Employee Application...

Employee Application Form

Revised 5/2015


Provider Directory Opt-In

Public Partnerships, LLC maintains a provider directory to help new participants/employers locate available

personal support workers in their area. Would you like to be listed in this directory?

___ Yes, please list my name, city and phone number and email in the provider directory.

___ No, I would prefer not to be listed in the provider directory.

Trainings

Personal Support Workers are not currently required to complete any training. If you have First Aid

and/or CPR training, you may include copies of your current credentials for inclusion with your provider

profile.

Application

Date

Participant First & Last Name:

Employer First & Last Name:

Provider’s Personal Information

Last Name Middle Initial First Name

Physical Address

City State Zip Code

Phone No. Alternate Phone No.

Email Address

Social Security Number Date of Birth


Revised 5/2015


Background & Registry Checks

In order to provide services in this program, you will be required to pass several registry and background checks,

including Illinois State Police Sex Offender Database, Illinois Child Abuse and Neglect Tracking System

(CANTS), Illinois Department of Public Health’s Healthcare Worker’s Registry, Illinois State Police Bureau of

Identification Criminal Background Check

You will be required to submit/authorize these checks. Any offer of employment is contingent upon successfully

passing the criminal background check. The Health Care Worker Registry, Illinois Child Abuse and Neglect

Tracking System (CANTS), and Illinois Sex Offender Registry will be conducted annually.

Disqualifying cases included: “Offenses Against the Person” or “Offenses against Morals, Decency, and Family.”

This includes but is not limited to crimes such as: homicide, kidnapping, sexual assault, robbery and blackmail,

assault and battery, bigamy, incest, abandoning or endangering children, violation of an order of protection, or

endangering children via controlled substances.

Signature

By signing here, you certify that: “All answers given herein are true and complete to the best of my knowledge. I

authorize the background and registry checks above, as well as the investigation of all matters contained in this

application and I understand that misrepresentations, omissions of fact or incomplete information requested in this

application may remove me from further consideration for employment.”

Signature: ____________________________________________ Date: ___________________

If you have other questions, please feel free to contact Customer Service at (888) 866-0582.

Thank you,

Public Partnerships, LLC (PPL)

IL DD Employment Agreement Between Employer & Service Provider

Revised 5/2015

IL DD Employment Agreement

This document must be signed and retained by the Employer and Employee.

A copy must also be sent to PPL.

Parties to Agreement

This agreement confirms the conditions of employment between the following parties within the IL Department of Human

Services Division of Developmental Disabilities (IL DD) Home-based Support Services Personal Direction Program:

___________________________________________ ___________________________________________ Participant/Employer Provider/Employee

Mutual Responsibilities The parties agree to follow the policies and procedures of the program. The Employee and Participant agree to hold

harmless, release, and forever discharge IL DD and Public Partnerships, LLC (PPL) from any claims and/or damages that

might arise out of any action or omissions by the Employee, Employer, or Participant.

The Employer shall:

1. Verify Employee qualifications, including ability to work in the United States;

2. Schedule Employee to provide services for payment only after being authorized by PPL;

3. Orient, train, direct, and supervise the Employee;

4. Establish a mutually agreeable schedule for the Employee’s services;

5. Provide a safe workplace free from excess hazards, employment discrimination, and harassment;

6. Request Employee to perform permitted and planned for duties, as determined in the Participant’s Individual Service

Plan;

7. Notify Employee in advance if services are not required or if Participant is no longer eligible for services;

8. Verify services provided by Employee by reviewing and approving timesheets and documentation of services

rendered, and ensuring submission to PPL;

9. Accept responsibility for compensating the Employee for any services performed in excess of the amount authorized

in the Individual Service Plan/Service Authorization; and

10. Ensure that there is no misrepresentation of time, services, individuals and/or other information.

The Employee shall:

1. Be 18 years of age or older and not the parent, step-parent or legally responsible relative of the Participant

(Children’s waiver) or the spouse of the participant (Adult Waiver);

2. Be punctual, neatly dressed, and respectful of employer’s person, belongings, family members and acquaintances;

3. Use Participant’s personal property only if agreed upon by both parties;

4. Submit accurate timesheets and documentation to Employer for review and signature;

5. Notify the Participant in advance if not able to provide services as scheduled or if quitting employment;

6. Report any allegations or suspicions of abuse, neglect, or exploitation immediately to IL DD;

7. Maintain confidentiality of all Participant information, and only release information with the written consent of

the Participant; and, 8. Ensure that there is no misrepresentation of time, services, individuals and/or other information.

