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 300 Rosewood Drive #100 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:

Phone #:

1

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 300 Rosewood Drive #100 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:

Dirección Electrónica:

# Telefónico:

Dirección Electrónica:

Dirección Electrónica:

2

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 mailΦ Please be on the lookout for this as PCA’s

ǿho do qualify must complete orientation within 9 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 correoΦPor favor, este en la espera de esta carta, ya que el PCA que califique

Řebe completar esta Orientación dentro de los 9 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

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SP

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LA

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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 laterthan 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 aState or outlying possession of theUnited 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 Numbercard, unless the card includes one ofthe following restrictions:(1) NOT VALID FOR EMPLOYMENT

(2) VALID FORWORK ONLY WITHINS AUTHORIZATION

(3) VALID FORWORK ONLY WITHDHS AUTHORIZATION

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

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

2. ID card issued by federal, state or localgovernment 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 Documentthat contains a photograph (FormI-766)

2. Certification of report of birth issuedby the Department of State (FormsDS-1350, FS-545, FS-240)

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

to work for a specific employerbecause of his or her status:a. Foreign passport; andb. 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 asthat period of endorsement hasnot yet expired and theproposed employment is not inconflict with any restrictions orlimitations identified on the form.

3. Original or certified copy of birthcertificate issued by a State,county, municipal authority, orterritory of the United Statesbearing 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 MarinerCard

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 UnitedStates (Form I-179)

9. Driver's license issued by a Canadiangovernment authority

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

listed above:

7. Employment authorizationdocument issued by theDepartment of Homeland Security

6. Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with Form I-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe 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 312

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 theemployee 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 establishescontinuing 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 13

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Consumer #:

300 Rosewood rive #100 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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300 Rosewood Drive #100 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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Dear MassHealth PCA consumer,

We want to inform you about a new feature available to you and your personal care attendants (PCAs)!

What’s new All Fiscal Intermediaries (FIs) in the PCA Program now offer electronic access to PCA pay stubs. Both you and your PCA(s) can access their pay stubs whenever it is convenient.

How to access this new feature To access this new feature, go to:

https://www8.paychoiceonline.com/fea/FEA_Login.aspx

What you need to know Beginning in October 2019, you will no longer receive paper pay stubs because they can be accessed electronically. However, you will still receive a paper payroll register summarizing PCA hours in the mail.

In addition to the electronic pay stub, your PCA can choose to receive a mailed paper pay stub if they are paid electronically (via direct deposit or debit card). To choose the paper option, they must do one of the following:

1. Go to this website www.nearcfi.org/ and complete the required information; or2. Mail the information at the end of this letter to your FI.

Again, this option is only available to PCAs who are paid electronically. If your PCA does not get paid electronically, they must sign up for electronic payment online by going to http://www.nearcfi.org/

Please note: PCAs who receive paper checks will still have their checks mailed to their consumer employer.

What you should do now Share this information with your PCA(s) to let them know they can access their pay stubs electronically.

Questions? Contact your Fiscal Intermediary (FI) at: 978-762-8307

Your FI agency has all the latest information and can help answer questions or concerns.

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PCA PAPER PAY STUB OPTION

To be completed by PCAs only (not consumers) if they want to receive mailed paper pay stubs in addition to their electronic pay stub

Please print clearly.

PCA unique ID PCA First Name PCA Last Name

Street Address

City State Zip Code

Consumer Full Name

PCA Signature Date

⃞ I am a PCA in the Personal Care Attendant Program and I am paid via direct deposit or debit card. I understand that I can access my pay stub electronically but I wish to have a physical copy mailed to me. I understand that I am responsible for providing a valid mailing address and that it will be my responsibility to maintain my address with the FI.

Please send this information through fax to 978-624-3755, or via mail to Northeast Arc, FI department, 300 Rosewood Drive Suite 100, Danvers MA 01923.

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Estimado consumidor de MassHealth:

Queremos informarle acerca de la nueva función disponible para usted y sus asistentes de cuidado personal (PCA).

Novedades Todos los Intermediarios Fiscales (FI) en el programa PCA ofrecen acceso electrónico a los talonarios de pago de los PCAs. Tanto usted como su(s) PCA(s) pueden acceder a los talonarios de pago cuando usted desee.

