t

Louisiana Self-Direction OPtion

New Opportunities Waiver
Applicant Verification Form

APPLICANT [Link]:

PaRrtcrPautNnPm:

Supponr CooRorNaron Nnus:

A nns tt
L, ar+i
required qualifications:
The potential employee/applicant must meet the following

1. Be at least eighteen (1 8) years of age'

in the area of human services' has
2. Have a high school diplorn4 GED, or trade school diploma
or has verifiable work experience in providing support
to individuals
demonstrated
with disabilities.
"oip"t"r.y,
3. Be able to complete the tasks listed on the participant's Plan of care.
4. Must not be the emPloYer.
5. Must not be the participant or the participant's spouse'
6. Must not be an authorized representative'
7. Must not live in the same househotd as the participant' regstry checks' as well as
8. Must pass criminal history background and direct service workers
will veriff that the applicant is not
agent
Federal and Stale exclusion lists. The fiscaVemployer
on the results of the criminal background check'
barred tom based
g. ".ptoyment and rqquirements as all paid staff
If employee is a relative, they must meet the same guidelines
able to complete tasks on Plan of
(pass background checks, not live in same house aJparticipant,
Care, etc.).

on the results
The fiscal agent will veriff that the applicant is not barred from employment based potential
not allow any
of the criminal Uucfgp;a check. The participanuemptoyer may
agent clears the potential employee
employee to begin w-orking for him/h^er until the fiscat
days for the fiscal agent to clear an
for hire. It will t"d;p-d*;ately four (4) businesl
is received.
applicant to begin wortini once the iequired paperwork

listed qualifications ahve'

By signing below, I attest that the employee meets the

C't ro-\J'l" e G-brr rI

EI'IPLOYER' S NANIE (nEAsE PRsn)

]D -8->7
'S SIGNATURE
Dars
LANOW
REv 03011?
 EMPLOYMENT APPLICATION

PARTICIPANTS NAME: M[,n( A.

PERSONAL
APPLICANT'S l',lAME: L DATE: /
STREET r CITY
Lf
STATE: #:
HOME PHONE OTHER:
[Link] ADDR

EIIPLOYMENT ELIGIBILITY:
Are you interested in serving as a (check all that apply):
emprovee? emprovee? Backup emprovee?
Are you cuneniir;fr5:I$" .s -Jft5,ime
Date available for employment: -.i.' -
How many hours a week can you work?

Are you 18 years of age or older? _rZeS- NO

LICENSES AND CERNHCATIONS:

Do you have a valid Louisiana driver's license? jr,
Are you willing to complete all required training? a'ves _-No
No

High School Graduate or equivalent (GED)? _"/ YES NO _

VocationaUBusiness School?
if yes, field ol study:
_YES NO _
.. NO College Graduate?
# of months: completion date: _
College? _YES _vtsZrvo
if yes, degree: completion date: _
LIST THREE PERSONAL REFERENCES:

f{is, )-orert 6tfL"+tu vitb f * 332-Sse-iss

[e B*\ist" fr,t*d,. s{fl*{6n;lle L 337 q> wq3

(Name) (Address) (Phone Number)
c
ie 6rru.u €)" 337 b?&U
(Name) Number)
LIST PREVIOUS JOBS YOU HAVE HAD (BEGTNNTNG WITH MOST REGENT):

EMPLOYER'S NAME: llo LLE

DATES OF EMP
EMPLOYER'S ADDRESS:
SUPERVISOR'S NAME:
LIST OF JOB DUTIES: trl-
REASON FOR LEAVING:

EMPLOYER'S NAME:
DATES OF EMPLOYMENT:
EMPLOYER'S AD
SUPERVISOR'S NAME: ^) PHONE
LIST OF JOB DUTIES:
REASON FOR LEAVING:

EMPLOYER'$ NAME: h( I CC
DATES OF EMPLOYMENT:
EMPLOYER'S ADDRESS: {* <rf
SUPEHVISOR'S NAME: B
LIST OF JOB DUTIES:
REASON FOR LEAVING:

N ,/a9 llAr
rs" L

ENT
You may not contact my current employer. lf not, reason:

lf otfered a position, will you be able to be at work on time and according to the schedule discussed? ,,- Yes No
Comments:

t name), the applicant certify that the information provided is true and conectio
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 criminal background history check is required and that some convictions prevent employment. I
also acknowledge that I may be required to keep certain certifications current and may be required to complete additional
training as a condition of my 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 prigr notice of such disclosure.

