Instructions: 1. The Consumer, Surrogate or Legal Guardian should sign as the Employer.2. FI will contact you when the Employee/PCA becomes active or if there is a problem within 5 business

days upon receipt.3. Employee/PCA should not start working until the hiring process is complete.4. Timesheet will be rejected when Employee/PCA is not active in the system

Reminder: MassHealth, SCO or OneCare Consumers cannot hire their Spouse, Parent (if consumer is a minor), Surrogate, Foster Parent, or Legally Responsible Relative.

Union#: (For FI use only) Rev. 11/8/2018

www.nearcfi.org 6 Southside Road Danvers, MA 01923

Telephone 1-800-231-5409, Fax 978-624-3755

Employee/PCA Registration Form

CONSUMER’S INFORMATION

Name: Consumer#:

Street:

Apt: Email Address:

City: State: Zip:

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

Check One: Masshealth SCO Self-Direct One-Care MFP:

New Address? Yes Signature:

Signature: New Address? Yes

SURROGATE’S INFORMATION (if applicable):

Name:

Street: Phone:

Apt: Email Address:

City: State: Zip:

Street: Phone:

Apt: Email Address:

City: State: Zip:

Social Security#:

Birth Date:

EMPLOYEE/PCA’S INFORMATION

Name:

1

Phone #:

Instrucciones: 1. Sólo el consumidor, Sustituto o el Guardián Legal puede firmar como el Empleador.2. Dentro de los siguientes 5 días hábiles después que la aplicación sea recibida, El Departamento del

Intermediario Fiscal lo contactará para informarle que el empleado/PCA está activo en nuestro sistema, o si hayerrores en la aplicación.

3. El Empleado/PCA no debe empezar a trabajar hasta que el proceso de contratación sea completado.4. Si envía hojas de tiempo, estas serán rechazadas, solo se aceptaran las que envíe después que el empleado esté

activo en el sistema.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.

Union#: (For FI use only) Rev. 11/8/2018

www.nearcfi.org 6 Southside Road Danvers, MA 01923

Teléfono 1-800-231-5409, 978-762-8307 Fax 978-624-3755

Formulario de Registración del Empleado/PCA

INFORMACION DEL CONSUMIDOR

Nombre:

Calle:

Apt:

# de Consumidor:

Ciudad: Estado: Zip:

Primer día del Empleado/PCA: (La fecha en que el empleado/PCA comenzará a trabajar con usted)

Marque Uno: MassHealth SCO Self-Direct One-Care MFP:

Su dirección es nueva? Si Firma:

Firma: Su dirección es nueva? Si

INFORMACION DEL SUSTITUTO (si aplica):

Nombre:

Calle:

Apt:

# Telefónico:

Ciudad: Estado: Zip:

INFORMACION DEL EMPLEADO/PCA

Nombre: Fecha de Nacimiento:

Calle: # Telefónico:

Apt:

Ciudad: Estado: Zip:

# Seguro Social:

2

Dirección Electrónica:

# Telefónico:

Dirección Electrónica:

Dirección Electrónica:

Please keep a copy of fax confirmation

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

FORM COMPLETED

BY CONSUMER ()

For FI Use only

Error/

incomplete

For FI Use only

Complete

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 oftheir 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 id 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 Employer CertificationSection in Section 2?

• The business address is the consumer’s address.

Electronic Payment Required effective 1/1/17 (Direct Deposit)

-Direct Deposit Application• Did the PCA include a voided check or an official bank form?

If the PCA is interested in the debit card please contact FI Customer Service

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, phonenumbers, e-mail and bank account information. This will allow us to send you any live PTO check,FICA refund check and/or yearend W-2.

Rev 11/8/2018 For FI Use: Sage OIG SS

3

Por favor retenga una copia de su confirmación de su fax

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.

