1 Cabot Road; Suite 102 Medford, MA 02155

Please confirm or complete all information below.

If any information is incorrect, please contact PPL.

Participant Name:

Participant CLTC ID: Employer Name:

Employee Information

Employee Formal Information First Name & Last Name and Suffix (Jr, Sr.)

if applicable

Address Line 1

Address Line 2

City

State, Zip Code

Phone Number

Employee Social Security Number

Employee Date of Birth

Relation to Participant

Relation to Employer

Please answer the following questions:

Does the employee live in the home of the employer? YES NO

Does the employee live in the home of the person receiving the care? YES NO

South Carolina Financial Management Services

Employee Tax Form Packet Review, Sign, and Submit to PPL

Welcome to Public Partnerships, LLC!

In order to assist you in hiring employees, we are providing you the checklist below that identifies the necessary documents and information that describes each form. Please review each form with each employee, and have him/her sign where applicable. Also, please make sure you sign all forms that require your signature as an employer.

IRS Form W-4, Employee’s Federal Withholding Allowance Certificate (signed by Employee)

USCIS Form I-9 Form, Employment Eligibility Verification (signed by Employee and Employer)

Application for Tax Exemptions (signed by Employee)

All forms should be returned to PPL at 1 Cabot Road; Suite 102, Medford, MA 02155

EFT - Electronic Funds Transfer Application Form

Important: To avoid delay in payments, please make sure all forms are completely filled out and signed by both you and your employee where applicable.

If you have any questions, please contact your local CLTC office.

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South Carolina Financial Management Services

Form W-4 (2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

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

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:

• Is age 65 or older,

• Is blind, or

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

The exceptions don’t apply to supplemental wages greater than $1,000,000.

Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below.

See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

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

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or

• You’re married, have only one job, and your spouse doesn’t work; or . . .

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

} B

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

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

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

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

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

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children.

• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

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

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

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

Form W-4 Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

1 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

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

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

4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here

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

Employee’s signature

(This form is not valid unless you sign it.) Date

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

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

Form W-4 (2017) Page 2

Deductions and Adjustments Worksheet

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

1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,700 if married filing jointly or qualifying widow(er) $9,350 if head of household $6,350 if single or married filing separately

} 2 $

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

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

9 Enter the number from the Personal Allowances Worksheet, line H, page 1

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

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note: Use this worksheet only if the instructions under line H on page 1 direct you here.

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

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

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

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

4 Enter the number from line 2 of this worksheet

5 Enter the number from line 1 of this worksheet

6 Subtract line 5 from line 4

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1

Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 0 7,001 - 14,000 1

14,001 - 22,000 2 22,001 - 27,000 3 27,001 - 35,000 4 35,001 - 44,000 5 44,001 - 55,000 6 55,001 - 65,000 7 65,001 - 75,000 8 75,001 - 80,000 9 80,001 - 95,000 10

95,001 - 115,000 11 115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $8,000 0 8,001 - 16,000 1

16,001 - 26,000 2 26,001 - 34,000 3 34,001 - 44,000 4 44,001 - 70,000 5 70,001 - 85,000 6 85,001 - 110,000 7

110,001 - 125,000 8 125,001 - 140,000 9 140,001 and over 10

Table 2

Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $610 75,001 - 135,000 1,010

135,001 - 205,000 1,130 205,001 - 360,000 1,340 360,001 - 405,000 1,420 405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $610 38,001 - 85,000 1,010 85,001 - 185,000 1,130

185,001 - 400,000 1,340 400,001 and over 1,600

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

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

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

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

USCIS

Form I-9

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

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

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

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

Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

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

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

Employee's E-mail Address Employee's Telephone Number

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

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

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

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

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

Employer Completes Next Page

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

USCIS

Form I-9

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

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

List A Identity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

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

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

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

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial

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

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

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

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

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

LISTS OF ACCEPTABLE 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

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

b. Form I-94 or Form I-94A that has the following:

(1) The same name as the passport;

and

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

a. Foreign passport; and

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

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

2. Certification of Birth Abroad issued by the Department of State (Form

FS-545)

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

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

5. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

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

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

Refer to the instructions for more information about acceptable receipts.