Employee understands and acknowledges the following:

1. Employee is employed by the Participant/Employer; not PPL or IL DD.

2. Employment is “at-will.” No guarantee or promise of continued employment is intended or implied by this agreement.

3. Employees may work more than 40 hours per work week; however, authorized services are exempt from overtime

requirements under the Fair Labor Standards Act (FLSA) as companionship services. Accordingly, no Employee will

receive overtime premium pay. Services provided must be directly related to the care of the Participant

4. Employee shall only perform work within the amount authorized by IL DD as stated within the Participant’s Individual

Service Plan. Employee shall not be compensated by IL DD or PPL for any work performed in excess of the authorized

amount.

5. PPL is required to report certain information on newly-hired employees to the Illinois Department of Employment

Security as required by Federal and State Child Support Enforcement Laws.

IL DD Employment Agreement Between Employer & Service Provider

Both Employee and Participant acknowledge the following:

Any false claims, statements, documents, or concealment of material facts by Employer or Employee may be considered

Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State laws.

The Participant/Employer and Employee agree to indemnify and hold harmless PPL, its officers, employees and agents

from any and all costs, expenses, losses, claims, damages, liabilities, settlements and judgments, including reasonable

value of time spent by counsel for PPL and the costs and expenses and reasonable attorneys' fees of other counsel required

to defend PPL relating to or arising from any and all claims brought by Personal Support Workers against PPL relating to

damages caused by work related injuries.

Compensation

The Personal Support Worker shall be compensated for his or her services at the hourly rate as stated in the Service

Authorization.

Hourly rate of pay for Personal Assistance Services (55D): $______________

Hourly rate of pay for Crisis Services (53C): $______________

Payment for Services and Work Performed

PPL shall pay the Employee for services provided by the Employee and verified by the Employer in accordance with the

in effect at the time of service provision.

Termination of Agreement

Either party may terminate this agreement by notifying the other party and PPL in writing.

Signatures

By signing below, the Employer and Employee agree to the above terms and conditions.

________________________________________________________ ______________________

Participant/Employer Date

______________________________________________________ ______________________

Employee Date

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which

document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future

expiration date may also constitute illegal discrimination.

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

Address (Street Number and Name)

E-mail Address Telephone NumberDate of Birth (mm/dd/yyyy)

Other Names Used (if any)

U.S. Social Security Number

►

Middle Initial

Apt. Number City or Town State Zip Code

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):

An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)

Signature of Employee: Date (mm/dd/yyyy):

Date (mm/dd/yyyy):Signature of Preparer or Translator:

Address (Street Number and Name) City or Town Zip CodeState

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

A citizen of the United States

A noncitizen national of the United States (See instructions)

1. Alien Registration Number/USCIS Number:

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

If you obtained your admission number from CBP in connection with your arrival in the United

States, include the following:

2. Form I-94 Admission Number:

Country of Issuance:

Foreign Passport Number:

(See instructions)

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

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

- -

. Some aliens may write "N/A" in this field.

Page 7 of 9Form I-9 03/08/13 N

Employer Completes Next Page

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

information is true and correct.

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

OR

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

3-D Barcode

Do Not Write in This Space

of 9Form I-9 03/08/13 N

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

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

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.)

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

Employer's Business or Organization Address (Street Number and Name)

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

City or Town Zip CodeState

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee

presented that establishes current employment authorization in the space provided below.

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

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

Signature of Employer or Authorized Representative: Date (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.