FORMULARIO

COMPLETADO POR EL CONSUMIDOR

()

For FI Use only

Error/ incompleto

For FI Use only

Complete

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 documentadaen la sección 2? Título de la identificación ID, número y fecha deexpiración, si aplica. (Vea la parte de atrás del I-9 para revisar la listade documentos aceptables)• El consumidor completó la fecha de contratación y firmó laCertificación en la Sección 2?Pago Electrónico *MANDATORIO* desde 1/1/17 (Depósito Directo) Aplicación para Depósito Directo -

· El PCA incluyó un cheque cancelado o una carta oficial del banco?Si el PCA está interesado la tarjeta de débito, por favor contacte FI.

Permiso de Trabajo 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 sudirección, teléfono, e-mail e información de su cuenta bancaria. Esto nos permitirá enviarle cualquier cheque dePTO, cheque de compensación de FICA o su W-2 a fin de año.

Rev11/8/2018

4

Personal Care Attendant Signature Form

Northeast Arc Consumer # Name of fiscal intermediary (FI)

● All PCAs hired by a PCA consumer must fill out andsign this form and give it to their employer (the PCAconsumer).

● The PCA’s employer (the PCA consumer) must submitthis form to the FI, along with all other paperworkrequired by the FI and MassHealth.

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

● MassHealth and the FI cannot pay a PCA to worko 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 belowbefore 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 services. 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 Department 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 services 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 services. PCA services must be provided in accordance with the PCA consumer’s authorized PCA evaluation or reevaluation, service 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 services that are essential to the PCA consumer’s care such as laundry, shopping, housekeeping, meal preparation and cleanup, transportation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiving personal care services, 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 services require me to provide physical assistance.

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 certify under pains and penalties of perjury 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 certify 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 intermediary, 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)

responsible relative of the PCA consumer.

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

5

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

Ayudante de Atención Individual Formulario para la firma

Northeast Arc Nombre del intermediario fiscal (FI, por sus siglas en inglés):

● Todos los Ayudantes de atención individual (PCA, por sus siglas eninglés) contratados por un usuario de PCA deberán llenar y firmareste formulario y entregárselo a su empleador (el usuario de PCA).

● El empleador de PCA (el usuario de PCA) deberá enviarle esteformulario al intermediario fiscal, junto con toda ladocumentación adicional que exijan el intermediario yMassHealth.

● El FI no podrá realizarle pagos a un PCA hasta que se hayarecibido 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 autorizadose haya agotado o no sea suficiente.

● El PCA deberá leer el resto de este formulario yfirmar en el espacio siguiente antes de recibir pagosdel IF.

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 Departamento de Seguridad Nacional (Department 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 servicios 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 servicios 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 servicios 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 servicios 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 servicios se requiere que yo le preste asistencia física.

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)

Certifico 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 certifico 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.

Fecha:

Firma del PCA:

PCA-S (Rev. 06/11)

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.)

Executive Office of Health and Human Services

Nombre del PCA:

Consumidor #

6

Form W-4 (2019) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4. 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. You may claim exemption from withholding for 2019 if both of the following apply. • For 2018 you had a right to a refund of allfederal income tax withheld because youhad no tax liability, and• For 2019 you expect a refund of allfederal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions If you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens,before completing this form.

Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim. Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status. Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return. Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate ▶ Whether you’re 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

2019 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married filing separately, check “Married, but withhold at higher Single rate.”

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 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5 6 $

7 I claim exemption from withholding for 2019, 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 boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)

7

PCA ORIENTATION NOTES

If your new PCA qualifies for PCA orientation you will be receiving a letter in the mail,

Please be on the lookout for this as PCA’s

Who do qualify must complete orientation within 6 months of their hire date.

NOTAS SOBRE LA ORIENTACION DE LOS PCAS

Si su Nuevo PCA califica para la Orientación del PCA, usted va a recibir una carta en el correo,

Por favor, este en la espera de esta carta, ya que el PCA que califique

Debe completar esta Orientación dentro de los 6 meses después de su primer día de contratación.

8

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

Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City. . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . . . Zip . . . . . . . . . . . . . . . .

