Ohio Veteran-Directed Services Program Employee Packet (Keep This Folder for Your Records)

Ohio Veteran-Directed Services Program Employee Packet (keep this folder for your records)

You will need to complete the following steps in order to hire an employee:

 Interview applicants and decide who you think would be the best fit for your particular needs.  Have background checks completed as required.  Once the employee is approved for hire by your Care Manager from AAA7, have your employee complete and send the following forms and information to Acumen:  Employee Agreement Form  Employee Rate Information Form  I-9 Employment Eligibility Verification o Your employee fills out Section I. o As the Employer, you fill out Section II. Employers must enter the date the employee began or will begin work for pay on the I-9. If the actual date of hire (first date of providing services for pay) for the employee changes from the date entered, it is the employer's responsibility to correct and re-submit the form to Acumen within three days of the actual date of hire. o To review Frequently Asked Questions about Form I-9, please visit www.acumenfiscalagent.com, and click on Resources.  W-4 Employee’s Withholding Allowance Certificate  IT-4 Ohio Employee’s Withholding Exemption Certificate  Pay Selection Options Form  Authorization for Direct Deposit/Pay Card (optional)  Employee Background Check Clearance Form (provided to Acumen by Care Manager)  Application for Employment (optional)

Acumen will notify you when your employee can begin working. Do not allow any work to be performed prior to this notification. It will take approximately 5-7 business days before an applicant is cleared for hire. However, it could take longer.

Acumen recommends that you download the forms from our website to ensure that you have the most current versions. You may contact our Customer Service Center to be sure you have the most up-to- date forms or to request copies be sent to you.

Acumen Fiscal Agent, LLC. 5416 E. Baseline Rd., Suite 200 Mesa, AZ 85206 Phone (866) 862-6861 Fax (866) 862-6862 [email protected] OH AAA7 03-2019

Employee State and Local Tax Withholding Ohio state and local income tax will be withheld from all employees' pay based on state and local income tax withholding guidelines. Employees who live in another state may be required to file and pay state withholding tax in Ohio and the state in which they live. Individuals in this situation should consult a tax advisor with any concerns they may have about their state tax liability.

Employee Changes and Termination As the employer, it is your responsibility to notify Acumen when employee information changes or when an employee no longer works for you.  Complete the Employee Change Form if an employee changes his or her name or address. This ensures that Acumen maintains accurate employee information to prevent interruption or delay of payment for services.  Complete the Termination Form when an employee no longer works for you. This formally ends the employer employee relationship and notifies Acumen to NOT make any payments for that employee after his/her termination date. Failure to notify Acumen of an employee termination in a timely manner increases the risk of an unauthorized payment if your employee submits time without your knowledge.

Employee Files Acumen recommends that you maintain a current, confidential and accurate file on each employee hired. This file should contain all employee documentation as previously listed, as well as all employee timesheets. It is recommended that you keep a copy of all forms submitted to Acumen and note the date and time you submitted them.

Confidentiality If you mail forms to Acumen, always make a copy first. If you fax forms to Acumen retain the original in your files. Remember that these forms contain sensitive and confidential information about you and your employees, and they need to be kept in a safe place. Employees must not disclose or knowingly permit the disclosure of any information concerning the Veteran, the employer, or his/her family to any unauthorized person.

Internet Options We encourage you to try our easy and reliable internet options for reporting and electronic time sheet submission (DCI Web Portal) for the AAA7 Veterans program. Visit www.acumenfiscalagent.com, choose your state page under the Participant Employers link and click on the “Web Time Entry” link. A username and password are required, this information will be provided by Acumen once all paperwork is complete!

Employee Overtime Your employees are eligible for overtime pay if they work more than 40 hours in a week (from Sunday to Saturday). Overtime is paid at one and a half times their regular hourly rate. Consider hiring more than one employee if you require more than 40 hours per week of care as your spending plan is calculated assuming you will not use overtime. The RDF (Rainy Day Fund) can be used for overtime payments when necessary, should you use the full amount of Personal Care funds for the month. If you do not have enough funds in your Personal Care and Rainy Day Fund, you will be responsible to pay your employee for the remaining amount you owe them.

Earned Income Credit Some employees are eligible for Earned Income Tax Credit (EITC). EITC is a refundable federal income tax credit for low to moderate income working individuals and families. To qualify, taxpayers must meet certain requirements and file a tax return, even if they do not have a filing requirement. To learn more about the rules and income limits to qualify for EITC, contact the IRS at www.irs.gov/eitc or call 1-800- 829-1040.