Como accesar a esta nueva función Para accesar a esta nueva función diríjase a la siguiente dirección electrónica:

https://www8.paychoiceonline.com/fea/FEA_Login.aspx

Información importante A partir del mes de octubre 2019, usted ya no recibirá talonarios de pago impresos, porque ahora los puede obtener electrónicamente accesando al sitio web descrito arriba. Sin embargo, usted seguirá recibiendo a través de correo el registro de nómina impreso que resume las horas de PCA.

Además de los talonarios de pago, su PCA puede optar por recibir un talonario de pago impreso por correo siempre y cuando el PCA reciba pago electrónicamente (a través de depósito directo o tarjeta de débito). Para recibir la opción impresa, el PCA debe realiza una de las siguientes acciones:

1. Diríjase al sitio web www.nearcfi.org/ y complete la información requerida; o bien,2. Llene y envié la forma al final de esta carta a Northeast Arc, Fiscal Intermediary.

Una vez más, esa opción está disponible únicamente para los PCA que reciben pago electrónico. Si su PCA no recibe pago electrónico, debe registrarse en línea para recibir pago electrónicamente. El PCA puede registrarse en línea a través de la dirección web http://www.nearcfi.org/

Tenga en cuenta: los PCAs que reciben cheques impresos seguirán recibiendo sus cheques a través de su consumidor.

Lo que debe hacer ahora Comparta esta información con su(s) PCA(s) para hacerle(s) saber que pueden acceder a sus talonarios de pago electrónicamente.

Preguntas? Contacte su Intermediario Fisca (FI) en Northeast Arc al número: 978-762-8307

Su Fiscal Intermediario tiene toda la información mas reciente y puede responder preguntas e inquietudes que usted tenga.

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OPCION DE TALONARIOS DE PAGO DE PCA IMPRESOS

Este formulario debe ser completado únicamente por el PCA (no consumidores) si desea recibir talonarios de pago impresos a través del correo además de los

talonarios electrónicos.

Por favor escriba con claridad.

ID del PCA Primer Nombre del PCA Apellido del PCA

Calle y número de casa (incluya apartamento)

Ciudad Estado Código Postal

Nombre completo de su consumidor

Firma del PCA Fecha

⃞ Soy un PCA en el programa de Asistentes de Cuidado Personal y recibo pago a través de depósito directo o tarjeta de débito. Entiendo que puedo acceder a mi talonario de pago electrónicamente, pero deseo que se me envié una copia impreso por correo. Entiendo que soy responsable de proporcionar una dirección postal valida y que será mi responsabilidad mantener mi dirección actualizada con mi FI.

Por favor envié esta información a través de fax al 978-624-3755, o por correo a Northeast Arc, FI department, 300 Rosewood Drive Suite 100, Danvers MA 01923.

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I. About The Electronic Timesheets Modulea. 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 andapprove 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 aConsumer does have a Surrogate and the Consumer approves the Surrogate to have access tothe Electronic Timesheets Submission Interface, both the Consumer and Surrogate will haveidentical abilities to enter and approve timesheets for payment.

II. Terms and ConditionsBy 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 addresswhich they access frequently.

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

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

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

d. An individual Electronic Timesheets Agreement is required for each Consumer/PCArelationship that chooses to use the Electronic Timesheets Submission Interface. This istrue even if the Consumer or PCA is already using the Electronic Timesheets SubmissionInterface 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 978‐624-3755OR

MAIL TO: Northeast Arc FI300 Rosewood Dr#100

Danvers, MA 01923

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I. Acerca del sistema de Hojas de Tiempo Electrónicasa. 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 fiscalpodrán 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 parasometer y aprobar hojas de tiempo con las hora que el PCA trabaja para que sean pagadas por elIntermediario Fiscal.

c. No es requerido que el Consumidor tenga un sustituto para poder usar este Nuevo sistema. Peroen casos donde el Consumidor tenga un sustituto y el consumidor apruebe al sustituto para quetenga acceso a enviar las hojas de tiempo electrónicas, ambos deben tener habilidades idénticaspara 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 unotener 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 usarel 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 depapel, es aun aceptable.