FORMM-4

M

ASSACHUSETTS

DE

PAR

T

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SP

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LA

C

IDA M

S V BLIB

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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 “4.” If your spouse is age 65 or over or will

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

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

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

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

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

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

D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual 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 THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

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 ofexemptions increases. You must file a new certificate within 10 days if thenumber of exemptions previously claimed by you decreases. For example,if during the year your dependent son’s income indicates that you will notprovide 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 notclaiming 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 tofile separate annual tax returns, you should not claim withholding exemp-tions for your spouse or for any dependents that will not be claimed on yourannual tax return.If claiming a wife or husband, write “4” in line 2. Using “4” is the withholdingsystem adjustment for the $4,400 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 andadjustments” 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.

D D D

D

9

10

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

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

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

►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 (Alien Registration Number/USCIS Number):

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

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:

OR 2. Form I-94 Admission Number:

OR 3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space

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

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 07/17/17 N Page 1 of 3

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.)

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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 Documents that Establish

Both Identity and Employment Authorization

OR

LIST B LIST C Documents that Establish Documents that Establish

Identity Employment Authorization AND

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

1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT

(2) VALID FORWORK ONLY WITH INS AUTHORIZATION

(3) VALID FORWORK ONLY WITH DHS AUTHORIZATION

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

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

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

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

3. School ID card with a photograph 5. For a nonimmigrant alien authorized

to work for a specific employer because of his or her status: a. Foreign passport; and 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.

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

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197) 8. Native American tribal document 6. Identification Card for Use of

Resident Citizen in the United States (Form I-179)

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

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

listed above:

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

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

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 07/17/17 N Page 3 of 3

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Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 OMB No. 1615-0047 Expires 08/31/2019

USCIS

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.")

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

List A OR Identity and Employment Authorization

List B Identity

AND List C Employment Authorization

Document Title Document Title Document Title

Issuing Authority Issuing Authority Issuing Authority

Document Number Document Number Document Number

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

Document Title

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

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) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (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. Document Title Document Number Expiration Date (if any) (mm/dd/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 Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

Form I-9 07/17/17 N Page 2 of 3

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Consumer #:

6 Southside Road Danvers, MA 01923 Telephone 1-800-231-5409, Fax 978-624-3755

Direct Deposit Application

Employee/PCA’s Name: Direct Deposit Accounts must be in the name of the PCA Only, the account cannot be a joint account shared by the PCA and the Consumer or the Surrogate.

Bank Name:

Routing#: Account#:

Checking Account – Copy of voided check required. No starter checks accepted. Please make sure a valid bank routing number and checking account number are printed legibly.

*Please tape or glue a voided check here

Savings Account –Official bank form required this from should include your bank name, your name, bank routing number, and account number. This document must be signed by a Bank Representative and the account information must be typed not handwritten.

I hereby authorize Northeast Arc FI (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:

Rev. 11/8/2018

PLEASE NOTE: Effective 1/1/17 all PCA payments are required to be EFT (Electronic Funds Transfer) In the event of a change in the PCA's banking information, the PCA must provide FI with new EFT information to ensure there is no delay in the PCA receiving payment.

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6 Southside Road Danvers, MA 01923 Teléfono 1-800-231-5409, Fax 978-624-3755

Aplicación para Depósito Directo Número de Consumidor:

Empleado/Nombre del PCA: Cuentas para Depósito Directo deben de contener el nombre del PCA sólamente, la cuenta no puede ser una cuenta conjunta con el Consumidor o con el Surrogate/Sustituto.

Nombre del Banco:

Número 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 válidos.

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, número 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 Northeast Arc FI (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:

Rev. 11/8/2018

IMPORTANTE: A partir del 1/1/2017, todos los pagos emitidos a los PCAs deben de hacerse de manera electrónica (EFT-Transferencia de Fondos Electrónica), en el caso en que el PCA haga algún cambio en su información bancaria, el PCA debe de proveer al departamento del FI con nueva información de pago electrónico para asegurarse de que el pago de su PCA no se retrase.