Fraud Fraud is committed when an EMPLOYER or EMPLOYEE is untruthful regarding services provided in order to obtain improper payment. Fraud is a felony, and conviction can lead to substantial penalties.

Examples of Fraud include:  Signing or submitting a timesheet for services that were not actually provided.  Signing or submitting a timesheet for services provided by a different person.  Signing or submitting a timesheet for services that were reimbursed by another source.  Signing or submitting a duplicate timesheet for reimbursement from the same source.

As required by the State of Ohio, suspected cases of fraud will be referred to the state for further investigation and possible prosecution.

To view Acumen’s False Claims Policy go to www.acumenfiscalagent.com, select the “Resources” tab, then locate our “False Claim Policy.”

Acumen Fiscal Agent, LLC. 5416 E. Baseline Rd., Suite 200 Mesa, AZ 85206 Phone (866) 862-6861 Fax (866) 862-6862 [email protected] OH AAA7 03-2019

Acumen Fiscal Agent, LLC. 5416 E. Baseline Rd. Suite 200 Mesa, AZ 85206 Toll-Free Phone: (866) 862-6861 Toll-Free Fax: (866) 862-6862 [email protected] www.acumenfiscalagent.com

EMPLOYMENT APPLICATION

PARTICIPANT’S NAME: ______

PERSONAL INFORMATION: APPLICANT’S NAME: ______DATE: ______STREET ADDRESS: ______CITY: ______STATE: ZIP: SOCIAL SECURITY #: HOME PHONE NUMBER: OTHER: E-MAIL ADDRESS: ______

EMPLOYMENT ELIGIBILITY: Are you interested in serving as a (check all that apply): Full-time employee? Part-time employee? Backup employee?

Are you currently employed: ___YES NO

Date available for employment: How many hours a week can you work?

Are you 18 years of age or older? ___YES NO

LICENSES AND CERTIFICATIONS: Do you have a valid driver's license? ___YES NO

Do you have current First Aid Certification? ___YES NO if yes, expiration date: ______

Do you have current CPR Certification? ___YES NO if yes, expiration date: ______

Please list any other professional certifications:

LIST THREE PERSONAL REFERENCES:

(Name) (Address) (Phone Number)

LIST PREVIOUS JOBS YOU HAVE HAD (BEGINNING WITH MOST RECENT):

EMPLOYER’S NAME: DATES OF EMPLOYMENT: EMPLOYER’S ADDRESS: SUPERVISOR’S NAME: PHONE NUMBER: LIST OF JOB DUTIES: REASON FOR LEAVING:

BRIEFLY LIST REASONS YOU SHOULD BE CONSIDERED FOR THIS JOB:

APPLICANT ACKNOWLEDGEMENT You ___may ____may not contact my current employer. If not, reason:

If offered a position, will you be able to be at work on time and according to the schedule discussed? __ Yes ___ No Comments:

I, ______(print name), the applicant, certify that the information provided is true and correct to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if employer has employed me, no matter when discovered by employer. I also acknowledge that a background check is required and that some convictions prevent employment.

I authorize this potential employer to investigate all statements contained in this application, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation, without giving me prior notice of such disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or this employer. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon this employer unless made in writing.

Signature: Date:

OH AAA7 Vets Rev. 09/18/13 Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number - -

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

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

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

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) QR Code - Section 1 Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space 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:

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

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

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

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

Employer Completes Next Page

Form I-9 10/21/2019 Page 1 of 3 Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.") Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status Employee Info from Section 1

List A OR List B AND List C Identity and Employment Authorization Identity 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

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

Document Number

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

Document Title

Issuing Authority

Document Number

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

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

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

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

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

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

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

Form I-9 10/21/2019 Page 2 of 3 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

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

LIST A LIST B LIST C Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form I-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye 3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary I-551 stamp or temporary INS AUTHORIZATION I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or 4. Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms I-766) DS-1350, FS-545, FS-240) 3. School ID card with a photograph 5. For a nonimmigrant alien authorized 3. Original or certified copy of birth to work for a specific employer 4. Voter's registration card certificate issued by a State, because of his or her status: county, municipal authority, or 5. U.S. Military card or draft record territory of the United States a. Foreign passport; and bearing an official seal b. Form I-94 or Form I-94A that has 6. Military dependent's ID card the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document Card (1) The same name as the passport; 5. U.S. Citizen ID Card (Form I-197) and 8. Native American tribal document (2) An endorsement of the alien's 6. Identification Card for Use of nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United that period of endorsement has government authority States (Form I-179) not yet expired and the proposed employment is not in For persons under age 18 who are 7. Employment authorization conflict with any restrictions or unable to present a document document issued by the Department of Homeland Security limitations identified on the form. listed above: 6. Passport from the Federated States 10. School record or report card of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with 11. Clinic, doctor, or hospital record Form I-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI

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

Refer to the instructions for more information about acceptable receipts.