Middle InitialFirst Name (Given Name)Last Name (Family Name)

Issuing Authority: Issuing Authority:

Document Number:

Document Title:Document Title:

Document Number:

Issuing Authority:

List A OR ANDList B List C

Document Number:

Document Title:

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

Document Title:

Issuing Authority:


Document Title:

Issuing Authority:


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

Identity and Employment Authorization Identity Employment Authorization

Document Number:

Document Number:

Print Name of Employer or Authorized Representative:

3-D Barcode

Do Not Write in This Space

of 9Form I-9 03/08/13 N

LISTS OF ACCEPTABLE DOCUMENTS

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

For persons under age 18 who are

unable to present a document

listed above:

LIST A LIST B LIST C

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

8. Employment authorization

document issued by the

Department of Homeland Security

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:

9. Driver's license issued by a Canadian

government authority

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

2. Certification of Birth Abroad issued

by the Department of State (Form

FS-545)

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)

3. Certification of Report of Birth

issued by the Department of State

(Form DS-1350)

3. School ID card with a photograph5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

6. Military dependent's ID card

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

7. U.S. Coast Guard Merchant Mariner

Card

5. Native American tribal document8. Native American tribal document

7. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

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

Both Identity and

Employment Authorization


Identity


Employment Authorization

OR AND

All documents must be UNEXPIRED

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

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

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

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review

and Verification," for more information about acceptable receipts.

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

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

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

• Is blind, or

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

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

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

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

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

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

} B

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

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

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

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

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

For accuracy, complete all worksheets that apply. {

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

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

Form W-4Department of the Treasury Internal Revenue Service

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

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

OMB No. 1545-0074

20151 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

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

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

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

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

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

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

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

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

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

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

Form W-4 (2015) Page 2 Deductions and Adjustments 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 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details . . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,250 if head of household . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2015 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 2015 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2015 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 $4,000 and enter the result here. Drop any fraction . . . . . . . 89 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/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 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) 12 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 . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 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 2015. 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 2015. 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 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $6,000 06,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 34,000 434,001 - 44,000 544,001 - 50,000 650,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14

150,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 17,000 117,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $75,000 $60075,001 - 135,000 1,000

135,001 - 205,000 1,120205,001 - 360,000 1,320360,001 - 405,000 1,400405,001 and over 1,580

All Others

If wages from HIGHEST paying job are—


$0 - $38,000 $60038,001 - 83,000 1,00083,001 - 180,000 1,120

180,001 - 395,000 1,320395,001 and over 1,580

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person 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 for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

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

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

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

How do I figure the correct number of allowances?Complete the worksheet on the back of this page to figure the correct number of allow-ances you are entitled to claim. Give your completed Form IL-W-4 to your employer. Keep the worksheet for your records.

If you have more than one job or your spouse works, your withholding usually will be more accurate if you claim all of your al-lowances on the Form IL-W-4 for the highest-paying job and claim zero on all of your other IL-W-4 forms.

How do I avoid underpaying my tax and owing a penalty?You can avoid underpayment by reducing the number of allowances or requesting that your employer withhold an additional amount from your pay. Even if your withholding covers the tax you owe on your wages, if you have non-wage income that is taxable, such as interest on a bank account or dividends on an investment, you may have additional tax liability. If you owe more than $500 tax at the end of the year, you may owe a late-payment penalty or will be required to make estimated tax payments. For additional information on penalties see Publication 103, Uniform Penalties and Interest. Visit our website at tax.illinois.gov to obtain a copy.

Where do I get help? • Visit our website at tax.illinois.gov • Call our Taxpayer Assistance Division at 1 800 732-8866 or 217 782-3336 • Call our TDD (telecommunications device for the deaf) at 1 800 544-5304 • Write to ILLINOIS DEPARTMENT OF REVENUE PO BOX 19044 SPRINGFIELD IL 62794-9044

Illinois Department of Revenue

Form IL-W-4 Employee’s and other Payee’s Illinois Withholding

Allowance Certificate and Instructions

IL-W-4 (R-12/14)

Note: These instructions are written for em-ployees to address withholding from wages. However, this form can also be completed and submitted to a payor if an agreement was made to voluntarily withhold Illinois Income tax from other (non-wage) Illinois income.