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

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

300 Rosewood Dr#100,Danvers, MA 01923

22

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms (Rev 7/19)

PERSONAL CARE ATTENDANT EARNED PAID TIME OFF

Effective July 1, 2019, Personal Care Attendants (PCAs) shall be eligible for earned Paid Time Off (PTO). Formerly, PCAs were eligible for earned sick time. As of July 1, 2019, all earned sick time will convert to PTO and PCAs shall only be eligible for earned PTO.

Used PTO must be reported on a separate timesheet: the PCA Paid Time Off Activity Form Time Sheet. Your employer, the MassHealth Member, will obtain PCA Paid Time Off Activity Forms from their Fiscal Intermediary. Any PTO reported on a Regular Activity Form Time Sheet will not be processed for payment.

Please familiarize yourself with the following important information about PTO.

Important Information about Paid Time Off:

PCAs will earn 1 hour of PTO for every 30 hours worked. PCAs can accrue up to 50 hours of PTO.For purposes of PTO, a year is defined as the state fiscal year (July 1- June 30). The accrual isdetermined by adding all the hours worked as a PCA across all consumer employers in theMassHealth PCA Program.

PCAS may not accrue more than 50 hours of PTO. However, if a PCA uses PTO, the PCA maycontinue to accrue up to 50 hours of PTO. For example, if a PCA earned 50 hours of PTO and inthe 10th month of the year took 20 hours of PTO, the PCA would have a balance of 30 hours ofPTO. That PCA could continue to earn additional PTO up to the maximum amount of 50 hoursPTO.

PCAs may carry over up to 50 hours of unused earned PTO to the next year. However, a PCAmay never have more than 50 hours of unused earned PTO so the PCA must use PTO to be ableto start accruing again.

All PCAs who work enough hours must be allowed to accrue 50 hours per year of earned PTO.

PCAs begin accruing PTO from their first date of actual work.

A PCA can begin utilizing earned PTO 90 days after the PCA started working for a consumer.

PTO can be used for any reason that the PCA cannot or chooses not to work scheduled time.Reasons may include vacation, personal time, sick time, domestic violence or memberunavailability.

It is the PCA’s responsibility to use PTO in amounts consistent with their regular schedule. Forexample, if a PCA typically works 5 hours a day 3 days a week, he or she should use PTOconsistent with that schedule. That PCA should not, for example, take 8 hours of PTO for 5 daysin a week.

23

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms (Rev 7/19)

PTO cannot be taken at the same time/same hours that the PCA is providing personal care toanother consumer in the PCA program (i.e., a PCA cannot submit an activity form for providingPCA services seeking regular pay and also submit a PTO activity form seeking pay for usingearned PTO for the same hours).

PCAs are entitled to use earned PTO in 15-minute intervals. The shortest time period for whicha PCA may use earned PTO is 15 minutes.

PTO will not count toward the calculation of overtime or other premium rates. However, a PCAwho works more than 40 hours in a given week can receive overtime pay in the same week thata PCA uses PTO. For example, if a PCA typically worked 50 hours in a week and took 5 hours ofPTO, that PCA would be paid for 45 hours of regular time, 5 hours of overtime premium and 5hours of PTO.

PCAs should submit a Paid Time Off Activity Form for each consumer from whom they arerequesting PTO. For example, if a PCA works for 2 employers on Monday and would like to takeMonday off, the PCA should submit two Paid Time Off Activity Forms. The Paid Time Off ActivityForms should reflect the regularly scheduled hours for which the PCA is taking PTO. The PCAshould not submit Paid Time Off Activity Forms for different consumers with overlapping PTOreported.

Unused accrued PTO will be paid out to PCAs at the end of employment, regardless of whetherthe PCA left voluntarily or involuntarily.

A PCA must end employment with all consumers to be eligible for payment of unused accruedPTO.

A PCA must work for a PCA Consumer, and an activity form must be submitted, for dates ofservices on or after July 1, 2019, for a PCA to be eligible for payout for any remaining PTO at theend of employment as a PCA. In addition, the Termination Form must be submitted within 1year of the last date worked to be eligible for payout.