Form I-9 10/21/2019 Page 3 of 3

As of 12/7/20 this new version of the IT 4 combines and replaces the following forms: IT 4 (previous version), IT 4NR, IT 4 MIL, and IT MIL SP. IT 4 epartment of Rev. 12/20 hio Taxation

Employee’s Withholding Exemption Certificate

Submit form IT 4 to your employer on or before the start date of employment so your employer will withhold and remit Ohio income tax from your compensation. If applicable, your employer will also withhold school district income tax. You must file an updated IT 4 when any of the information listed below changes (including your marital status or number of dependents). You should contact your employer for instructions on how to complete an updated IT 4. Your employer may require you to complete this form electronically.

Section I: Personal Information

Employee Name: Employee SSN:

Address, city, state, ZIP code:

School district of residence (See The Finder at tax.ohio.gov): School district number (####):

Section II: Claiming Withholding Exemptions

1. Enter “0“ if you are a dependent on another individual’s Ohio return; otherwise enter “1”...... ______

2. Enter “0” if single or if your spouse files a separate Ohio return; otherwise enter “1“...... ______

3. Number of dependents...... ______

4. Total withholding exemptions (sum of line 1, 2, and 3)...... ______

5. Additional Ohio income tax withholding per pay period (optional)...... $______

Section III: Withholding Waiver

I am not subject to Ohio or school district income tax withholding because (check all that apply):

I am a full-year resident of Indiana, Kentucky, Michigan, Pennsylvania, or West Virginia.

I am a resident military servicemember who is stationed outside Ohio on active duty military orders.

I am a nonresident military servicemember who is stationed in Ohio due to military orders.

I am a nonresident civilian spouse of a military servicemember and I am present in Ohio solely due to my spouse’s military orders.

I am exempt from Ohio withholding under R.C. 5747.06(A)(1) through (6).

Section IV: Signature (required)

Under penalties of perjury, I declare that, to the best of my knowledge and belief, the information is true, correct and complete.

Signature Date As of 12/7/20 this new version of the IT 4 combines and replaces the following forms: IT 4 (previous version), IT 4NR, IT 4 MIL, and IT MIL SP. IT 4 Instructions