Revised: 6/1/12 PCG Public Partnerships, LLC

Form TE 20 Financial Administrator 1 Cabot Road; Suite 102 Medford, MA 02155

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

State Worked: ____South Carolina______________________ Program: ___Care Call___________________________

Participant Name: _____________________________ Employer Name: ______________________________________

Employee Name: ______________________________ Employee Date of Birth: ______ /______ /____________

Employees providing domestic services, such as personal assistance, may be exempt from paying certain federal and state taxes based on the employee’s age, student status, or family relationship to the employer. In some cases, the employer may also be exempt based on the employee’s status. If you and your employer qualify for these exemptions you must take them. PCG Public Partnerships will determine the tax exemptions that apply to you and to your employer (see enclosed guidelines). Employee – Please answer all the following questions based on your age, student status, and relationship to the employer:

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

Yes, that description fits my status. No, that description does not fit my status.

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

Yes, my employer is my parent (mother or father). No, my employer is not my parent.

3. Are you the spouse of the employer?

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

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

Yes, my employer is my child (son or daughter). No, my employer is not my child.

5. If you answered “Yes” to Question 4, check any of the following that apply. If you answered “No”, proceed to

Question 6.

Yes, I also provide care for my grandchild or step‐grandchild in my child’s home.

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

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

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

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

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

Is the job of performing household services (personal assistance) your principal occupation? Note: Do not answer “Yes” if you are a student.

Yes, performing household services is my principal occupation. No, performing household services is not my principle occupation, or I am a student.

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

Employee Signature: ______________________________________ Date: ______/______/__________

Submit to:

1 Cabot Road; Suite 102 Medford, MA 02155

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

Employees providing domestic services such as personal assistance may be exempt from paying certain federal and state taxes based on the employee’s age, student status or family relationship to the employer. In some cases, the employer may also be exempt from paying certain taxes based on the employee’s status. IMPORTANT: Please see IRS Publication:

#926 – Household Employer’s Tax Guide, and IRS website article: “Foreign Student Liability for Social Security and Medicare Taxes” for additional information.

IMPORTANT:

These exemptions are not optional. If the employee and employer qualify for these tax exemptions they must be taken.

If the employee’s earnings are exempt from these taxes, the employee may not qualify for the related benefits, such as retirement benefits and unemployment compensation.

The questions regarding family relationship refer to the relationship between the employee and the employer of record (common law employer). In some cases, the program participant is the employer of record. In other cases, the employer of record may be someone other than the program participant. Check program rules.

Program rules may prohibit some types of employees. For example, most Medicaid‐funded programs do not permit a spouse to be paid as an employee for providing services to a spouse. Check program rules.

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

Tax Exemptions for Non‐Resident Students

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

Tax Exemptions for Children Employed by Parent

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

Tax Exemptions for Spouses Employed Spouses

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

1 Cabot Road; Suite 102 Medford, MA 02155

Tax Exemptions for Parents Employed by Children

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

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

Tax Exemptions for Employee under Age 18

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

Employment Relationship

Status Federal Insurance Contributions

Act ‐ Social Security and Medicare Taxes

Federal Unemployment Tax Act

State Unemployment Insurance

(FICA) (FUTA) (SUI)

Foreign Student on VISA in US for Purpose of Providing Domestic Service

FICA exempt FUTA exempt See footnote (1)

Child Employed by Parent

FICA exempt only until 21st birthday

FUTA exempt only until 21st birthday

See footnote (2)

Spouse Employed by Spouse

FICA exempt FUTA exempt SUI exempt (3)

Parent Employed by Child FICA exempt only if not also caring for dependent child of the employer (employee’s grandchild)

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

Employee Under 18 or Turning Age 18 in Calendar Year

FICA exempt through year of 18th birthday only if enrolled as a full‐ time student

Not Applicable Not Applicable

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

(2) Child under 18 employed by parent is SUI exempt in the following states: CA, IL, MA, ME, NJ, NV, OH, OR, PA, SC, TN, WA, WV.