A Termination Form will initiate the pay-out of unused accrued PTO if the PCA is leaving allemployment in the PCA program. A Termination Form must be submitted to the FiscalIntermediary immediately after a PCA’s employment ends. The Termination Form is requiredregardless of the reason for the end of employment. It is preferred to have both the PCA andthe consumer employer sign the Termination Form; however, the Fiscal Intermediary will accepta Termination Form submitted and signed by either the PCA or the consumer employer. If thePCA signs the form, the PCA will attest on the form if he or she is leaving all employment in thePCA program or if he or she is employed by one or more other consumers.

The PCA and consumer will be asked to attest as to the Date of Separation from employment onthe Termination Form. The PCA will be paid out at the wage rate effective as of the Date ofSeparation. The Date of Separation is defined as the date that the consumer employer and thePCA ended their employment relationship. If the Date of Separation is unknown, please use thelast date that the PCA worked for the consumer employer.

24

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms (Rev 7/19)

Payout of unused accrued PTO will be issued by the Fiscal Intermediary with the next scheduledpayroll after receiving an accurately completed Termination Form.

PCAs must make a good faith effort to provide reasonable notice to the consumer employer ofthe intent to use PTO in advance of the use of earned PTO. Reasonable notice may includecompliance with the consumers’ reasonable notification policy and procedure that the PCAcustomarily uses to communicate with the consumer for absences or requesting leave. If theconsumer does not have an existing policy and procedure for providing reasonable notice, theconsumer must establish such a policy or procedure, preferably in writing. The policy andprocedure should enable the PCA to effectively provide reasonable notice in a way that can bedocumented.

A PCA can view his or her unused accrued Paid Time Off balance at the iSolve web portal athttps://www.OnlineEmployer.com/feapca. Should PCAs or consumer employers have questionsregarding PTO, they may contact the Fiscal Intermediary that issues the PCA’s payment.

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THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms ES (Rev 7/19)

TIEMPO LIBRE PAGADO DE LOS ASISTENTES DE CUIDADOS PERSONALES

Con vigencia a partir del 1 de julio del 2019, los Asistentes de Cuidados Personales (PCA) tendrán derecho a acumular Tiempo Libre Pagado (PTO). Anteriormente, los PCA podían acumular licencias por enfermedad. A partir del 1 de julio del 2019, todo el tiempo de las licencias por enfermedad se convertirá en PTO y los PCA solo podrán acumular Tiempo Libre Pagado (PTO).

El PTO deberá reportarse en una planilla de horas trabajadas por separado: la Planilla de horas para el Formulario de actividades de tiempo libre pagado del PCA. Su empleador, el afiliado de MassHealth, obtendrá los Formularios de actividades de tiempo libre pagado de su Intermediario Fiscal (FI). No se procesará para pagos ningún PTO que se reporte en una Planilla de horas trabajadas del Formulario de actividades normal.

Por favor, dedique tiempo a familiarice con la siguiente información importante sobre el PTO.

Información importante sobre el Tiempo Libre Pagado (PTO):

Los PCA acumularán 1 hora de PTO por cada 30 horas trabajadas. Los PCA pueden acumularhasta 50 horas de PTO. Para efectos del PTO, un año se define como el año fiscal del estado (del1 de julio al 30 de junio). La acumulación se determina sumando todas las horas trabajadascomo PCA entre todos los consumidores empleadores en el programa de PCA de MassHealth.

Los PCA no podrán acumular más de 50 horas de PTO. Sin embargo, si un PCA usa su PTO, el PCApodrá seguir acumulando hasta tener 50 horas de PTO. Por ejemplo, si un PCA obtuvo 50 horasde PTO y en el décimo mes del año utilizó 20 horas de ese PTO, el PCA tendría un saldo de 30horas de PTO. Dicho PCA podría seguir acumulando PTO adicional hasta un máximo de 50 horasde PTO.

Los PCA pueden pasar al año siguiente hasta 50 horas de PTO acumuladas y sin usar. Noobstante, un PCA nunca podrá tener más de 50 horas de PTO acumuladas y sin usar, de maneraque el PCA tiene que utilizar su PTO para poder comenzar a acumular nuevamente.