Most individuals are subject to Ohio income tax on their Note: If you do not request additional withholding from your wages, salaries, or other compensation. To ensure this compensation, you may need to make estimated income tax tax is paid, employers maintaining an office or transacting payments using form IT 1040ES or estimated school district business in Ohio must withhold Ohio income tax, and school income tax payments using the SD 100ES. Individuals who district income tax if applicable, from each individual who is commonly owe more in Ohio income taxes than what is an employee. withheld from their compensation include: Such employees who are subject to Ohio income tax (and z Spouses who file a joint Ohio income tax return and both school district income tax, if applicable) should complete report income, and sections I, II, and IV of the IT 4 to have their employer withhold z Individuals who have multiple jobs, all of which are the appropriate Ohio taxes from their compensation. If the subject to Ohio withholding. employee does not complete the IT 4 and return it to his/her employer, the employer: Section III z Will withhold Ohio tax based on the employee claiming This section is for individuals whose income is deductible zero exemptions, and or excludable from Ohio income tax, and thus employer z Will not withhold school district income tax, even if the withholding is not required. Such employee should check employee lives in a taxing school district. the appropriate box to indicate which exemption applies to him/her. Checking the box will cause your employer to not An individual may be subject to an interest penalty for withhold Ohio income tax and/or school district income tax. underpayment of estimated taxes (on form IT/SD 2210) The exemptions include: based on under-withholding. z Reciprocity Exemption: If you are a resident of Indiana, Certain employees may be exempt from Ohio withholding Kentucky, Pennsylvania, Michigan or West Virginia and because their income is not subject to Ohio tax. Such you work in Ohio, you do not owe Ohio income tax on employees should complete sections I, III, and IV of the IT your compensation. Instead, you should have your 4 only. employer withhold income tax for your resident state. R.C. 5747.05(A)(2). The IT 4 does not need to be filed with the Department of Taxation. Your employer must maintain a copy as part of z Resident Military Servicemember Exemption: If you are its records. an Ohio resident and a member of the United States Army, Air Force, Navy, Marine Corps, or Coast Guard (or R.C. 5747.06(A) and Ohio Adm.Code 5703-7-10. the reserve components of these branches of the military) or a member of the National Guard, you do not owe Section I Ohio income tax or school district income tax on your Enter the four-digit school district number of your primary active duty military pay and allowances received while address. If you do not know your school district of residence stationed outside of Ohio. or its school district number, use The Finder at tax.ohio.gov. This exemption does not apply to compensation for nonactive You can also verify your school district by contacting your duty status or received while you are stationed in Ohio. county auditor or county board of elections. R.C. 5747.01(A)(21). If you move during the tax year, complete an updated IT 4 immediately reflecting your new address and/ or school z Nonresident Military Servicemember Exemption: If district of residence. you are a nonresident of Ohio and a member of the uniformed services (as defined in 10 U.S.C. §101), Section II you do not owe Ohio income tax or school district Line 1: If you can be claimed on someone else’s Ohio income income tax on your military pay and allowances. tax return as a dependent, then you are to enter “0” on this line. Everyone else may enter “1”. z Nonresident Civilian Spouse of a Military Servicemember Exemption: If you are the civilian spouse of a military Line 2: If you are single, enter “0” on this line. If you are servicemember, your pay may be exempt from Ohio married and you and your spouse file separate Ohio Income income tax and school district income tax if all of the tax returns as “Married filing Separately” then enter “0” on following are true: this line. y Your spouse is a nonresident of Ohio; Line 3: You are allowed one exemption for each dependent. y You and your spouse are residents of the same state; Your dependents for Ohio income tax purposes are the y Your spouse is stationed in Ohio on military orders; and same as your dependents for federal income tax purposes. y You are present in Ohio solely to be with your spouse. See R.C. 5747.01(O). You must provide a copy of the employee’s spousal military Line 5: If you expect to owe more Ohio income tax than the identification card issued to the employee by the Department amount withheld from your compensation, you can request of Defense when completing the IT 4. that your employer withhold an additional amount of Ohio income tax. This amount should be reported in whole dollars. As of 12/7/20 this new version of the IT 4 combines and replaces the following forms: IT 4 (previous version), IT 4NR, IT 4 MIL, and IT MIL SP. Note: For more information on taxation of military y Newspaper or shopping news delivery or distribution servicemembers and their civilian spouses, see 50a U.S.C. directly to a consumer, performed by an individual §571. under the age of 18; y Services performed for a foreign government or an z Statutory Withholding Exemptions: Compensation international organization; and earned in any of the following circumstances is not y Services performed outside the employer’s trade or subject to Ohio income tax or school district income tax business if paid in any medium other than cash. withholding: *These exemptions are not common. y Agricultural labor (as defined in 26 U.S.C. §3121(g)); y Domestic service in a private home, local college Note: While the employer is not required to withhold on club, or local chapter of a college fraternity or these amounts, the income is still subject to Ohio income tax sorority; and school district income tax (if applicable). As such, you y Services performed by an employee who is regularly may need to make estimated income tax payments using employed by an employer to perform such service if form IT 1040ES and/or estimated school district income tax she or he earns less than $300 during a calendar payments using form SD 100ES. quarter; See R.C. 5747.06(A)(1) through (6). OHIO AAA7 VETERAN-DIRECTED SERVICES Employee Background Check Clearance Form

Date: ______

This notice is to inform you that AAA7 has reviewed the results of the background check(s) for the employee listed below.

Veteran Name: ______

Employee Name: ______

Background Check Type: ______Background Check Run Date: ______

Background Check Results: Cleared for Hired Not Approved for Hire

Background Check Type: ______Background Check Run Date: ______Background Check Results: Cleared for Hired Not Approved for Hire

I, ______, the care manager for the above veteran have read and reviewed the provided background check results and have made the below decision regarding this employee’s employment.

Yes, I wish to approve this employee for hire within the Ohio Veteran-Directed Services Program. By marking “Yes” and signing, you are stating that you have read the enclosed criminal background check report and are deciding to hire the employee anyway.

The employee’s Start date will be ______. No, I do not approve this employee for hire within the Ohio Veteran-Directed Services Program.