I understand and agree that nothing contained in this application, or conveyed during any inteMew, 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 be terminated at any time, with or without cause and without prior notice, at the option of either myself
or this promises regarding employment have been made to me, and I understand that no such promise or
guarantee is this made in writing.

Signature: e9
LA SDO
Rev. 02 26 14
 Mernber

AccuScreen SystemstM
1O38 Main Street

a Baton Rouge, Louisiana 70802

e25) 343-TEST

As a mndition of employmeirt with the self{irected program with the State of louisian4 I have been informed Iouisiana State
Law, Title 40 RS. t300.51, requires a SEtte Police records check be performed prior to employrnent. I hereby authorize
AccuScreen Systems through Lary Bruoe Childers and/or Darin N. Morgaq authorized ageffs uder Title 40 RS. 1300.51 to
perform this check I hereby hold harmless AccuSsreen Systetrs, Larry Bruce Childers, and Darin N. Morgaq and Acumen
Fiscal Agent LLC' OAAS, and OCDD from any cause of action that rnay arise from inaccurate information contained in
State Police records. I also understand any adverse inforrnation contained within the files of State Police and released to the
authorized ag€ncy will be provided to me upon written request within ten (10) business days of receiving notice that a record
[Link],applicantauthorizeAcumenFiscalAgentLLC, OAAS, and OCDD torelease
infomation to the selfdirected prograrn with the State of Louisiana and my prospective employer as it pertainr 1s py
potential emplo5ment AIso by stping this form, applicant adrnowledges it is unlawfol to pnovide false or misleading
lnformation concer:ning a criminal history or security check to an employer.
Far this form to: 86G923-5334

Applicant's Signature : rald IN( Gr.b L uat*, /doY-)B

To ensure an please print dearlv and complete this form enrtreb.

Print Complete Name: &e ..*[ cin'*f G*brr.1

Date of Birth: -b r-a"e: [Link] frmr;unrsar, P r\
SSN: 'l3x-l Tq,I L S
Driver's Lic. #: DO g b3 StateWhere Issued: Lt@i*iq,:* u t:r-
Steet Address: 3DL0errufer
City, State, Zip: 5+ rr\c*\c'e v;ll€ 1-o-. 2 o Sg'*)
lf you have lived in any stab otherthan Louisiana in the LAST 7 YEARS ONLY, cornple& tfte follrowing:

_GMEI6-- (Courty/Padsh) (All I-AST names YOU used while lMng here) (Mo./ Yr.) - (MoJ Yr.)

(clty, SHe) (CowtylPiril$ (A[ ISST name6 YOU used wtile lMry here) (MoJ Yr.) - (MoJ Yr.)

(City, Stete) (County/Parioh) (All I-AST names YOU used wtrile living haret (Mo./ Yr.) . (MoJ Yr.)

