayed. Call PPL for help if you need it.

Keep these important instructions. Timesheets are paid on a bi-weekly check run. See the attached check run schedule. Timesheets are due by Monday at noon after the close of the pay period. Any timesheets received after the deadline will be processed in an off cycle check run the following Friday.

Completed timesheets should be faxed toll free to 1-866-743-2680 Timesheets can also be mailed to the following address: Public Partnerships, LLC, DESE/DDS Program, One Cabot Rd, STE 102, Medford, MA 02155. Faxing timesheets may speed the payment process for you. If possible, please fax your timesheets to PPL. For additional copies go to http://www.publicpartnerships.com.

Important Do’s and Don’ts

MUST DO MUST NOT DO Use black ink Don’t use pencil or colored ink Stay inside the lines Don’t use military time Write numbers and letters clearly. A machine will read your timesheet. Take the time to write clearly, or ask someone else to write for you.

Do not round time. PPL will do this.

Complete one timesheet per consumer. Use a new timesheet for each consumer you serve.

Don’t use any other timesheet. PPL cannot pay attendants if a different timesheet is submitted.

Use a separate timesheet for each service type. Don’t use one timesheet for two consumers or more than one service type.

Consumers (or designated signatory) and Attendants must sign and date the timesheet

Try not to touch the edges of the box when writing numbers and letters.

Fill in ALL required boxes, including Consumer and Provider Name, ID and Service Type.

Don’t cross out information if you make a mistake. Start a new timesheet.

Use 2 lines when a provider starts and stops work 2 times in the same day

Don’t write notes on the timesheet. This will cause our scanners to reject the timesheet and may delay payment.

Use A.M. and P.M. correctly. We show you how on the following page.

Don’t forget to fill in all information such as Attendant and Consumer Name, ID, Service Type. Timesheets must be signed and dated by both the consumer and the attendant.

26

Recording Header Information:

1. Complete all header information for the Provider and the Consumer.Include name and ID of the Provider and Consumer. The Provider ID is the ID provided toyour employee by PPL. Please contact DDS for your consumer ID. Contact PPL CustomerService if you have any questions regarding these identification numbers.

2. Use the correct pay period for your region (attached). Write the date inMM/DD/YYYY format.Make sure you write the start and end date for your pay period.

3. Record the time of day correctly using A.M. and P.M.A.M. means morning. Morning starts at midnight, and ends at 11:59:59, or 11 o’clock, fifty-nine minutes and 59 seconds, or one second before noon.

P.M. Afternoon and evening (or night time) is captured by the initials P.M. Afternoon startsat noon, or 12:00, and ends at 11:59:59, or 11 o’clock, 59 minutes and 59 seconds, or onesecond before midnight. The date changes at midnight.

4. Indicate the correct service typeConfirm only ONE service type has been bubbled in completely. Each service type has aspecific tax implication which is why it is important to fill each timesheet out based onservice type provided.

5. Be sure to sign and date the timesheet.

27

PPL Provider ID:

E

#CNSMRServed

#CNSMRServed

PUBLIC PARTNERSHIPS, LLC Provider TIMESHEET (Financial Management Services for MA DESE/DDS Program)

FAX: PPL @ 1-866-743-2680

MAIL: PUBLIC PARTNERSHIPS LLC, One Cabot Rd, STE 102, Medford, MA 02155

USE B L A C K INK, PRINT O N E CHARACTER PER BOX, F I L L C I R C L E S COMPLETELY, DO NOT WRITE ON THE LINES !!!

Provider Signature:

Date:

/ /By signing below, I certify thatI have provided the services tothe consumer during the timesdescribed on this time sheet.

Begin: Sunday (mm/dd/yyyy) / / T i m e IN

:

T i m e OUT

:

Total Hours

:

Week 1

Fri

Sun

Mon

Tue

Wed

Thu

Sat

: : :

: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :

End: Saturday (mm/dd/yyyy) / / T i m e IN

:

T i m e OUT

:

Total Hours

:

Week 2

Fri

Sun

Mon

Tue

Wed

Thu

Sat

: : :

: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :

Parent or Responsible Party Signature:

Date:

/ /I certify that the consumerhas received hours of serviceas reported above.