A todos los PCA que trabajen suficientes horas se les debe permitir que acumulen hasta un totalde 50 horas por año de PTO obtenido.

Los PCA comienzan a acumular PTO a partir de su primer día de trabajo.

Los PCA pueden comenzar a usar su PTO acumulado, 90 días después de que el PCA hayacomenzado a trabajar para un consumidor.

El PTO se puede usar por cualquier motivo por el que el PCA no pueda o no desee trabajardurante un tiempo que tenga programado. Las razones pueden incluir: vacaciones, tiempopersonal, licencia por enfermedad, violencia doméstica o que el afiliado no esté disponible.

Es responsabilidad del PCA usar el PTO en cantidades que sean coherentes con su horarionormal. Por ejemplo, si un PCA típicamente trabaja 5 horas al día por 3 días a la semana, debe

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THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms ES (Rev 7/19)

usar su PTO de manera coherente con ese horario. Ese PCA no debe, por ejemplo, tomar 8 horas de PTO durante 5 días en una semana.

El PTO no se puede usar al mismo tiempo ni en las mismas horas en las que el PCA está dándolecuidado personal a otro consumidor en el programa PCA (es decir, un PCA no puede presentarun formulario de actividades por prestar servicios de PCA aspirando a recibir su pago corriente ya la vez presentar un formulario de actividades de PTO con el que aspire a recibir pago por PTOacumulado por las mismas horas).

Los PCA tienen derecho a usar el PTO acumulado en intervalos de 15 minutos cada uno. Elperíodo de tiempo más breve por el cual un PCA puede usar su PTO acumulado es de 15minutos.

No se considerará el PTO para el cálculo de horas extra ni de otras tarifas superiores. Sinembargo, el PCA que trabaje más de 40 horas en una semana dada, podrá recibir pago por horasextra en la misma semana en la que el PCA use su PTO. Por ejemplo, si un PCA típicamentetrabaja 50 horas en una semana y se tomó 5 horas de PTO, a dicho PCA se le pagarían 45 horasde tiempo normal, 5 horas de horas extra de tarifa superior y 5 horas de PTO.

Los PCA deberán presentar un Formulario de actividades de tiempo libre pagado por cadaconsumidor por el cual estén solicitando PTO. Por ejemplo, si un PCA trabaja para dosempleadores el lunes y quisiera tomarse libre un lunes, el PCA debe presentar dos Formulariosde actividades de tiempo libre pagado. Esos formularios deben reflejar las horas programadasnormales por las que el PCA va a usar el PTO. El PCA no debe presentar Formularios deactividades de tiempo libre pagado para diferentes consumidores que reporten PTO que sesuperpongan.

El PTO acumulado y sin usar se pagará a los PCA al finalizar su empleo, independientemente desi el PCA se haya dejado el puesto voluntaria o involuntariamente.

El PCA debe haber terminado su empleo con todos los consumidores para tener derecho apercibir el pago del PTO acumulado y sin usar.

El PCA debe trabajar para un Consumidor de servicios de PCA y debe presentar un formulario deactividades correspondiente a las fechas de los servicios prestados desde el 1 de julio del 2019,para que un PCA tenga derecho a recibir el pago de cualquier cantidad de PTO que le quedecuando concluya su empleo como PCA. Adicionalmente, Formulario de cese del empleo tieneque presentarse entre un ano des te última fecha trabajada para tener derecho a recibir el pago.

Se utilizará un Formulario de cese del empleo para iniciar el pago del PTO sin usar si el PCA seestá retirando de todo su empleo en el programa de PCA. Dicho Formulario de cese del empleodebe presentarse al Intermediario Fiscal inmediatamente después de que concluya el empleocon el programa de PCA. El Formulario de cese del empleo es obligatorio independientementedel motivo por el cual finalice el empleo. Se prefiere que tanto el PCA como el consumidorempleador firmen el Formulario de cese del empleo. No obstante, el Intermediario Fiscalaceptará un Formulario de cese del empleo presentado con la firma de ya sea el PCA o el

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THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services

PTO Terms ES (Rev 7/19)

consumidor empleador. Si el PCA firma el formulario, dicha persona declarará en el formulario que se está retirando de todo empleo en el programa de PCA o si seguirá trabajando para uno o más otros consumidores.