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I. About The Electronic Timesheets Module a. The Electronic Timesheets Module

is a web‐based interface through which Consumers, Surrogates, Personal Care Attendants (PCA), and Fiscal Intermediary staff can respectively view relevant timesheet information.

b. Consumers, Surrogates and PCAs will be able to use the system to both submit and approve timesheets electronically for payment by the Fiscal Intermediary.

c. A Consumer is not required to have a Surrogate in order to use the system. But in cases where a Consumer does have a Surrogate and the Consumer approves the Surrogate to have access to the Electronic Timesheets Submission Interface, both the Consumer and Surrogate will have identical abilities to enter and approve timesheets for payment.

II. Terms and Conditions By signing below, you are agreeing to the following Terms and Conditions:

a. The Consumer and/or Surrogate and the PCA each have a valid, separate e‐mail address which they access frequently.

b. The Consumer, Surrogate and the PCA agree to use the Electronic Timesheets Submission Interface as a method of submitting timesheets.

i. Signing this Agreement does not require you to only use the Electronic Timesheets Submission Interface. Other methods of submitting time, such as faxing or mailing, are still acceptable.

c. A timesheet may not be submitted electronically if the Consumer, Surrogate and the PCA have not both signed and agreed to use the Electronic Timesheets Submission Interface via this Agreement.

d. An individual Electronic Timesheets Agreement is required for each Consumer/PCA relationship that chooses to use the Electronic Timesheets Submission Interface. This is true even if the Consumer or PCA is already using the Electronic Timesheets Submission Interface in another Consumer/PCA relationship.

Consumer Name: ______________________________________________________________________ Consumer # ___________________________

Consumer E‐mail (Please Print Clearly):

□□□□□□□□□□□□□□□□□□□□□□□ Consumer Signature: _________________________________________________________________ Date: ____________________________

Surrogate Name: ______________________________________________________________________

Surrogate E‐mail (Please Print Clearly):

□□□□□□□□□□□□□□□□□□□□□□□ Surrogate Signature: _________________________________________________________________ Date: ____________________________

PCA Name: ______________________________________________________________________________

PCA E‐mail (Please Print Clearly):

□□□□□□□□□□□□□□□□□□□□□□□ PCA Signature: ________________________________________________________________________ Date: _____________________________

Revised 10/24/18

Electronic Timesheets Agreement FAX THIS FORM TO 978‐624-3755

OR MAIL TO: Northeast Arc FI, 6 Southside Rd,

Danvers, MA 01923

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I. Acerca del sistema de Hojas de Tiempo Electrónicas a. El sistema de hojas electrónicas es una sistema que se accesa a través del Internet en el cual

Consumidores, Sustitutos, Asistentes de cuidado personal y el Personal del Intermediario fiscal podrán ver la información relevante a la información de sus hojas de tiempo.

b. Consumidores, Sustitutos y los Asistentes de Cuidado Persona podrán usar este sistema para someter y aprobar hojas de tiempo con las hora que el PCA trabaja para que sean pagadas por el Intermediario Fiscal.

c. No es requerido que el Consumidor tenga un sustituto para poder usar este Nuevo sistema. Pero en casos donde el Consumidor tenga un sustituto y el consumidor apruebe al sustituto para que tenga acceso a enviar las hojas de tiempo electrónicas, ambos deben tener habilidades idénticas para entrar y aprobar estas hojas de tiempo para su pago.

