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employee and employer. PPL will withhold appropriate taxes and issue taxstatements based on tax forms filed by the employee and employer, respectively.Benefits:Supervision:Registry:The employee is not eligible to receive benefits under this agreement, orparticipate in any state pension or retirement plan.Continued employment will be determined by the FSSA, Division of Aging andthe employer. Employment eligibility is based on satisfactory employeeperformance, the employee remaining in good standing with their criminalbackground, the employer’s needs, and the availability of State Program fundingfor the waiver program participant.The employee will be listed in a web-based provider registry as an approvedprovider available for hire by other waiver program participants. If you do notwant to be include in the provider registry please check the opt-out box below:Opt-out Criminal History:By signing this agreement, the employee signals his or her understanding that heor she will be subject to a statewide limited criminal history and the result of thehistory may determine employment eligibility.Also, by signing this agreement, you acknowledge the following federalregulation that may affect employment: The United States Department of Healthand Human Services-Office of the Inspector General (HHS-OIG) maintains aList of Excluded Individuals/Entities (LEIE), which includes persons withconvictions for program-related fraud, patient abuse, or licensing board actions.Medicaid payments cannot be made for services furnished by an excluded personwho is on the LEIE. PPL, in coordination with EverCare Select, is screeningprospective and current attendants monthly to assure compliance with thisfederal law.Transportation:If the employee is providing transportation to the employer, the employee mustprovide a copy of his or her valid driver’s license and proof of insurance. Ifthere are any changes to an employee’s driving history, the employee isobligated to update the employer and Fiscal Intermediary.Termination:Either party may terminate this agreement by notifying the other party and PPL,in writing by submitting the “Notice of Termination” form 5 days prior to formalseparation of employment.Form I-9:Employer is responsible for proper execution of USCIS Form I-9, as defined inInstructions for Employment Eligibility Verification, Department of HomelandSecurity. Employer must retain original Form I-9. PPL will only provide FormI-9 in employment packets and retain a forwarded copy in PPL maintainedemployee files.Employment Terms and Conditions AgreementPage 2 of 3

ConfidentialityUpon receipt of information relating to the waiver program participant, the employee will becomea holder of confidential data. The employee agrees to use confidential data solely for carrying outhis/her responsibilities under this agreement.IndemnificationThe employee agrees to indemnify and hold PPL and PPL’s principals, agents, employees andsubcontractors harmless for all claims, losses, expenses, fees, including attorney fees, costs andjudgments that may be asserted against PPL based on any acts or omissions of the employee and/oremployer in carrying out their individual responsibilities under this agreement.Accepted:Employer Signature/DateEmployee Signature/DateSend Signed Agreement to PPL to Finalize EmploymentPlease return one signed copy of this agreement to PPL and keep copies for the employer and employeerecords. Upon receipt by PPL, this agreement will be executed. An executed agreement will authorize PPLto issue paychecks to the employee on behalf of the employer using FSSA funds awarded to the participant.Public Partnerships, LLCFiscal Intermediary7776 Pointe Pkwy W Ste. 150Phoenix, AZ 85044Employment Terms and Conditions Agreement(866) 799-9381 Fax(866) 264-2296 PhoneINPPLFAX@pcgus.com EmailPage 3 of 3

Attendant/Employee Training ChecklistAs a participant in the Indiana Self-Directed Attendant Care Program, I, the undersigned, affirmthat I have received training in how to fulfill my role in the program and am presently in goodunderstanding of how the program will work and what my responsibilities will be: I will complete all necessary paperwork required to become and employee.I will report my time accurately and appropriately in accordance with the program’soutlined timekeeping procedures.I understand that Worker’s Compensation will not be provided by my employer, the fiscalintermediary (PPL), or the State of Indiana and that I am responsible for my own negligentacts. As such, I will not take on responsibility for services that are outside the range of thejob description, specifically medically-related services.I will be treated with dignity and respect, which includes respect of my privacy andconfidentiality, and I will extend this respect to my employer.I will report abuse or fraud promptly to the specified authorities.My signature below affirms that I have read and understood these responsibilities and willdo my best to discharge them.SignatureDate