AM/PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM/PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM/PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM/PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

��������

AM PM AM PM AM PM AM PM

Provider's Name:

Consumer's Name:

Consumer's ID Number:

C

Service Type(fill one)

Family Service Navigation

Senior Behavioral Therapist- PhD

Senior Behavioral Therapist- MA

In-Home Behavioral Therapist

Speech Therapy

Physical Therapy

Occupational Therapy

Skills Trainer

Respite- Respite In Home

3033

0

3033

0

28

Public Partnerships, LLCMA DESE DDS Payment ScheduleFiscal Year 2018 (July 1, 2017-June 30, 2018)

One Cabot Rd, STE 102

Medford, MA 02155

Phone: (888) 623-5688

TS Fax: (866) 743-2680

Admin Fax: (866) 457-7276

Will be mailed on:

Check Run Date

NOTE: Timesheets and invoices are due by the Monday at noon prior to each check run. Checks are cut every other Friday.

Start (Sunday) Finish (Saturday)

Invoices Received by PPL…

June 25, 2017

July 9, 2017

July 23, 2017

August 6, 2017

August 20, 2017

September 3, 2017

September 17, 2017

October 1, 2017

October 15, 2017

October 29, 2017

November 12, 2017November 26, 2017

December 10, 2017

December 24, 2017

January 7, 2018

January 21, 2018

February 4, 2018February 18, 2018

March 4, 2018

March 18, 2018

April 1, 2018

April 15, 2018

April 29, 2018

May 13, 2018

May 27, 2018

June 10, 2018

June 24, 2018

July 8, 2017

July 22, 2017

August 5, 2017

August 19, 2017

September 2, 2017

September 16, 2017

September 30, 2017

October 14, 2017

October 28, 2017November 11, 2017

November 25, 2017

December 9, 2017

December 23, 2017

January 6, 2018

January 20, 2018February 3, 2018

February 17, 2018

March 3, 2018March 17, 2018

March 31, 2018

April 14, 2018

April 28, 2018

May 12, 2018

May 26, 2018

June 9, 2018

June 23, 2018

July 7, 2018

July 14, 2017

July 28, 2017

August 11, 2017

August 25, 2017

September 8, 2017

September 22, 2017

October 6, 2017

October 20, 2017

November 3, 2017

November 17, 2017

December 1, 2017

December 15, 2017

December 29, 2017

January 12, 2018

January 26, 2018

February 9, 2018

February 23, 2018

March 9, 2018

March 23, 2018

April 6, 2018

April 20, 2018

May 4, 2018

May 18, 2018

June 1, 2018

June 15, 2018

June 29, 2018

July 13, 2018

DDIIRREECCTT DDEEPPOOSSIITT

IINNFFOORRMMAATTIIOONN GGUUIIDDEE

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

1. Meet Direct Deposit Requirements Complete the Direct Deposit Application. Agree to immediately notify PPL in writing if you change your bank, account number, account

type, ABA routing number, or contact information. You may need to submit a new Direct DepositApplication form. Failure to comply with this may result in delay of payment.

2. Go Green – Paperless Remittance Advice

In an effort to reduce our carbon footprint, Public Partnerships, LLC has undertaken a ‘Go Green

Initiative’. A major aspect of this initiative is concentrating our efforts on reducing paper usage. With this in mind, effective February 28th, 2014, MA DESE providers currently receeiving direct deposit payments will no longer be issued a paper remittance advice as proof of payment via the US Postal Service. Instead, PPL has made the process of receiving remittance advice more convenient and eco-friendly by making all remittance advices available at any time through the PPL Web Portal. This advice may be accessed at any time and is also easily printable if needed.