Penon Submitting Phone Number &

this Search: Area Code:

Promodn€ A DruE Fte€ Wor* Envlronrrent

o Drug Testing o Criminal History . Driving Records o Employment and Education Verification I Nationwide Servioe o
 Employee lnformation Form
Rel atio nsh i p Disclosu re

Employee Name: Jd,;*e *-L rJe\ SSN

Physical Address: {tb f rdi t"t /,f*n + il lle City/State/Zip:
q?'\
-, U .-J
Mailing Address (if different):

County of Physical Address:

Phone Number: '3?-3VI-SO3 c (optional):
Narne of Participant:
Name of Employel (if applicable):

Instructions: There are some tax exemptions for certain domestic employer and employee relationships.
Please select any of ihe below boxes if a relationship exists between you as the employee and the employer:

ftr uone,no relation to employer

*Spouse of the employer,
tr *Childof the employer and under the age of 21
tr *Parcnt ol the employer - if this option is marked, read below and check all that apply:
tr You are employed by your son or daughter
I Your son or daughter has a child or stepchild livtng in the home
! Your son or daughter ls a widower, divorced, or is living with a spouse who, b*ause of a
mental or physical condition, cannot care for the child or stepchild for at least 4
continuous uveeks in a calendar quarler
n Your son or daughter's child or stepchild is under the age of lE and requires the
petsonal care of an adult for at least 4 continuous weefts ln a calendar quarter due to a
mental or physical codition
*lnternal Use Only
. lf Parent (employee) selected all4 parent conditions, parent/en'c oy'ee is FUTA and SUTA Exempt
o lf Parent (employee) did NOT select all 4 parent conditions Dare-: e-1c cyee is FIGA, FUTA, SUTA
Exempt
a lf Spouse or Child are selected, employee is FICA,

The fine print - under IRS guidelines, Publicaton 15 (Circular E) Section 3, employecs are nclt sfr;es( to Social S*-,int], Mediia-rB and
fuderal unemployment tax (FUTA) if these relationships exist- The exemptions are as fullours:
A. Chit ehpbyed by pardnb - Payments fcr vrork other than in a trade or business, such as domestic (lRS rrvork in the parenl's
private h6m6, are hdt subieci to Sociat Se€urity Medicare, and FUTA tax until the child reaches age 21. Pub.15, Sectlon
3, Parugnqh 1)
B. Cine spouie employed by another - Paymenb frcr servi:es of one spouse ernploy^ed by another in other than a trade or
business, such is iomeitic service in a private home, are not subjecl to Social Sealnty, Medicare, and FUIA tax. (/RS
Pub.15, Secfion 3, ParagraPh 2)
G. parent employed by cnitO - piyrnents fur the services of a parent employed by his or her cfiild in other than a trade or
business, iuctr as bomestic servioes, are not subject to Social Security, Medicare and FUTA tax as long as the above
oonditions appty. (rRS Pub.15, Sectbn 3, Pangnph 4)

The $ate of Louisiana follows the tuderal guidelines in applying liability for state unemployrnent tax (SUTA). lf the Caregiver fialls into
the category of Spouse or Child as outlined above, Social Secr.r nty and [{edicare tax will not be withheld from their checks. lf the
Caregiver falls into the category of Parent and meets ail 4 parent corditions, Social Security and Medicare tax will be withheld from
their cfrecks. lf the emPloyee is exempt from FtftA, St-lIA, Social [Link] and Medicare, the employer will not be charged for their
share of Social Securtty and or FTFIA and StrIA withholdings.

Employee Signature: 0^^., l,t-l/ ?-8-t3

Acumen FiscalAgent, LLC. Phone: (855) 51+9938 Fax (866) 923-5334 enrollment@[Link]
l-A ALL 0S2018
 Employment Eligibility Verification USCIS

@
tr'orm I-9
Department of Homeland Security OMB No. 1615-0047
U.S. Citizenship and Immigration Services Exphes l0l3lD022

>STAFff HERE Read lnstuctlons caEfully before completlng thb iorm. The in9truG{oB must be avallable, eitfier in paper or electronacslly,
during completlon of thls form. Employem are liable for enorc ln ths completion of thls form.
ANn-DSCRlIrllt{AnON ilOTICE: lt is illegal to discriminate against work-autfrorized indMduals. Employers CANNOT specify whiclt document(s) an
employee may present to establish employment aulhorizetion and identity. The refusal to hire or continue to employ an lndividual because the
documentatlon pres€nted has a fufure qeirafon date may also oonstitute illegal disqtmination.