______

Care Manager’s Signature Date

Ohio AAA7 Veterans June 2012

OHIO AAA7 VETERAN-DIRECTED SERVICES Employee Agreement Form

Employee Name: Employee Physical Address: Mailing Address (if different): Employee City/State/Zip: Employee Phone Number: Employee Email Address:

Name of Veteran Employer Name

(if different than veteran):

There are some tax exemptions given to certain employer and employee relationships. Please mark Yes or No to the below questions. These questions will help Acumen determine which tax laws and/or exemptions apply to the employee wages.

Are you the spouse of the employer? Yes No Are you the parent of the employer? Yes No Are you the child of the employer and under the age of 21? Yes No

Terms of Employment I recognize that my employment is contingent upon the enrollment of the veteran in this Program. If my veteran is no longer in the Program, I may no longer be employed. In order to acknowledge the terms of my employment, I agree to the following: 1. I understand and acknowledge that the veteran or their representative is my employer. My employer is not Acumen or any other entity involved with this Veteran Directed Program. 2. I will accept payment from Acumen as payment in full for the services provided. I cannot accept any additional compensation for the hours I have worked. 3. I will provide only the services that have been approved by my employer and authorized in the veteran’s Spending Plan. 4. I will immediately notify a person designated by the employer of any veteran medical emergency or illness. 5. I agree to complete all required paperwork including the background check forms and that I must be approved prior to providing any services under this program. 6. I understand that the results of my background checks will be made available to my prospective employer and other program staff as necessary and/or required. 7. I understand and acknowledge that any untruthful submission of services provided in an attempt to obtain improper payment is subject to investigation as Fraud. Fraud is a felony and can lead to substantial penalties and/or imprisonment.

By signing below, I confirm that I have read this “Employee Agreement Form”. I also confirm by signing below that I understand what is being required of me and agree to follow its terms and conditions.

Employee Signature: ______Date:______

OH AAA7 – Veterans 2012

OH AAA7 VETERAN-DIRECTED SERVICES Employee Pay Rate Form

 To ensure proper payment for your employee, please complete this rate form and submit it to Acumen. Fax Number: 1- 866-862-6862 E-mail Address: [email protected] Mailing Address: Acumen Fiscal Agent 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206

 Rate change forms must be received by Acumen 2 weeks before the requested effective start date in order to be processed. Acumen cannot back pay employees with a new rate for pay periods that have already passed.

 Please consult with your Care Manager regarding:  Maximum rates that cannot be exceeded  Rules on changing employee pay rates

Employee Name: Employee Acumen ID# or Employee SS#:

Veteran’s/Employer’s Name:

Is this a new employee or an existing employee? Check one box below:

For a New Employee: The below rate/s will start on this employee’s approved good to go date. The employees good to go date will be provided by Acumen.

For an Existing Employee: Rates can only change on the 1st or 16th of a month. Make the below rate/s start on (select one option only): ______1st ______16th Month Month

Service Code Employee Pay “Cost to You” Indicate if the code is NEW Rate (Employee Rate + or if the rate for an existing Employer Burden) code is CHANGING

PCS – Personal Care Services $ $

ERB – Emergency Backup Services $ $

______Veteran or Employer Representative’s Signature Date

______Care Manager’s Signature Date OH AAA7 Veterans November 2018 Pay Selection Options

Below are the options employees have for receiving their paychecks through Acumen. Please read the information about each option and select the one that is right for you. Paystubs will be sent to the email provided on the Authorization for Direct Deposit or Pay Card on the following page. You will need to provide additional information based on your selection; please read the instructions below and return all the necessary forms.

Direct Deposit With this option, your paycheck will be automatically deposited into your bank account on payday. There is no charge from Acumen to receive your pay via direct deposit. You won’t have to wait for the mail or make a trip to the bank. Paystubs will be sent to you by email on payday. You can have your paycheck deposited into one or two accounts, and you may change your account information at any time. Please note: You have the option to deposit a flat dollar amount or a percentage amount of your check to the primary account. If you choose to have a flat dollar amount deposited into your primary account you will need to provide a secondary account in which the remainder of the funds will be deposited to. If you choose to have a percentage amount of your check deposited into two accounts, you must indicate the percentage to be deposited to each. The percentage total must be 100%. If no amounts are indicated, 100% will be deposited into the primary account. To enroll, fill out the information on the Authorization for Direct Deposit section of the form and return it, along with the additional requested items, to Acumen. You will receive paper checks by mail until your bank information is verified – usually within two pay periods.