Who must complete Form IL-W-4? If you are an employee, you must complete this form so your employer can withhold the correct amount of Illinois Income Tax from your pay. The amount withheld from your pay depends, in part, on the number of allow-ances you claim on this form.Even if you claimed exemption from with-holding on your federal Form W-4, U.S. Employee’s Withholding Allowance Cer-tificate, because you do not expect to owe any federal income tax, you may be required to have Illinois Income Tax with-held from your pay (see Publication 130, Who is Required to Withhold Illinois In-come Tax). If you are claiming exempt status from Illinois withholding, you must check the exempt status box on Form IL-W-4 and sign and date the certificate. Do not complete Lines 1 through 3. If you are a resident of Iowa, Kentucky, Michigan, or Wisconsin, or a military spouse, see Form W-5-NR, Employees Statement of Nonresidence in Illinois, to determine if you are exempt.

If you do not file a completed Form IL-W-4 with your employer, if you fail to sign the form or to include all necessary informa-tion, or if you alter the form, your employer must withhold Illinois Income Tax on the entire amount of your compensation, without allowing any exemptions.

When must I submit this form?You should complete this form and give it to your employer on or before the date you start work. You must submit Form IL-W-4 when Illinois Income Tax is required to be withheld from compensation that you receive as an employee. You may file a new Form IL-W-4 any time your withholding allowances increase. If the number of your claimed al-lowances decreases, you must file a new Form IL-W-4 within 10 days. However, the death of a spouse or a dependent does not affect your withholding allowances until the next tax year.

When does my Form IL-W-4 take effect?If you do not already have a Form IL-W-4 on file with your employer, this form will be

effective for the first payment of compensa-tion made to you after this form is filed. If you already have a Form IL-W-4 on file with this employer, your employer may allow any change you file on this form to become effec-tive immediately, but is not required by law to change your withholding until the first pay-ment of compensation is made to you after the first day of the next calendar quarter (that is, January 1, April 1, July 1, or October 1) that falls at least 30 days after the date you file the change with your employer.Example: If you have a baby and file a new Form IL-W-4 with your employer to claim an additional allowance for the baby, your employer may immediately change the withholding for all future payments of compensation. However, if you file the new form on September 1, your employer does not have to change your withholding until the first payment of compensation is made to you after October 1. If you file the new form on September 2, your employer does not have to change your withholding until the first payment of compensation made to you after December 31.

How long is Form IL-W-4 valid?Your Form IL-W-4 remains valid until a new form you have submitted takes effect or until your employer is required by the Department to disregard it. Your employer is required to disregard your Form IL-W-4 if • you claim total exemption from Illinois

Income Tax withholding, but you have not filed a federal Form W-4 claiming total exemption, or

• the Internal Revenue Service (IRS) has instructed your employer to disregard your federal Form W-4.

What is an “exemption”?An “exemption” is a dollar amount on which you do not have to pay Illinois Income Tax that you may claim on your Illinois Income tax return.

What is an “allowance”?The dollar amount that is exempt from Illinois Income Tax is based on the number of allowances you claim on this form. As an employee, you receive one allowance unless you are claimed as a dependent on another person’s tax return (e.g., your parents claim you as a dependent on their tax return). If you are married, you may claim additional allowances for your spouse and any depen-dents that you are entitled to claim for federal income tax purposes. You also will receive additional allowances if you or your spouse are age 65 or older, or if you or your spouse are legally blind.

Illinois Withholding Allowance Worksheet

Step 1: Figure your basic personal allowances (including allowances for dependents) Check all that apply:

No one else can claim me as a dependent.

I can claim my spouse as a dependent.