Child under 21 employed by parent is SUI exempt in the following states: AZ, GA, IN, KS, NY, OK, VA, WY, and District of Columbia.

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

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

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Direct Deposit, also called Electronic Funds Transfer (EFT), a fast, easy, and safe way to receive payment from PPL for delivery of services to participants who receive support from the South

Carolina Attendant Care Program.

For specific instructions to set-up a Direct Deposit account, review the 3 steps below and complete the application on the back of this page.

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You may receive payment for services by Direct Deposit if you meet the following requirements:

1. You must fill-out the Direct Deposit Application form (the person filling out the form must have the authority to authorize processing).

2. You must agree to immediately notify PPL in writing if you change your bank, account number or type, ABA routing number, or contact information. With changes, you may need to submit a new Direct Deposit Application form.

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Complete and sign the Direct Deposit application and send it with a voided check for checking accounts or a letter from the bank indicating the account and bank routing number for savings accounts. For personal debit cards, please submit the Direct Deposit application with a letter from the organization that issued the card. Please note that Direct Deposit applications without proper documentation will not be processed.

Fax: 866-745-7230

OR

Mail: Public Partnerships, LLC

SC Attendant Care Program

Medford, Ma 02155

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Your Direct Deposit account will become active after PPL verifies your bank account number with your bank. The complete process will take 1 to 2 weeks from the time we receive your signed application.

If there is a change in bank account information, your PPL payment account will be taken off Direct

Deposit status until the new bank account information is verified. Verification may take a few weeks. You will receive regular paper checks in the interim period.

The Direct Deposit payment is sent on payday as listed in the payment schedule. If you do not see your funds by Tuesday immediately following the Payment Issued date, please contact PPL. Please be aware that bank holidays may delay payment posting. After considering bank holidays, contact

PPL if you don’t receive your payment on time.

Public Partnerships, LLC SC Attendant Care Program

Public Partnerships, LLC ‐ South Carolina Attendant Care Program FORM ‐EFT1

CREATE OR CHANGE PPL EFT ACCOUNT CLOSE EXISTING PPL EFT ACCOUNT

PAYEE INFORMATION

OR

3 Payee Name 4 Payee Telephone Number

5 Payee Address

6 Payee City 7 Payee State 8 Payee Zip

AUTHORIZATION FOR SET‐UP, CHANGE OR CANCELLATION

I authorize PPL to stop making electronic transfers to my account without advance notice. I certify that I'm authorized to contract for entity receiving deposits per this agreement, & that all information provided is accurate.

9 Signature (Required) 10 Title 11 Date

ACCOUNT DETAIL INFORMATION

12 Financial Institution Name (My Bank's Name)

13 Bank Address

14 Bank Routing Number Checking Savings Personal Debit Card

16 My Account Number

17 Bank City 18 Bank State 19 Bank Zip

CANCELLATION

Cancellation Reason

Participant CLTC#:

15 Account Type

Staff Entry:

Date:

PPL Use ONLY

Se ct io n

Se ct io n

EIN

SSN

Se ct io n

Household Employee

FAX WITH VOIDED CHECK TO: 1‐866‐745‐7230 OR MAIL TO: SC ACP, Public Partnerships, LLC, 1 Cabot Road, Suite 102 Medford, MA 02155

Change Account Number

Change Account Type

Cancellation Request

Change Financial Institution

New Direct Deposit Set‐up

Check the appropriate box below based on your request.

Se ct io n

DIRECT DEPOSIT APPLICATION (for use with checking, savings, and personal debit card direct deposit requests only)

Se ct io n

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

Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPL will use to file required information returns to IRS.

1 Federal Employer Identification No. (EIN)

2 Social Security Number (SSN)

SOUTH CAROLINA FINANCIAL MANAGEMENT SERVICES

EFT for Providers using Debit Cards

These instructions are for providers who want their pay Direct Deposited to their bank account but who use only an ATM card and do not have checks or deposits slips.