Public Partnerships, LLCIN FSSAFinancial Administrator7776 S Pointe Pkwy W Ste. 150Phoenix, AZ 85044Consumer and Employee Relationship FormWhat is the purpose of this form?Our contract with IN FSSA has specific guidelines as to who is allowed to provide services to ourconsumers. Please complete this form with your employer.I provide services to the(Print Employee’s Name)Participant/Consumer . My relationship to the consumer is (Check One):(Print Participant’s Name)I am his/her SpouseI am his/her ParentI am his/her Legal GuardianI am his/her Power of Attorney (POA); or his/her Health Care Representative(HCR); or the person directing care for the consumer (EOR)I am None of the AboveI hereby certify that the information presented above is correct to the best of my knowledge.Employer Signature:Employee Signature:NEED HELP? CALL TOLL FREE 1-866-264-2296

Application for Tax Exemptions Based on Age, Student Status, and Family RelationshipState Worked:Program: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 andstate taxes based on the employee’s age, student status, or family relationship to the employer. In some cases, theemployer may also be exempt based on the employee’s status. If you and your employer qualify for these exemptionsyou 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, andrelationship 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 USfor 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 toQuestion 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 requirespersonal care of an adult for at least four continuous weeks during the calendar quarter in which services areperformed.Yes, my child (son or daughter) is widowed or divorced and not remarried, or living with a spouse who hasa mental or physical condition which prohibits the spouse from caring for my grandchild for at least fourcontinuous 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 notanswer “Yes” if you are a student.Yes, performing household services is my principal occupation.No, performing household services isnot my principle occupation, or I am a student.IMPORTANT: You must notify PCG Public Partnerships if your status changes.Employee Signature: Date: / /Submit to:Revised: 6/1/12Form TE 20PCG Public Partnerships, LLCFinancial Administrator7776 Pointe Pkwy W Ste. 150Phoenix, AZ 85044

Guide to Tax Exemptions Based on Age, Student Status, and Family RelationshipEmployee Copy – Keep for your recordsEmployees providing domestic services such as personal assistance may be exempt from paying certain federal and statetaxes based on the employee’s age, student status or family relationship to the employer. In some cases, the employermay 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 andMedicare Taxes” for additional information.IMPORTANT: These exemptions are not optional. If the employee and employer qualify for these tax exemptions they mustbe 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 ofrecord (common law employer). In some cases, the program participant is the employer of record. In othercases, 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 notpermit 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 onthe information provided by the employee. PCG Public Partnerships cannot provide tax advice.Tax Exemptions for Non-Resident StudentsFor 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 thepurpose of providing domestic services, the employer and employee are exempt from paying FICA (SocialSecurity and Medicare taxes) and the employer is exempt from paying FUTA (Federal Unemployment Tax) onwages paid to this employee. The employer may also be exempt from paying State UnemploymentInsurance, depending on the rules in the state.Tax Exemptions for Children Employed by ParentFor 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 UnemploymentTax) on wages paid to this employee until the child (employee) turns 21 years of age. The employer may alsobe exempt from paying State Unemployment Insurance, depending on the rules in the state.Tax Exemptions for Spouses Employed SpousesFor a spouse (husband, wife, or domestic partner in some states) employed by his or her spouse, theemployer and employee are exempt from paying FICA (Social Security and Medicare taxes) and the employeris exempt from paying FUTA (Federal Unemployment Tax) on wages paid to this employee. The employermay also be exempt from paying State Unemployment Insurance, depending on the rules in the state.Revised: 6/1/12Form TE 20PCG Public Partnerships, LLCFinancial Administrator7776 Pointe Pkwy W Ste. 150Phoenix, AZ 85044