1 Enter the total number of boxes you checked. 1 _______________

2 Enter the number of dependents (other than you or your spouse) you will claim on your tax return. 2 _______________

3 Add Lines 1 and 2. Enter the result. This is the total number of basic personal allowances to which you are entitled. You are not required to claim these allowances. The number of basic personal allowances that you choose to claim will determine how much money is withheld from your pay. See Line 4 for more information. 3 _______________ 4 Enter the total number of basic personal allowances you choose to claim on this line and Line 1 of Form IL-W-4 below. This number may not exceed the amount on Line 3 above, however you can claim as few as zero. Entering lower numbers here will result in more money being withheld(deducted) from your pay. 4 _______________

Step 2: Figure your additional allowances Check all that apply:

I am 65 or older. I am legally blind.

My spouse is 65 or older. My spouse is legally blind.

5 Enter the total number of boxes you checked. 5 _______________

6 Enter any amount that you reported on Line 4 of the Deductions and Adjustments Worksheet for federal Form W-4 plus any additional Illinois subtractions or deductions. 6 _______________

7 Divide Line 6 by 1,000. Round to the nearest whole number. Enter the result on Line 7. 7 _______________

8 Add Lines 5 and 7. Enter the result. This is the total number of additional allowances to which you are entitled. You are not required to claim these allowances. The number of additional allowances that you choose to claim will determine how much money is withheld from your pay. 8 _______________ 9 Enter the total number of additional allowances you elect to claim on Line 2 of Form IL-W-4, below. This number may not exceed the amount on Line 8 above, however you can claim as few as zero. Entering lower numbers here will result in more money being withheld(deducted) from your pay. 9 _______________IMPORTANT: If you want to have additional amounts withheld from your pay, you may enter a dollar amount on Line 3 of Form IL-W-4 below. This amount will be deducted from your pay in addition to the amounts that are withheld as a result of the allowances you have claimed.

Cut here and give the certificate to your employer. Keep the top portion for your records.

General InformationComplete this worksheet to figure your total withholding allowances.Complete Step 1. Complete Step 2 if • you (or your spouse) are age 65 or older or legally blind, or • you wrote an amount on Line 4 of the Deductions and

Adjustments Worksheet for federal Form W-4.

Illinois Department of Revenue

IL-W-4 Employee’s Illinois Withholding Allowance Certificate

____ ____ ____ - ____ ____ - ____ ____ ____ ____Social Security number

________________________________________________________________________Name

________________________________________________________________________Street address

________________________________________________________________________City State ZIP

Check the box if you are exempt from federal and Illinois Income Tax withholding and sign and date the certificate.

IL-W-4 (R-12/14)

If you have more than one job or your spouse works, your with-holding usually will be more accurate if you claim all of your allow-ances on the Form IL-W-4 for the highest-paying job and claim zero on all of your other IL-W-4 forms.You may reduce the number of allowances or request that your employer withhold an additional amount from your pay, which may help avoid having too little tax withheld.

Employer: Keep this certificate with your records. If you have referred the employee’s federal certificate to the IRS and the IRS has notified you to disregard it, you may also be required to disregard this certificate. Even if you are not required to refer the employee’s federal certificate to the IRS, you still may be required to refer this certificate to the Illinois Department of Revenue for inspection. See Illinois Income Tax Regulations 86 Ill. Adm. Code 100.7110.

1 Enter the total number of basic allowances that you are claiming (Step 1, Line 4, of the worksheet). 1 ____________2 Enter the total number of additional allowances that you are claiming (Step 2, Line 9, of the worksheet). 2 ____________3 Enter the additional amount you want withheld (deducted) from each pay. 3 ____________

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

______________________________________________________________________Your signature Date

This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required. Failure to provide information may result in this form not being processed and may result in a penalty.

Revised 5/2015 Tax Exemptions Form

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

State Worked: _________________________________ Program: ______________________________________

Employer Name: _______________________________ Provider Name: _______________________________

Employees providing domestic services such as personal assistance may be exempt from paying certain federal and state

taxes based on the employee’s age, student status, or family relationship to the employer. In some cases, the employer may

also be exempt based on the employee’s status. These exemptions are not optional. If you and your employer qualify for these

exemptions, you must take them. Services Providers — Please answer all the following questions based on your age, student

status, and relationship to employer.