Your bank has a Direct Deposit or Electronic Funds Transfer (EFT) Form that you can complete with the bank's assistance and send to Public Partnerships, LLC. This form will provide all the necessary bank information such as account number, routing number, type of account, name of the account owner, the address and phone number.

This Bank Direct Deposit Form must be signed by a Bank representative and the provider in order to be accepted by Public Partnerships, LLC (PPL).

Once fully completed and signed by the bank representative and the provider, please mail the form to:

Public Partnerships, LLC South Carolina - FMS 1 Cabot Road; Suite 102 Medford, Ma 02155

Or you can fax the form to: (866) 745-7230

When PPL receives the form, it will take up to 14 days before your first payment is directly deposited to your account. You will receive a paper check in the mail until the direct deposit takes effect.

After the direct deposit is in place, you will receive a check stub in the mail after each payroll telling you what was deposited into your bank account.

Please contact your CLTC office for any questions regarding your pay.

Public Partnerships Management

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MMAANNAAGGEEMMEENNTT SSEERRVVIICCEESS

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South Carolina Financial Management Services

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What is the Money Network Services Debit Card?

The Money Network Services Debit Card is a new payment option offered by PPL and is a dependable, safe, and convenient way to receive and access your attendant care pay. With this option, you will receive a Money Network debit card, and PPL will deposit your funds directly to this debit card account each payday following the current payroll schedule.

What are the Benefits of the Money Network Services Debit Card?

Eliminates the need to wait for your paycheck to arrive in the mail or to pay for your check to be cashed

Avoids the chance that your paycheck is lost in the mail and has to be reissued

Does not require that you have a checking or savings account for funds to be deposited to

Provides immediate, worldwide access wherever the logos displayed on your card are accepted for ATM cash withdrawals, bank-branch withdrawals, and store purchases

(including "cash back"). There is no fee for withdrawals from in-network ATMs.

Allows for money transfers to a personal or joint checking account

Allows for free balance inquiries by phone

There is no monthly service charge for the card as long as you are employed in the

Attendant Care Program

Many card transactions are free, and Money Network Checks can be used to access funds free of charge too, but there are fees for some optional services if you choose to use them

(all fees for optional services are listed in the Money Network Welcome Packet that you will receive with your card).

How do I sign up for the Money Network Services Debit Card?

Read and complete the application included in this packet that looks like the form in the image to the right.

Fax: 866-745-7230

OR

Mail: Public Partnerships, LLC

SC Attendant Care Program

Once PPL has received and processed your application, you will receive a Welcome Packet, along with your debit card from Money

Network. This packet will explain additional details about the

Money Network services available to you and will provide you with responses to Frequently Asked Questions and contact information. For additional information visit the Money Network website (www.moneynetwork.com).

Public Partnerships, LLC SC Attendant Care Program

Public Partnerships, LLC ‐ South Carolina Attendant Care Program

PAYEE INFORMATION

Payee Name Payee Telephone Number

Payee Address ( Must be Physical Address ‐ where you live ‐ No P.O. Box accepted)

Payee City Payee State Payee Zip

AUTHORIZATION FOR SET‐UP

Signature (Required) Title Date

MONEY NETWORK SERVICES DEBIT CARD

APPLICATION

Money Network® Check. The Money Network Check ("Check") is a paycheck that I can easily complete on or after each payday morning wherever I am, eliminating the need to wait for my paycheck to be mailed, or pay for it to be cashed. The

Check can be deposited into my personal bank account or cashed free at Money Network check‐cashing partners. There is no fee for using Money Network Checks.

MONEY NETWORK® SERVICE ‐ To set up Money Network Services Debit Card information, review Section 1 and complete Sections 2 and 3

Money Network Services Debit Card offered by PPL. The Money Network Payroll Debit Card ("Card") provides a dependable, safe, optional, and convenient way to receive and access my pay on and after each payday morning with the following features: 1. Eliminates the need to wait for your paycheck to arrive in the mail or to pay for your check to be cashed; 2. Does not require that you have a checking or savings account for funds to be deposited to; 3. Provides immediate, worldwide access wherever the logos displayed on your card are accepted for ATM cash withdrawals, bank‐ branch withdrawals, and store purchases (including "cash back"). There is no fee for withdrawals from in‐network ATMs;

4. Allows for money transfers to a personal or joint checking account ; 5. Allows for free balance inquiries by phone; 6.