Tanto al PCA como al consumidor se les pedirá que declaren la Fecha de cese del empleo en elFormulario de cese del empleo. Al PCA se le pagará a la tarifa salarial vigente a la Fecha de cese.La Fecha de cese se define como la fecha en la que el consumidor empleador y el PCA ponen fina su relación laboral. Si se desconoce la Fecha de cese, por favor use la última fecha en la que elPCA trabajó para el consumidor empleador.

El Intermediario Fiscal emitirá el pago del PTO acumulado y sin usar en la siguiente nóminaprogramada una vez que haya recibido el Formulario de cese del empleo debidamentecompletado.

Los PCA harán un esfuerzo de buena fe para dar suficiente tiempo de preaviso al consumidorempleador de su intención de usar el PTO con antelación a usar dicho PTO acumulado. Eltiempo de preaviso razonable puede incluir el cumplimiento de la norma y el procedimiento denotificación razonable que el PCA acostumbra a utilizar para comunicarle al consumidor todaausencia o solicitud de licencia. Si el consumidor no tiene una norma y procedimiento paraefectos de dar una notificación razonable, el consumidor tiene que fijar tal norma yprocedimiento, preferiblemente por escrito. La norma y procedimiento debe permitir al PCA darun preaviso razonable de manera que este quede documentado.

El PCA puede controlar cuál es su saldo de PTO sin usar en el portal de internet iSolve enhttps://www.OnlineEmployer.com/feapca. Si el PCA o el consumidor empleador llegara a tenerpreguntas sobe el PTO, deben comunicarse con el Intermediario Fiscal que emita los pagos parael PCA.

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CHARLES D. BAKER Governor

KARYN E. POLITO

Lieutenant Governor

MARYLOU SUDDERS

Secretary

Tel: (617) 573-1712 www.mass.gov/pca

Email: pcacouncil@state.ma.us Facebook:

www.facebook.com/MassPCA

Personal Care Attendant Quality Home Care Workforce Council 1 Ashburton Place, 11th Floor

Boston, Massachusetts 02108

Dear Personal Care Attendant (PCA):

You are receiving this notice because you provide Personal Care Attendant (PCA) services to a MassHealth member who is your consumer-employer. This notice provides benefit and other information related to the Massachusetts Family and Medical Leave law. The PCA Quality Home Care Workforce Council (FEIN: 81-0783359) is sending you this notice in accordance with M.G.L. c. 175M.

Employer Notice to Employee Rights and Obligations under the Massachusetts Family and Medical Leave Law, M.G.L. c. 175M

IMPORTANT INFORMATION FOR ALL PERSONAL CARE ATTENDANTS (PCAs)

Explanation of Benefits Beginning October 1, 2019: Fiscal intermediaries for the PCA Program will deduct contributions from your wages to fund the Department of Family and Medical Leave (DFML) Employment Security Trust Fund. This means you will start seeing new deductions starting October 1, 2019. The benefits will be available starting in 2021.

Beginning January 1, 2021:

You may be entitled to up to 12 weeks of paid family leave in a benefit year for the birth, adoption,or foster care placement of a child.

You may be entitled to up to 12 weeks of paid family leave in a benefit year because a familymember is on active duty or has an upcoming call to active duty in the Armed Forces.

You may be entitled to up to 20 weeks of paid medical leave in a benefit year if you have a serioushealth condition that prevents you from working.

You may be entitled to up to 26 weeks of paid family leave in a benefit year to care for a familymember who is a covered service member undergoing medical treatment or addressingconsequences of a serious health condition related to military service.

Beginning July 1, 2021:

You may be entitled to up to 12 weeks of paid family leave in a benefit year to care for a familymember with a serious health condition.

You may be eligible for up to 26 total weeks, in the aggregate, of paid family and medical leave in asingle benefit year.

A weekly benefit amount will be based on your earnings, with a maximum benefit of $850 per week.