Tax Exemptions for Parents Employed by ChildrenFor a parent employed by his or her child and answering “No” to any of the additional questions underQuestion #6 regarding caring for a grandchild or step grandchild, the employer and employee are exemptfrom paying FICA (Social Security and Medicare taxes) and the employer is exempt from paying FUTA (FederalUnemployment Tax) on wages paid to this employee. The employer may also be exempt from paying Stat eUnemployment 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 regardingcaring 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 UnemploymentInsurance, depending on the rules in the state.Tax Exemptions for Employee under Age 18For employees under the age of 18 or turning 18 in the calendar year: If the employee is a student, domesticservices are deemed not to be the employee’s principle occupation and the employer and employee areexempt from paying FICA (Social Security and Medicare taxes).Employment RelationshipStatusForeign Student on VISA in USfor Purpose of ProvidingDomestic ServiceChild Employed by ParentSpouse Employed by SpouseParent Employed by ChildEmployee Under 18 or TurningAge 18 in Calendar YearFederal Insurance ContributionsAct - Social Security andMedicare Taxes(FICA)FICA exemptFederal Unemployment TaxActState UnemploymentInsurance(FUTA)FUTA exempt(SUI)See footnote (1)FICA exempt only until 21stbirthdayFUTA exempt only until 21stbirthdaySee footnote (2)FICA exemptFUTA exemptSUI exempt (3)FICA exempt only if not alsocaring for dependent child of theemployer (employee’sgrandchild)FICA exempt through year of 18thbirthday only if enrolled as a fulltime studentFUTA exemptSUI exempt except in NY andWA. See footnote (4)Not ApplicableNot 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 ofColumbia.(3) For California only, a registered domestic partner employed by his/her re gistered 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 N Y and WA.Revised: 6/1/12Form TE 20PCG Public Partnerships, LLCFinancial Administrator7776 Pointe Pkwy W Ste. 150Phoenix, AZ 85044

Public Partnerships, LLCAttention: IN FSSA7776 S Pointe Pkwy W Suite 150Phoenix, AZ 85044Paperwork Reminder: Form I-9Please note that Federal rules require employees and employers to complete therelevant sections of the Form I-9. Employers must examine identity documentsand record the employment eligibility of each employee they wish to hire.As a reminder, third parties such as PPL are not permitted to complete this form onbehalf of you or your employees. It is the responsibility of employers andemployees to complete Form I-9 themselves.PPL provides Employers with an enrollment package with a number of forms,including the Form I-9 and instructions for completing this form. Employers must:Direct employees they wish to hire to properly and fully complete the I-9Ensure that the employee completes and signs Section 1 of the I-9Verify I-9 documentation and complete Section 2 of the I-9Complete and sign as the employer in the Certification section of the I-9Forward a copy of the completed I-9, along with all other completedenrollment forms, to PPL for record-keeping purposesAs the employer, you should retain the original Form I-9 for your own records.PPL will maintain its copy, along with the other enrollment forms, per the recordsretention terms of the IN FSSA Program.As always, we are here to assist you. If you have any questions or need furtherinformation, please contact PPL Customer Service at 866-264-2296.

USCIS FORM I-9Employment Eligibility VerificationWhat is it for?This form tells the USCIS that you – the employee - are eligible for employment in theUnited States.Who needs to sign?Two people need to sign it – 1) the employeeand 2) the employer.Why does the employer need to signthis?The IRS holds both the employer and theemployee responsible for an individual’s legalstatus and eligibility for employment.I have a temporary workauthorization that needs to berenewed at a later date. Can I stillwork?Yes. If you are eligible to work now, you cancomplete this form. It is important that youkeep your work authorizations up-to-date.Your employer will need to verify your statusagain once your temporary authorization hasexpired.Do I need to do anything more than sign the I-9?Yes. You need to show proof that you are legally eligible to work. There are 10 types ofdocuments that verify work eligibility listed on page 2. Show these documents to youremployer when he/she certifies the I-9.

USCISForm I-9Employment Eligibility VerificationDepartment of Homeland SecurityU.S. Citizenship and Immigration ServicesOMB No. 1615-0047Expires 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) anemployee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because thedocumentation 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)Address (Street Number and Name)Date of Birth (mm/dd/yyyy)Middle InitialFirst Name (Given Name)Apt. NumberU.S. Social Security Number-Other Last Names Used (if any)StateCity or TownZIP CodeEmployee's Telephone NumberEmployee's E-mail Address-I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents inconnection 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 States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident(Alien Registration Number/USCIS Number):4. An alien authorized to workuntil (expiration date, if applicable, mm/dd/yyyy):Some aliens may write "N/A" in the expiration date field. (See instructions)QR Code - Section 1Do Not Write In This SpaceAliens 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:OR2. Form I-94 Admission Number:OR3. Foreign Passport Number:Country of Issuance:Signature of EmployeeToday'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 complet

issue your paychecks to you based on either telephonic or signed physical timesheets. These paychecks will reflect tax withholdings. If you have any questions, please call or email Public Partnerships at (866) 264- 2296 or INfssa-cs@pcgus.com. Thank you. How do I complete the forms? Is there an easy way to tell which ones apply to me?