Last Name (Family Name) First Name (Given Name) Middle lnitial Other Last Names Used (lf any)

Gahrv) Gemldirr- State

Address (Steet Numberand Namo) Apt. Number Citv or Town ZIP Cod6

*.in"+', 'n yl llL Lh 'I05BL

Date of Bidh (mm/ddlyWy) U.S. Sodal Security Number Employee's E-mall hddress Employee's Telephone Number

oula lco WR\'IH Pf/fm rPral d i wn abr ; el\ tB 6a * 33'[-342-5^fu

Iam awarc that bdeml law provides for finea false statements uae documents in
conneetion with the complefron of this fiorm.
I attest, under penalty of perlury, that I am (check one of the following boxes):

A citizen of the United Slates

X e. n nondtzen naffonal ofthe United States fsee,nsfructbns)

fJ e. n UwU permanent resident (Alien Registration NumberruSClS Number):

4. An alien authorized to work until (expiraton date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See thstrucftons)

Aliens authorized to woft mug ptovide only one of the fgllowing &cument numbers to @mplete Form l-9: Do Not Vriib ln This Spaca
An Alien Regigntion Number/USCIS Number OR Form l-94 Admisslon Number OR Forcign Pasgpoft Number.

1. Alien Regi$tration NumberruSClS Numben

OR
2. Form l-94 Admis8ion Numben
OR
3. Foreign Passport Number

County of lssuane:

Signature of

in the of my
the b tnre and coflect
Slgnatur€ of Preparer or Translator TodaYs Date (mm/ddlyyy)

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

Address (Sfreet Numberand Name) City or To,vn State Code

l'''

@ @
Form I-9 l0?l/2019 Page I of 3
 Employment Eligibility Verification USCrc

@ Department of Homeland Security

U.S. Citizenship and lmmigration Services
Form I-9
OMBNo. 1515-0047
Expira 1013112022

Name Nane)
Employee lnfu from $ectlon I

ldenfty and Employment Authorlzatlon ldentity Employment AuthorlzaUon

Document
a ve6 Licr*rg
a 6n
(if any)
any) (mm/dd/yyyy)

Dorument Ti0e

Additional lnformation
Do i,lot Wtite ln This Spae

Oale (it any)

Document Tide

lssulng

any)

Cerdflcation: I atte{rt, under penalty of periury, that ({) I have examined the documen(s) prcsented by the above-named employee,
(2) the above-lbted documeril(s) appear to be genuine and to relate to tfte employee named, and (3) t6 the best of my know6dge the
employee is authorized to work ln the United States.
The employee's first day of employment (mmlddtyyyy): (See insfiuc,tions for xempfrons)
SigFture of Employer orlAutprized ReDresentative Todays O?le (nrq/dww) Title of Ernployer or Aulhorized Representatfue
fllnfi-,)<Y-o-az*Z
Last Name orAutrofized Name of
to/to /nz3 DomeSfr 9 Emolo^ef
or Representative Busin*s
is v
Eriployefs Addr€ss (SfBet Number and Namel City orTom ZlPCode
Na^: futia -lo5o3

Last Name (FamW Name) First Name (Given Name) Mittdle lnitial Dale (mm/dUfyyy)

DocumentTifle Document Number Expiration Dale (ff anyl (mmddlyyyy)

I atest, und6r penalty of pedury, thatto the best of my knflledge, thls employee ls authorlpd to wort ln the United States, and if
th€ employee pr€sonbd documen(s), the d,ocumenqs) ! haw sxamlned appear to be genuine and to lglatr to the tndivtdual.
Signature of Employer or Authorized ReprBentath,e Todays Dale (n mlddgyyy) Name of Employer or Aulhorized Representatve

Form I-9 lODlD0lg Page 2 of3

 :E?%r@"%

I
1

{
I
I
t

i
t

i?sel8.,+s0r.
 Employee Rate Change Form
LA Self Directed Services Option
ln efforts to ensure proper payment, please provide Acumen with the following information so the
employee is paid the conect rate for the service(s) provided. This is a request for ACUMEN to make the
following rate change for the below employee. Rate change forms must be received by Acumen two
weeks prior to the effective date for which the rate change is to take effect. lf a two week notice is not
provided, the form will not be processed. Retroactive (backdated) rate changes are not allowed. Please
cpnsult the "Show me the Monef [Link] information.