There is no monthly service charge for the card as long as you are employed in the Attendant Care Program; 7. Many card transactions are free, and Money Network Checks can be used to access funds free of charge too, but there are fees for some optional services if you choose to use them (all fees for optional services are listed in the Money Network Welcome

Packet that you will receive with your card).

FAX TO: 1‐866‐745‐7230 or MAIL TO: SC ACP, Public Partnerships, LLC, 1 Cabot Road, Suite 102 Medford, MA 02155

FORM ‐ MONEY NETWORK SERVICES

DEBIT CARD

Se ct io n

Se ct io n

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

Social Security Number (SSN)

Se ct io n

SSN

Household Employee

Staff Entry:

Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPL will use to file required information returns to IRS.

I authorize PPL to stop making electronic transfers to my account without advance notice. I certify that I'm authorized to contract for entity receiving deposits per this agreement, & that all information provided is accurate.

Date:

PPL Use ONLYNOTE: If you later decide to cancel your Money Network Debit Card Service, you will need to sign up for Direct Deposit to receive payments.

A Gramm-Leach-Bliley Privacy Notice For Providers in the South Carolina Care Call Program

The following notice is designed to comply with the Gramm-Leach-Bliley Act. This notice applies to those financial management services administered by Public

Partnerships, LLC in connection with your participation as an attendant care or companion service provider in the South Carolina Care Call Program (Program) through the Department of Health & Human Services (DHHS).

This notice is for informational purposes only – no action is required by you.

Public Partnerships, LLC (PPL) would like to thank you for the opportunity to serve you as a provider in the South Carolina Care Call Program and assure you that we recognize our obligation to keep your information secure and confidential. This notice will provide you with more detail about the types of personal nonpublic information collected by PPL, and how we use and protect that information in compliance with the Gramm-Leach-Bliley Act.

Collection and Use of Information As the Fiscal/Employer Agent providing Financial Management Services for the Care Call Program, PPL acts on behalf of your employer to handle payroll under the Program and related employment tax matters. As part of these services in connection with the Program, PPL collects certain nonpublic personal information from you or your Program employer in order to issue your paycheck for your services, as well as withhold and file state and federal taxes, issue W-2 statements, handle employment tax matters, process Forms I-9 and W-4, and set up direct deposit of your paycheck if requested. Nonpublic personal information collected may include, but is not limited to, name, address, phone number, social security number, date of birth, and employment and tax-related information.

Nonpublic personal information may also include certain financial information, such as the name and address of your financial institution, the bank routing number, and your account number for the purpose of processing direct deposits if elected by you. Any information that PPL collects and/or receives is used by authorized personnel solely for the purposes described above, and is stored in our system for tracking and auditing purposes.

Protecting Your Information PPL is committed to protecting the privacy of your nonpublic information in our possession. We have established internal policies and procedures that clearly outline proper handling and maintenance of nonpublic personal information which include, but are not limited to, policies related to the transmission, storage, and disposal of paper and electronic records; controlling user access to information; and maintaining the security of files and electronic systems. PPL employees are instructed on these policies and any updates are communicated on a regular basis.

Disclosure of Information PPL does not share any nonpublic personal information about you with affiliates or non-affiliated third-parties, except as authorized by law or with proper authorization from you or from your employer. There are circumstances when we will disclose nonpublic personal information to third parties or affiliates without your authorization as legally permitted or required, such as in connection with the handling of a claim investigation or other activities relating to your employment. Some examples include disclosures to:

• Regulatory agencies, such as the Internal Revenue Service, Department of Revenue, Department of Labor, or Department of Employment and Workforce;

•…