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Employer/Employee Contributions to the DFML Security Trust Fund

Currently, the total contribution amount is 0.75% of wages. Of that 0.75% total contribution amount, there is a split: 17.3% is a family leave contribution and 82.7% is a medical leave contribution. Employees and employers will share in the contribution to this benefit. Employees will contribute to the benefit through 0.38% deductions from wages. MassHealth will contribute the remaining amount (0.37%) on behalf of your consumer-employer. This means that if you earned $100, $0.38 would be deducted from your paycheck. This consists of $0.13 to cover your family leave contribution and $0.25 to cover your medical leave contribution. These deductions are determined based on your total wages. That means if you made $95 in regular pay and $5 in overtime pay, the deduction would be determined based on the total $100 in wages.

How to File a Claim To access paid family and medical leave benefits, you must file claims with the DFML using DFML forms. Forms and claim instructions will be available before January 2021 on the Department’s website, www.mass.gov/DFML.

You are required to provide at least 30 days’ notice to your PCA consumer-employer of the anticipated date of any leave, the anticipated length of the leave, and the expected date of return. An employee who is unable to provide 30 days’ notice due to circumstances beyond his or her control is required to provide notice as soon as practical.

Department of Family and Medical Leave (DFML) Contact Information The Massachusetts Department of Family and Medical Leave Charles F. Hurley Building 19 Staniford Street, 1st Floor Boston, MA 02114 (617) 626-6565 / www.mass.gov/DFML

Payment for Concurrent Leave Any paid leave provided under a collective bargaining agreement or employer policy and paid at the same or higher rate than paid leave available under this law shall count against the allotment of leave benefits available under this law.

Questions

If you have questions about the law, please contact the Department of Family and Medical Leave at (617) 626-6565 or visit their website at www.mass.gov/DFML.

ACKNOWLEDGMENT Your signature below acknowledges your receipt of the information above. Please retain a copy for your reference. If you refuse to sign this acknowledgment, please submit a signed statement indicating that you refuse to sign this acknowledgement.

Signature Date

Name (Print)

Return to: Northeast Arc, FI Department, 300 Rosewood Drive, Suite 100, Danvers MA 01923. 30

CHARLES D. BAKER Governor

KARYN E. POLITO

Lieutenant Governor

MARYLOU SUDDERS

Secretary

Tel: (617) 573-1712 www.mass.gov/pca

Email: pcacouncil@state.ma.us Facebook:

www.facebook.com/MassPCA

Personal Care Attendant Quality Home Care Workforce Council 1 Ashburton Place, 11th Floor

Boston, Massachusetts 02108

Estimado/estimada Asistente de Cuidados Personales (PCA):

Usted recibe este aviso debido a que presta servicios de Asistente de Cuidados Personales (PCA) a un afiliado de MassHealth que es su consumidor-empleador. En el presente aviso le ofrecemos información sobre el beneficio y otros temas afines de la Ley de Licencia Familiar y Médica del estado de Massachusetts. El Consejo para la Calidad de la Fuerza Laboral de Asistencia en el Hogar de PCA (PCA Quality Home Care Workforce Council) (FEIN: 81-0783359) le envía este aviso según dicha ley M.G.L. c. 175M.

Aviso del empleador al empleadoDerechos y obligaciones conforme a la Ley de Licencia Familiar y Médica (FMLA), M.G.L. c. 175M

INFORMACIÓN IMPORTANTE PARA TODOS LOS ASISTENTES DE CUIDADOS PERSONALES (PCA)

Explicación de los beneficios A partir del 1.o de octubre del 2019: A partir del 1.o de octubre del 2019, comenzarán las contribuciones al Fondo Fiduciario de Seguridad Laboral y Familiar del Departamento de Licencias Familiares y Médicas (DFML). Esto significa que, a partir de esa fecha, usted empezará a ver nuevas deducciones en su cheque de pago.

A partir del 1.o de enero del 2021:

Los empleados tienen derecho a recibir hasta 12 semanas de licencia familiar pagada por año del beneficiodebido al nacimiento o a la adopción de un niño o por recibir a un niño en cuidado de crianza.