1. Are you a non-resident alien temporarily in the United States on an F-1, J-1, M-1, or Q-1 visa admitted to the 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, wife). __ No, my employer is not my spouse

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

__ Yes, my employer is my employer (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 age 18, or has a physical or mental condition that requires personal care of an adult for at least for continuous weeks during the calendar quarter in which services are performed. __ Yes, my child (son or daughter) is widowed or divorced and not remarried, or living with a spouse who has a mental or physical condition which prohibits the spouse from caring for my grandchild for at least four continuous weeks during the calendar quarter in which services are performed.

6. Are you under the age of 18 or do you turn 18 this calendar year?

__ Yes, I am under 18 or am turning 18 this calendar year. __ No, I am over 18 If you answered “Yes” to Question 6, answer the following question. If you answered “No”, skip this section If the job of performing household services (respite or nursing) your principal occupation? Note: Do not answer “Yes” if you are a student. __ Yes, performing household services is my principal occupation. __ No, performing household services is not my principle occupation, or I am a student.

IMPORTANT: You must notify Public Partnerships, Inc. if your status changes.

Provider Signature: ________________________________________ Date: ____/____/________

Employer Signature: _______________________________________ Date: ____/____/________

Revised 5/2015 Tax Exemptions Form

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 not

permit 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 on

the 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 FTA (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.

IL DDD Application For Tax Exemptions

Revised 5/7/15

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

(FICA)

Federal Unemployment Tax

Act

(FUTA)

State Unemployment

Insurance (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.

CFS 689 Rev 7/2012 State of Illinois

Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK Child Abuse and Neglect Tracking System (CANTS)

For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child care facility. Please contact your licensing representative.

Name: Last First Middle

Race: Male FemaleGender:

Current Address: Street/Apt #

City State Zip Code

If you currently reside in Illinois, please list all previous addresses for the past five years. OR

If you currently reside out-of-state, please provide ALL Illinois addresses in which you did reside while living in Illinois.Dates

(Street/Apt#/City/County/State/Zip Code) From/To

List maiden name and/or all other names by which you have been known: (last, first, middle)

I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect Tracking system (CANTS) to determine whether I have been a perpetrator of an indicated incident of child abuse and/or neglect or involved in a pending investigation. I further consent to the release of this information to the agency listed below.

Signed Date

Please type, use bold letters or label:

(Agency Name)

(Contact Person)

(Address)

(City/State/Zip)

FAX to: 217-782-3991Scan/Email to: [email protected]

Submit by mail OR fax OR email.Mail to: Department of Children and Family Services

406 E. Monroe – Station # 30 Springfield, IL 62701

(Submitting Agency Fax Number) (Submitting Email Address)

Date of Birth:

Print Form

Health Care Worker Background Check Authorization and Disclosure for Criminal History Records Information (CHRI) Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department’s designee, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information and photographs relative to the existence or nonexistence of any criminal record, which it might have concerning me, to any initiator/requestor solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records and photographs relating to me, including but not limited to a local unit of government in any State, to release those records and photographs to the ISP, FBI, or the Department. I authorize the Department to provide any health care facility, training program or staffing agency, to which I have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the FBI CHRI. I certify that the ISP, FBI, any entity that maintains criminal records and photographs, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that a educational entity or a health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer if I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

First Name Full Middle Name Last Name

Mailing Address City: State: Zip Code

Other Names Used Telephone - -

States Where You Have Lived?

Male Female Race ______________ Height _________Weight ___________ Date of Birth ___________________ Social Security Number ____________________________ (Enter a letter from below) Hair Color __________ Eye Color __________ Place of Birth ________________________________________________________________________________ Race A Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander.

B Black or African American (Not Hispanic or Latino) H Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) I American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states of the United States or Alaska who maintains

cultural identification through tribal affiliation or community recognition. U Of undeterminable race. Of Untold mixture. W Caucasian (not Hispanic or Latino)

Have you ever had an administrative finding of Abuse, Neglect or Theft? Yes No If “Yes,” give full details and state. Continue on back if more space is needed.

Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)? Yes No If “Yes,” give full details of each offense and the state in which convicted. Continue on back if more space is needed.

I certify that the above is true and correct and give my consent for my name to appear on Department’s Health Care Worker Registry with the results of my criminal history records check.

(Signature) (Date)

As the parent or guardian of the above named individual, who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.

(Signature of Parent or Guardian when applicable) (Date)

Health Care Worker Registry, 525 W. Jefferson St., Springfield, IL 62761 Phone: 217-785-5133

*** ALL FIELDS MUST BE COMPLETED OR APPLICATION WILL NOT BE PROCESSED***

State of Illinois Department of Human Services Division of Developmental Disabilities

WAIVER PROGRAM PROVIDER AGREEMENT

IL462-0170 (N-09-15) Waiver Program Provider Agreement Printed by Authority of the State of Illinois -0- Copies Page of


WHEREAS, , hereinafter referred to as "the Provider", is enrolled with the Illinois (Full Legal Name)

Department of Healthcare and Family Services, hereinafter referred to as "HFS", as an eligible provider in the Medical Assistance

Program; and

WHEREAS, the Provider is enrolling with the Department of Human Services, Division of Developmental Disabilities (hereinafter

referred to as "Waiver Agency") as a provider in the Adult Waiver and/or the Children's Support Waiver.

WHEREAS, the Provider wishes to submit claims for services rendered to eligible Healthcare and Family Services clients using a

Government Vendor Fiscal/Employer Agent (F/EA). The Provider is agreeing to permit a Fiscal Employer Agent to act on their

behalf in enrolling the Provider as an Illinois Medical Assistance Program Provider. Under penalties of perjury, the Provider

certifies that the information given to complete the enrollment is correct. The F/EA will have authority to complete the electronic

application using the Illinois Medical Assistance Program Advanced Cloud Technology (IMPACT) provider enrollment system.

The F/EA will maintain the provider's enrollment records in IMPACT including, but not limited to, updating information, making

changes to the provider's enrollment status and revalidating enrollment information. The F/EA will have legal authority to execute

the terms and conditions of the Trading Partner agreement in the IMPACT Provider Enrollment System.

NOW THEREFORE, the provider agrees as follows to the provisions:

1. The Provider shall, on a continuing basis, comply with all current and future program policy provisions as set forth

in any applicable Program handbooks/agreements with the appropriate administering Waiver Agency, Illinois

Medical Assistance or Waiver Agency, as appropriate, shall notify the Provider of changes in policy 30 days

before the effective date of the change unless there is an emergency, as defined in the Administrative Procedure

Act, or the change is to comply with State or Federal law or regulation.

2. The Provider shall, on a continuing basis, comply with applicable licensing or certification standards as contained

in State laws or regulations.

3. The Provider shall comply with Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the

Americans with Disabilities Act of 1990, and regulations promulgated thereunder which prohibit discrimination on

the grounds of sex, race, color, national origin or disability.

4. The Provider shall, on a continuing basis, comply with Federal standards specified in Title XIX on the Social

Security Act, and also with all apllicable Federal and State laws and regulations.

5. The Provider shall invoice Waiver Agency for Medical Assistance covered services; Waiver Agency will arrange

payment for covered services from Illinois Medical Assistance, as is outlined in the Social Security Act, Section

1902 (a)(27) and (a)(32).

6. Payment to the Provider under this Agreement shall constitute payment in full. Any payments received by the

Provider from other sources shall be shown as a credit and deducted from the Provider's charges.

7. The Provider shall be fully liable for the truth, accuracy, and completeness of all claims for payment submitted

electronically or in hard copy. Furthermore, the Provider agrees to review, affix an original signature on, and

retain in their files the billing certification. Any false or fraudulent claim or claims or any concealment of a material

fact may be prosecuted under applicable Federal and State laws.