II. Términos y Condiciones: Al firmar debajo, usted acuerda seguir los siguientes términos y condiciones:

a. Tanto el consumidor y/o su sustituto y como el Asistente de Cuidado Personal deben cada uno tener una dirección de correo electrónico valida a la cual accesan de manera frecuente.

b. El consumidor, su Sustituto (si aplica) y el Asistente de Cuidado Personal están de acuerdo en usar el Sistema electrónico de Hojas de tiempo como método para someter las horas de trabajo del PCA.

i. El firmar este acuerdo no requiere que solo pueda utilizar este medio para someter las horas trabajadas por su PCA. Otros métodos como faxear o enviar por correo la hoja de tiempo de papel, es aun aceptable.

c. Una hoja de tiempo no será sometida electrónicamente si el consumidor o su asistente de cuidado personal no han firmado y acordado el uso de Hojas de tiempo electrónicas a través de este acuerdo.

d. Se es requerido un acuerdo de uso de hojas electrónicas para cada relación de Consumidor/PCA que deseen utilizar este método para someter sus horas trabajadas. Esto es correcto aunque el consumidor o el Asistente de cuidado personal ya esté usando este sistema de hojas electrónicas en otra relación de consumidor/Asistente de cuidado personal.

Nombre del Consumidor: ____________________________________________________________ # Del Consumidor ______________________

Correo Electrónico del Consumidor: (Por favor escribir claramente):

□□□□□□□□□□□□□□□□□□□□□□□ Firma del Consumidor: _________________________________________________________________ Fecha: ____________________________

Nombre del Sustituto: __________________________________________________________________

Correo Electrónico del Sustituto: (Por favor escribir claramente):

□□□□□□□□□□□□□□□□□□□□□□□ Firma del Sustituto: _____________________________________________________________________ Fecha: __________________________

Nombre del PCA: _________________________________________________________________

Correo Electrónico del PCA: (Por favor escribir claramente):

□□□□□□□□□□□□□□□□□□□□□□□□ Firma del PCA: ____________________________________________________________________________ Fecha: _____________________________

Revised 10/24/18

Acuerdo de uso de Hojas de Tiempo Electrónicas ENVIE POR FAX AL 978‐624-3755

O

POR CORREO: Northeast Arc FI, 6 Southside Rd, Danvers, MA 01923

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C H ARL ES D. BAKER Governor

KARYN E. POLITO Lieutenant Governor

MARYLOU SUDDERS

Secretary

The Commonwealth of Massachusetts Executive Office of Health and Human Services

Office of Medicaid Office of Long Term Services and Supports

One Ashburton Place, 5th Floor Boston, Massachusetts 02108

DANIEL TSAI

Assistants Secretary for MassHealth

www.mass.gov/eohhs

KENNETH J. SMITH Director

TO: All PCAs Participating in the MassHealth Personal Care Attendant Program FROM: Ken Smith, Director, MassHealth Office of Long Term Services and Supports DATE: May 29, 2015 RE: Personal Care Attendant Earned Sick Leave

Effective July I, 2015, Personal Care Attendants shall be eligible for Earned Sick Leave. Draft Regulations 940 CMR 33.0 can be viewed at http://www.mass.gov/ago/earnedsicktime

Sick time can only be reported on a separate form: the PCA Sick Time Activity Form Time Sheet. Your employer, the MassHealth Member, will obtain PCA Sick Time Activity Forms from their Fiscal Intermediary.

Any sick time reported on a Regular Activity Form Time Sheet will not be processed for payment.

Please familiarize yourself with the following general provisions of Earned Sick Time.

General Provisions of Earned Sick Time: General Provisions are subject to the Final Regulations as promulgated by the Attorney General of Massachusetts.

• PCAs will earn I hour of earned sick time for every 30 hours worked. PCAs can accrue up to 40 hours of earned sick

time in a calendar year. The 40 hours include any hours rolled over from the previous year.

• The "calendar year" for tracking accrual, use, and carryover of earned sick time is any consecutive 12-month period of time as determined by MassHealth.

• Your employer, the MassHealth Member, shall inform you, the PCA, through the Fiscal Intermediary, the calendar year

that Mass Health uses. This information must be provided in writing. Any changes to what constitutes a calendar year shall be communicated to PCAs in writing and cannot cause the PCA to lose accrued sick time.

• PCAs may carry over up to 40 hours of unused earned sick time to the next year.