Employee Name (please print):

Employee SSN (last 4 digits): 9ttS

Service: IFD 12,25

Service: IFN Rate:$ tt, IFD = lndividual Family Day (ACS day)
IFN = lndividualFamily Night (ACS night)
Service: 52D Rate S2D = lndividual/Family Shared Support 2 persons Day
S2N = lndividual/Family Shared Support 2 persons Night
Service: s2N Rate:$ S3D = lndividuaUFamily Shared Support 3 persons Day
S3N = lndividuaUFamily Shared Support 3 persons Night
Service: S3D Rate:$_
Service: S3N Rate:$_

Effective Date (must be 1d or 16th of the month):

'rate changes @nnot be retrosdive

Employer Name (please print): ?

Participant Name (if different from

Employer Signature: o
a Please complete a new form for any employee to have the payroll rate changed
o This form must be received by Acumen two weeks prior to the effective date. lf a two week notice
is not provided, the ficm will not be processed.

EMAIL, FAX or MAIL to:

enrollment@acumen2. net
1-866-923-5334
Acumen Fiscal Agent, LLC
5416 E. Baseline Rd., Suite 200
Mesa, Arizona 85206

LA NOW Rev 1 1-1 3-201 I

 I cfioose to receive my pay by (pteq,se theck one box below):
Check n
Direct DePosit PaY Card n
fi
/
UREGT DEPOSIT INFORII'IATION
please send a printout from your bank
Attach a voided check for checking accorn(i). For savings.?ccoqnt9,
that provides tne routlnd;fiI;Eilno Jciiount intoniation. submit any chang6s
to vour account(s)
immediately!

Secondary Account 2 for Flat option)

Prtmary Account I
Account Type:
Checking (#dt a wided d'e*) ! Checking (attad a voided cte*)
& tr SavinSs (ath
n Flat Dollar n Remalnder account (Used if is less than
10070 or net PaY exceeds the dollar amount listed
n Percentage
for Account
Name

lnditution

Number
Number

Acount
b Account Number

deposited:- All remaining funds exceeding Acmunt I will

Fl dollaramountor% b be
inb ttis

Are you the account holder for the account(s) listed above? dYes trNo

lf
.no," employee agrees to have their funds deposited into this account' ,

EmPloYee Signature

/ 0-€r3
Date
ernait AOOress for PaYstub Delivery

Retum completed form by email

' @' Fl !8-99L923-5334 or mail
to 5416 E' easffieRdiuite 200, Mesa, AZ 85206
Pay Select 12-2019
 1039
GERALDINE GABRIEL 84-l 5316s2
513 PECAN ST
SAINT MARTINVILLE, LA 70582'3118
rtifqc$ tnqooi

Pay to the $
Order cf
?
6
FMBANK [Link]

For
r:OE5?Ol5lOti O ?I l?? lrrrflIO1{ l
,",. gg21 Tax lnformation Authorization
> Go to [Link],gOvlFormWl for instnrctlons and the lateet informafion. R!€lvod q[
(Rev. January 2021) ) Dont sign tlris fsrm unless all applicable lines have been oompletod. t|am
> Don't usg Form 8E21 to rcqu€st coples of your tax routms
Departneflt of the Treasury
lnt€rnal R€venus 8€Mc6 or to authorlze someone to t€pr8sent you. See lnswctions. Furcion

1 must and date this form on line

Taxpayer name and address identification number(s)
[Link] ,tr Atnb,',t I
fflr ef telephone number Plan number (f applicable)