Pay Card Pay cards – also called pre-paid debit cards – work just like a regular debit card, but are used only for payroll deposits. Acumen does not charge for this option, although the card provider may charge fees for certain transactions. Pay cards are up to 80% less expensive to use than check cashing services. Paystubs will be sent by email on payday. To enroll, complete the Authorization for Pay Card section of the form and return it to Acumen. Money Network will send you an information kit. You will need to activate the card with Money Network and then contact Acumen with your account information. You will receive paper checks by mail until this process is complete.

Please return the completed form to Acumen. You may send by email, fax, or mail listed below:

Email: [email protected] Fax: (866) 862-6862 Mail: 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206

Note: if you do not select one of the options, Acumen will send your pay check via regular mail, according to the established pay schedule you have received. We make every effort to get your check to you by payday; however it is impossible to guarantee the date that paper checks will arrive. Acumen is not responsible for any delays or misdirected mail after checks have been submitted to the U.S. Postal Service. If your paper check does not arrive within 5 business days of payday, you can call Acumen to issue a stop payment and have a new check issued. A processing fee of $35 will be deducted from the new check for each stop payment request. This fee may be waived by signing up for direct deposit or pay card.

Pay Select 12-2019 I choose to receive my pay by (please check one box below): Check □ Direct Deposit □ Pay Card □

DIRECT DEPOSIT INFORMATION Attach a voided check for checking account(s). For savings accounts, please send a printout from your bank that provides the routing number and account information. Submit any changes to your account(s) immediately!

Primary Account 1 Secondary Account 2 (Mandatory for Flat dollar option) Account Type: Account Type:  Checking (attach a voided check)  Checking (attach a voided check)  Savings (attach routing & account information printout)  Savings (attach routing & account information printout)  Flat Dollar Amount  Remainder account. (Used if percentage is less than  Percentage 100% or net pay exceeds the flat dollar amount listed for Primary Account 1) Financial Institution Name Financial Institution Name

Financial Institution Address Financial Institution Address

Routing Number Routing Number

Account Number Account Number

Flat dollar amount or % of check to be deposited:______All remaining funds exceeding Primary Account 1 allocations will deposit into this account.

Are you the account holder for the account(s) listed above? □ Yes □ No

If “no,” what is the name of the account holder?

If “no,” employee agrees to have their funds deposited into this account. Employee Signature

AUTHORIZATION FOR DIRECT DEPOSIT or PAY CARD or PAPER CHECK I hereby authorize Acumen Fiscal Agent, LLC (herein after “Company”) to deposit any amount owed to me for wages and/or reimbursements by initiation of credit entries to my account at the financial institution (hereinafter “Bank”) handling my choice indicated above. Further, I authorize Bank to accept and credit any credit entries indicated by Company to my account. In the event that Company deposits funds erroneously into my account, I authorize 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 Company receives written notice from me of its termination in such time and in such a manner as to afford a reasonable opportunity to act on it. If my method of payment is pay card, as the pay card holder, it is my responsibility to close this account should I no longer choose to have payments deposited in this manner. If I selected Paper Check, I understand that Acumen will make every effort to ensure my check will arrive by payday; however, it is impossible to guarantee the date that my paper check will arrive. Acumen is not responsible for any delays or misdirected mail after checks have been submitted to the U.S. Postal Service. If my paper check does not arrive within 5 business days of payday, I can call Acumen to issue a stop payment and have a new check issued. I understand that if I request a stop payment, a processing for of $35.00 will be deducted from my new check. If I require that this fee be waived, I must sign up for either direct deposit or a Pay Card.

Print Name Social Security Number Date of Birth

Email Address for Paystub Delivery Signature Date

Return completed form by email [email protected], fax (866) 862-6862 or mail to 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206

Pay Select 12-2019

CHANGE INFORMATION FORM: EMPLOYEE

Please complete this form and return to Acumen by one of the following methods:

Mail: 5416 E. Baseline Rd., Suite 200, Mesa, AZ 85206 Fax: (866) 862-6862 Email: [email protected]

Change Employee Information Complete this section when there is a change in employee information. The employee is the person providing service.

For a change in name, fax or mail this form, a copy of the new Social Security card, and the employee’s original I-9 form with Section 3 completed.

For a name change, please provide the previous and new name. For all other changes, only the new information is required.

Change In (select all that apply): Name□ Address □ Phone Number □ E-mail Address □ Current/Previous Name: New Name:

Street Address (if changed):

City/State/Zip (if changed):

Phone Number (if changed):

E-mail Address:

Client Name and ID Number:

Employee ID Number:

Signature (Employer or Authorized Rep):

Date:

Phone (866) 862-6861 Fax (866) 862-6862 [email protected] OH REV 11-16-18