• Under this law, all PCAs who work enough hours must be allowed to accrue 40 hours per year of earned sick time. PCAs

must also be allowed to use up to 40 hours per year of that accrued time.

• PCAs begin accruing sick time from their first date of actual work.

• A PCA can begin utilizing Earned Sick Time 90 days after the PCA started working for a consumer or consumer s of PCA Services in the MassHealth Personal Care Attendant Program.

• Under the law, Earned Sick Time can be used for the following reasons:

I) To care for the PCAs child, spouse, parent, or parent of a spouse who is suffering from a physical or mental ill ness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

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2) To care for the PCAs own physical or mental illness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

3) To attend the PCAs routine medical appointment or a routine medical appointment for the employee's child, spouse, parent, or parent of spouse; or

4) To address the psychological, physical or legal effects of domestic violence.

• A PCA retains the right to use any accrued sick time after a break in service, whether voluntary or not, for up to one year from the last date of work if the PCA returns to work.

• PCAs are entitled to use earned sick time in 15 minute increments. However, if your absence from work at a designated

time requires your employer, the MassHealth Member, to hire a replacement, and this employer does so, this employer may require you, the PCA using sick time, to use up to a full shift of Earned Sick Time.

• PCAs must make a good faith effort to provide reasonable notice of the need in advance of the use of earned sick time.

Reasonable notice may include compliance with your employers' reasonable notification system that you, the PCA customarily use to communicate with your employer for absences or requesting leave. If your employer does not have an existing policy and procedure for providing reasonable notice, your employer must establish such a policy or procedure, preferably in writing. The policy or procedure should enable you, the PCA to effectively provide reasonable notice in a way that can be documented.

• If a PCA anticipates a multi-day absence from work, the employer, the MassHealth Member, may require notification

on a daily basis from the PCA or PCAs proxy (e.g. spouse, adult family member or other responsible party), unless the circumstances make such notification infeasible.

• If a PCA is committing fraud or abuse by engaging in an activity that is not consistent with allowable purposes for leave

(e.g. being sick, caring for an ill family member) or by exhibiting a pattern of taking leave on days when the PCA is scheduled to perform duties perceived as undesirable, the employer, the MassHealth Member, may discipline the PCA for misuse of sick leave. When fraud is suspected, incidents shall be reported to the Bureau of Special Investigations at 617-727-8638.

• If a PCA is absent for medical reasons, the employer, the MassHealth Member, may require a statement from a health

care provider that the absence was for a purpose covered by the law. A PCA who does not have a health care provider may sign a written statement that earned sick time was needed for a reason covered by the law.

• If a PCA is absent from work due to domestic violence, the employer, the MassHealth Member must accept any of

the following: 1) A restraining order or other order issued by a court; 2) A police record documenting the abuse; 3) A document showing that the abuser has been convicted of a violent crime against a family or household member; 4) Medical documentation of the abuse; 5) A statement provided by a counselor, social worker, health worker, member of the clergy, shelter worker, legal

advocate or other professional who has assisted the individual in addressing the effects of the abuse on the individual or the individual's family; or 6) A signed, written statement from the individual that abuse took place.

MassHealth AND your employer, the MassHealth member cannot require further information about the employee's medical condition or details of the domestic violence.

• MassHealth and MassHealth Member/Consumers cannot retaliate against a PCA for using earned sick time, for

exercising or attempting to exercise rights under the law, including: requesting and using sick leave; filing a complaint for alleged violations of the law; communicating with any person, including coworkers, about any violation of the law; participating in an administrative or judicial action regarding an alleged violation of the law; or informing another person of that person's potential rights. Retaliation is illegal.

• Should you have questions regarding your accrued Earned Sick Leave, you may contact the Fiscal Intermediary that

issues your paycheck or visit the Pay Choice web portal at: https://www.OnlineEmploye.rcom/feapca

• Generally speaking, PCAs must be paid what they would have earned if they had worked instead of using Earned Sick Time. PCAs using Earned Sick Time will not receive overtime or other premium rates.

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