8. The Provider shall maintain all records necessary to fully disclose the nature and extent of services provided to

individuals under Articles V, VI, and VII of the Public Aid Code. The Provider shall maintain said records for not

less than six (6) years from date of service or as required by applicable Federal and State laws, whichever is

longer, and shall furnish these records upon demand when so requested by Illinois Medical Assistance, the

Waiver Agency or their designees. If an Illinois medical Assistance or a Waiver Agency audit is intitiated, the

Provider shall retain all original records until the audit is completed and every audit issue has been resolved,

even it the retention period extends beyond the required period.

9. If not a practitioner, the Provider shall comply with the Federal regulations requiring ownership and control

disclosure found at 42 CFR part 455, Subpart B.

(Continued on next page)

Notice of Enrollment of Medicaid Waiver Providers in the IMPACT System

Illinois implemented a new electronic provider enrollment system in July 2015. The new web-based system is know as Illinois Medicaid Program Advanced Cloud Technology (IMPACT). IMPACT will be used by all Medicaid and Waiver Program providers doing business with Illinois. All Personal Support Workers seeking to provide services with the DHS Division of Developmental Disabilities Medicaid Waiver Program will be required to be enrolled in IMPACT. The Fiscal Employer Agent will obtain the necessary personal information from the Personal Support Worker to be able to complete the enrollment in IMPACT on the worker's behalf. The Personal Support Worker is agreeing to the provisions of the Waiver Program Provider Agreement in collaboration with the terms and conditions of the Trading Partner agreement in the IMPACT Provider Enrollment System.

State of Illinois Department of Human Services Division of Developmental Disabilities


IL462-0170 (N-09-15) Waiver Program Provider Agreement Printed by Authority of the State of Illinois -0- Copies Page of

(Waiver Program Provider Agreement - Continued)

10. The Provider shall exhaust all other sources of reimbursement as required by medical Assistance Program policy

prior to seeking reimbursement from Illinois Medical Assistance.

11. The Provider shall be fully liable to Illinois medical Assistance and the Waiver Agency for any overpayments

which may result from the Provider's billings to Illinois medical Assistance and the Waiver Agency. The Provider

shall be responsible for promptly notifying Illinois Medical Assistance and the Waiver Agency of any

overpayments of which the Provider becomes aware. Illinois Medical Assistance and the Waiver Agency shall

recover any overpayments by setoff, crediting against future billings or by requiring direct repayment to Illinois

Medical Assistance and the Waiver Agency.

12. There has not been a prohibitive transfer of ownership interest to or in the provider by a relative who is

terminated or bared from participation in the Program pursuant to 305 ILCS 5/124.25.

13. The Provider shall furnish to Illinois Medical Assistance or the U.S. Department of Health and Human Services

(Hereinafter referred to as "HHS") on request, information related to business transactions in accordance with

42CFR 455.105 paragraph (b). The Provider agrees to submit, within 35 days after the date of such information

related to business transactions in accordance with 42 CFR 455.105 paragraph (b). The Provider agrees to

submit, within 35 days after the date of such request by Illinois Medical Assistance or HHS, complete information

about: (1) the ownership of any subcontractor with whom the Provider has had business transactions totaling

more the $25,000 during the 12 month period ending on the date of the request; and (2) any significant business

transactions between the provider and any wholly owned supplier, or significant between the Provider and any

subcontractor, during the 5 year period ending on the date of the request.

14. Knowingly falsifying or willfully withholding information on the Provider Enrollment Application and/or the

` Agreement for Participation may be cause for termination of participation in the Illinois Medical Assistance

Program.

15. The Provider, if a community developmental disabilities provider per the definitions and requirements of

59 Ill. Administrative Code 155-to 120, shall maintain compliance with applicable parts of the then effective

Attachment A to the Department of Human Services Community Services Agreement

(available via http://www.dhs.state.il.us/page.aspx?item=29741).

The signature below certifies that the Provider agrees to all of the provisions as stated in the Waiver Program Provider

Agreement for Participation in the Illinois Medical Assistance program.

Provider Signature:

Date:

Note: This Form is applicable only to individual Personal Support Workers paid via Fiscal Employment Agencies under contract with the Division of Developmental Disabilities.

Consumer Name/Number:

http://www.dhs.state.il.us/page.aspx?item=29741)

Employee Application...

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