2 Deslgneeg). lf you wish to nane more than two designees, attach a list to this form. Gheck here il a list of additionat
t8 attached )
Name and address CAF No.
Ae rnat Fr€,crl LL(g* PTIN
5+t&7 E, 'Bosetl Suite';rP Telephone No.
e Fax No.
if new: Address No. No.
Name and address GAF No.
PTIN
Telephone No.
Fax No.
if to sent and il Fax No.
3 Tax irformstion. Each designee is authorized to inspect and/or receive confidential tax information for the type of tax,
forms,
periods, and specific matters you list bekrw. See the line 3 instructions.

fl By cnecking here, I authorize access to my IRS records via an lntermediate Service Provider.

(b) {c}
Type of Tax Tax Form Number Yea(s) or Period(s) Speciffc Tax Matters
(1040,941, 720, etc.)

Q+l , q,+a fu'lp-'lazt+ u

4 Specific use not recorded on tle Centallzed Auttrorlzailon Flle (CAF). lf the tax information authorization ls for a
specific use not recorded on GAF,[Link],sklpline5..> tr
5 Retentioly'revocation of prior tax information aut{rorizatlons. lf the line 4 box is checked, skip this line. lf the line 4 box
isn't checked, the IRS will automatically revoke all prior tax information authorizations on file unless you check the line 5
box and attach a copy of the tax information authorization(s) that you want to retain
To revoke a prior tax information authorization(s) without submitting a new authorization, see the line S instructions.

6 Talqayer slgnature. lf signed by a corporate officer, partner, guardian, partnership representative (or designated
individual, if applicable), exeoutor, receiveG administrator, trustee, or individual other than the taxpayer, t certtty that I have
the legal authority to execute this form with respect to the tax matters and tax periods shown on llne O above.

>IF HOT COMPLETED, SIGNED, A,IID DATED, THIS TA)( INFORMATION AUTHOREANON w|LL BE RETURNED.

B'-ANK oR TN..MPLETE

flrt $fl il"

Siignatre
t)b-y93
Dats

Ge *{r/,'r* G"brV:)
Print Name Trile [f applicable)

For Prhracy A,ct and Paperuort Reducton Aqt Notce, see the insilrucdone. Cat. No.11596P Form 88i!1 @ev. 01-2021)
 Employee's UYithholding Gertificate OMB No. 15/t$0074
,"-W'4 ) GomCete Form w.s so trat yDl:TlPffiIffiT'llffi::.** lnoome tax from yo(' pey.
Departnatof ttnTnasry
ht€rnal Re\rem€ S6rvics ) Your withholding is subjcct b review by the IRS
2@22
nalne
$tep 1:
Enter
Lto"br,
> DoGa yorr mrno rEtcir t te
Personal
lnfonnation
() s7p isr 3f nerp on your 6odal security
carfl lf not, to €nsurB tou get
ortown,6teto, cr€dit for l,our eamings, contacl
Physical
Address
t ,*,
^
il [Link] SSA at 800-m-1213 or go to

(c) Slnglo or Mat'lad fiEng qaratony

Required
(No P.O Box) f] tU"r"hO ffing lolntry or Qua[ryhg wldow(arf
f] XeaO of [Link] (Check only it you're unmaried and pgy mor€ than half th6 costs qf a hcnB ior and a

Compleb Stap 2l-4 OI{LY il they opply to yo$ odrerrvlse, sklp to Step 5. See page 2 for more information on each step, who can
claim examption from withholding, when to use the estimator at [Link]. govDU4App, and privacy.