If you are not familiar with the PPL Web Portal, follow these steps to learn how to register for an

username and password as well as how to log in:

1. Visit www.publicpartnerships.com

2. Select the MA DESE program

3. Enter: username: madese / password: pcgdese194. View the instructions for registering for the Web Portal under the “Web Portal User Guides” section

5. These instructions will help you create your unique username and password and will also help you learn

how to log in to the PPL Web Portal

How do I view my remittance advice via the PPL Web Portal?

1. Go to the PPL Web Portal: https://fms.publicpartnerships.com/PPLPortal/Login.aspx

2. Log in with your unique username and password

3. Under the “timesheets” tab, select “all timesheets” with a status of “paid”

4. Click on “search”

5. All paid timesheets will appear. To the right of the paid timesheet, the “check number” column displays

your remittance advice number. Click on the remittance advice number.

6. A popup screen will appear to ask whether you want to open or save your remittance advice.

a. If you want to view it but do not wish to save it to your computer right now, click “open.”

b. If you would like to save the remittance advice to your local computer for your records, click

“save.”

**Please Note: If you still wish to receive your paper remittance advice, you may do so by simply calling PPL's customer service line at (888) 623-5688 and amking this request.**

Phone:

Email:

(888) 623-5688 madese@pcgus.com

Administrative Fax: (866) 457-7276 Timesheet Fax: (866) 743-2680Web: www.publicpartnerships.com

3. Submit Direct Deposit Application to PPLOnce you have completed the Direct Deposit application, you must gather and submit account verification documents to PPL. This differs depending on where you want your funds to go:

Checking account: Submit a voided check or a letter from your bank that states the checkingaccount number where your funds should be deposited.

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

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

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

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

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

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

That’s it! Once your Direct Deposit becomes active, you will be able to view a summary of your gross wages, tax withholding, etc. on the Remittance Advice that will be available to you on the Web Portal. Thank you for signing up – we hope you enjoy having faster access to your payments!

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Public Partnerships, LLC (PPL)

DIRECT DEPOSIT APPLICATION CREATE/CHANGE PPL Direct Deposit Account or CLOSE Existing PPL Direct Deposit Account Check the appropriate box below based on your request.

New Direct Deposit Set-up

New Pay Card/Debit Card Set-up

Change Account Number

Change Account Type

Cancellation Request

Change Financial Institution

PAYEE INFORMATION Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPC will use to f

1. Social Security Number (SSN)

2. Payee Name

ile required information returns to IRS.

3. Phone

4. Payee Address

5. City 6. State 7. Zip

AUTHORIZATION FOR SET-UP, CHANGE OR CANCELLATION I authorize Public Partnerships, LLC (PPL) to process payments owed to me for services authorized by the MA DESE Program. Per my request, PPL will deposit my payment directly to my bank or pay card account indicated below using an Automated Clearing House (ACH) transaction. I recognize that if I fail to provide complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously made. I authorize PPL to withdraw from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to PPL. The change or revocation is effective on the day PPL processes the request. I certify that I have read and agree to comply with PPL rules governing payments and electronic transfers as they exist on the day of my signature on this form or as subsequently adopted, amended, or repealed. I authorize PPL to stop making electronic transfers to my account without advance notice. If I choose to have my payments deposited to a pay card or debit card, I accept all responsibility for all terms, conditions and/or fees that may be applicable to my chosen pay card/debit card. I certify that I am authorized to contract for the entity receiving deposits per this agreement, and that all information provided is accurate.

8. Signature (Required) 9. Title 10. Date

ACCOUNT DETAIL INFORMATION

11. Financial Institution Name (My Bank or my Pay Card Bank's Name)

12. Bank Address

14. Account Type:13. Bank Routing Number Checking Savings

15. My Account Number

16. Bank City 17. Bank State 18. Bank Zip

Send with VOIDED CHECK or ACCOUNT VERIFICATION to: Public Partnerships, LLC, MA DESE; One Cabot Rd, STE 102, Medford, MA 02155

Pay Card/ Debit Card

Check here only if you would like to receive paper remittance instead of viewing your remittance online. To “Go Green” with PPL leave this check-box blank.