Los empleados tienen derecho a usar hasta 12 semanas de licencia familiar pagada por año del beneficiodebido a que un familiar esté prestando servicio activo o que haya sido notificado de un llamado inminentepara prestar servicio activo en las Fuerzas Armadas.

Los empleados tienen derecho a usar hasta 20 semanas de licencia médica pagada por año del beneficio sipadecieran una enfermedad grave que les impidiera trabajar.

Los empleados tienen derecho a usar hasta 26 semanas de licencia médica pagada por año del beneficio paracuidar a un familiar que sea un miembro de servicio cubierto por el beneficio y que esté en tratamientomédico o que padezca una enfermedad grave relacionada con su servicio militar.

A partir del 1.o de julio del 2021:

Los empleados tienen derecho a usar hasta 12 semanas de licencia familiar pagada por año del beneficiopara cuidar a un familiar que padezca una enfermedad grave.

Los empleados podrán usar hasta 26 semanas de licencia familiar y médica pagada, en total, en un mismoaño del beneficio.

El monto del beneficio semanal que recibirá el empleado dependerá de los ingresos del empleado,considerando un beneficio máximo de $850 por semana.

Contribuciones del empleador y del empleado al Fondo Fiduciario de Seguridad Laboral y Familiar del DFML

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A la fecha, la contribución total es del 0.75% de su salario. De ese aporte total del 0.75%, el 0.13% es la contribución para la licencia familiar y el 0.62% es la contribución para la licencia médica. Los empleadores y los empleados participan en la contribución que darán para financiar este beneficio. Los empleados contribuirán con el 100% del beneficio de licencia familiar mediante deducciones de la nómina. Los empleados contribuirán con el 40% de la licencia médica mediante deducciones de la nómina y los empleadores contribuirán el 60% (00.372% de ese salario) restante. Esto significa que si usted se gana $100, se le descontarán $0.38 de su cheque de pago. Esto representa una contribución de $0.13 para la licencia familiar y de $0.25 para su contribución para la licencia médica. El monto de estas deducciones se determina según el total de su salario. Esto significa que si usted percibió $95 en pago por horas corrientes y $5 por horas extra, la deducción se basaría en ese total de $100 de salario.

Cómo presentar una solicitud del beneficio Para acceder a los beneficios de la Licencia Familiar y Médica Pagada, los empleados tienen que presentar la solicitud al DFML, usando los formularios del DFML. Los formularios y las instrucciones de cómo presentar la solicitud estarán disponibles antes de enero del 2021 en el sitio web del Departamento: www.mass.gov/DFML.

Los empleados tienen la obligación de notificar a su empleador, con por lo menos 30 días de antelación, la fecha estimada de licencia, la duración prevista de la licencia y la fecha prevista para su regreso al trabajo. El empleado que no pueda dar los 30 días de aviso previo debido a circunstancias más allá de su control, debe notificarle a su empleador tan pronto como le sea práctico hacerlo.

Información de contacto del Departamento de Licencias Familiares y Médicas (DFML) The Massachusetts Department of Family and Medical Leave Charles F. Hurley Building 19 Staniford Street, 1st Floor Boston, MA 02114 (617)626-6565 / www.mass.gov/DFML

Pago por licencias concurrentes Toda licencia pagada que se otorgue según un contrato de negociación colectiva o según las normas internas del empleador y que se pague a la misma tasa o mayor que la licencia pagada disponible según la presente ley, deberá contarse como parte de los beneficios de licencia disponibles conforme a lo que se estipula en esta ley.

¿Tiene preguntas?

Si usted tiene preguntas acerca de la ley, por favor comuníquese con el Departamento de Licencias Familiares y Médicas, llamando al (617) 626-6565 o visite su sitio web www.mass.gov/DFML.

ACUSE DE RECIBO Con su firma consignada a continuación, usted reconoce haber recibido la información que se detalla anteriormente. Sírvase guardar una copia para su referencia. Si se niega a firmar este acuse de recibo, por favor presente una declaración firmada en la que indica que se niega a firmarlo.

Firma Fecha

Nombre (en letra de molde)

Return to: Northeast Arc, FI Department, 300 Rosewood Drive, Suite 100, Danvers MA 01923.

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