Step 2: Complete this step if you (1) hold more than one iob at a time, or @ are manied filing lointly and your spous€
It/iultipleJobs also works. The c,orrect amount of withholding depends on income eamed from all of these jobs.
orspouse Do only one of the following.
Worko (al Uae the estimator at [Link].govM4App for most accurate withholding for this step (and Steps 3-4); or
(bl Use the Multiple Jobs WorKheet on pagp 3 and enter the result in Step (c) below for roughly accurate withholding; or
lf applicable --> lf thsa aIB only tno jobs total, you may check this box. Do tha same on Form W-4 for the other job. This option
ls acanrate for iobs with similar pay; otherwise, more tax than nocossary rnay be u/i$held . >n
TIP: To be accurate, submit a 2U2. Form W-4 for all other jobs. lf you (or your spouse) have setf-
ernplo,yment inoome, including as an independent contractor, use the estimator.

Gomplete Step 3-0(bl on Form tll-4 for only ONE ol these lob+ Leave those stsps blank for the other jobs. (Your withholding will
bs most accurato if you complete Steps 3-4@) on the Form W-4 br the highest paying iob.)

Step 3. ff your total income will be $200,000 or less ($400,000 or less if manied flling jointly): Required field
Claim even if "0".
Dependents
Multiply the number of qualiffing children under age 17 by $2,000 ) $

Muttiply the number of other dependents by $500

Add the amounts above and enter the total here 3

Step 4 (a) Oher income (not frorn iobs). lf you want ta,r withheld for other income you expect
(optional): this yearthat won't have withholding, enter the arnount of other income here. This may
Other
include lrterest, dividends, and retirement income rgr
Adjusiments
(b) Deduction+ lf you expect to claim dedustions other than the standard deduction
Optional and want to reduce your withholding, use the Deductions Worksheet on page 3 and
Please refer enter the result here JEL
to the
instructions. (cl ExEa withholding. Enter any additional tax you want withheld mch pay p€rlod 4{c)
lf frling exempt, leave Step 3 & 4 blank. Write EXEN/PT here --->
Step 5: Under penatties of periury, I declare ttlat this oertificate, to the begt of my knoryrdedge and belief, is trua, corect, and complete.
Sign
Herp
) Employee's
i^f-
ffiis
I
form le not valid unless you sign it.)
to-8+9
Date

Employers Employer's name and address First dat6 of Employer identifi cation
ernployment number (ElN)
Only

T\
For PrlvacyActand Act see a car No.1(}2200 Form (cM2l

Employer Name & Address Required

B-1300 (1/22)

LOUISIANIA Employee Withholding

DEPARIMENTdREVENUE Exemption Certificate (L-4)

Purpoce: Complete brm L4 so that lour emplqer can wfrhhold the conect amourt of slate income tax from )eur salary.

lnstructlolls: EmplqBes wllo are suqed b state withholding should complete the personal allfirances workoheet indicating the number ot withholding
pemonal exemptions in BlockA and the number c[ dependerEy qedits ln Blod< B.

' olEmplo!rees musl file a new u,ihhddlng e)€mptiofl certificate within 10 days if the number of tholr exemptions decrBases, except lf the change is tho rosult
ths death of a spouse or a depondent.
. Emplq/€es may file a new certilicat€ arry time the number of their exemplions increases.
. Line 8 should be us6d to lncrease or decrgase the tax withheld br €ach pay perlod. Decrcases ehould be lndicated as a negati\r€ amount.
Penalties will be imposed br wilfully supplyilng false inbrmation or willful fiailure to supply inbrmatiofl that would reduce the withhol<ling exemptbn.
This bm must bo filed with your employer. tf an emplqBe fails to complete this withholding gxemption cortificaE, the emfloyer must withhold Louisiana
income tax fiom the employeds wages wr'thout e)cmdion.

Nobb El|lploFn lG€phb calrficabraitryour records tf pu be$erlB H an emplqea has irnproperlydalnpd bo many@fipuom ordep€ndency q€dts, ploase
bruadacopydtheenplq@sdgedL4toimwihaneQhrHionast)[Link],efHtfteernplo!,EelrnpopedymrnpleHthbhmandanydrerupportingdoqr-
medaiion. tha intumaliott dEuld b€ sent b he Lo*:bna Deparfnent of Ba,Bnue, Cdminal ln€digdiorB Dfifdorl, PO Bo( 2389, Bahn [Link], l,A 7@1-23S9.

BlockA
. Enter "0! to claim neither yourself nor your spouse, and check "No a@mptions or dependenB claimocf under number 3 below.
You may enter "0" if you are manied, and have a working spouse or mo[e tfian one iob to avoid having too
litle tax withheld.
. Enter "1'to claim louoelf, and check "Single'under number 3 below if you did not claim this exemption in connection with
other employment, or if your spouse has not claimed )our otemption. lf you will file as head of household, enter '1' to claim one
personal exemption and check'Singl€f under number 3 belofl.
r Enter 2" to claim yourself and your spouse, and check 'Married under number 3 below

Elod(E
. Enter th€ number of dependents, not lncluding you66lf ot !,our spouse, whom ],ou will daim on your tax rstum. f no dependentB
are claimed, enbr'0."

$F
Cut here and glt B ths botbm portion ol cenficate to your omployor. Ke6p the top portion for rccotds.

rorm L'4
Louisiana
Deparlment of
Em ployee's With hold i n g Allowance Certif icate
Revenue
or pdnt fitst and middle initial tast name

Number 3. Select one

VI/ S EI No exemptions or dependents claimed tr Manied
4, Home (number and orrural route)
D i(r
u'"*s/
itv;lle
ztP
osg)
6. Total number of exemptions daimed in Block A 6.
J
I
z Total number of depondents daimed in Blo€k B 7.

I
A lnre or decGase h tfE arnowit b bs wmrck, eacfi pay pedod. Decreses sftou6 be hdbaEd s a negdrre amNnt &

ldedar€ br flllng false reports lhat the number ol e)@mptions and dependency cedits dalmed on this certificate do not e)@eed

The ls lo be
9. Employe/s name and addEss 10. Employefs state withholding accouht number
 State of Louisiana
Departrnent of Health and Hosoitals
PROVIDERAGREEMENT

Agreement with the Bureau of Health Sewices Financing IBHSFJ, the Office for Citizens with
Developmental Disabilities (OCDD), and/or the Office of Aging and Adult Services (OAASI.

Provider/Em ptoy*r,CN r qld. *e Gqbw'e .'L

"
PLEASE PRINT

DESCRTPTTON/DETINTTTONS
Self'Direction is a service delivery option which allows eligible Medicaid particlpants (or their
autlorized representative) to become the Employer of the workers they choose to hire to provide
supports for them.

Self-Direction is supported by both federal and state funds. These funds are used to pay Providers, or
employees, to provide specific services to eligible participants, as authorized by the OCDD or OAAS.

The Plan of Care is a document which specifies the participant's needs, the types of tasla required to
meet those needs, and the amount of timq fi'equenry, and duration required for delivery of the
participant's services,

The Fiscal Ageut is a private entity which will process the employment-related payroll and withhold
t}re necessarytaxes on behalf of the Employer.

The Support Coordination Agency/Support Coordinator is a resource to assist participants and/or

their authorized representatives in the coordination of needed services. The support coordinator
monitors the participanfs service delivery to ensure that services meet his/her needs.

AGREEMENTS
1. The provider/employee understands and acknowledges that neither the Louisiana Department
of Health and Hospitals nor the fiscal/employer agen! Acumen Fiscal Agen! is the employer
and thatthey are not responsible for the actions of the employer.
2. The provider/employee agrees to accept payment from Acumen Fiscal Agent as payment in full
for services provided.
3. The provider/employee agrees that no additional charges will be made or accepted from the
participant or his/her authorized representative.
4. The provider/employee agrees to provide only the services authorized on the Plan of Care.
5. The provider/employee acknowledges that he/she meets the necessary skills and
requirements to be able to perform the seryices hired to perform.
6. The provider/employee understands and acknowledges that employees without a valid
drive/s license, curent state inspection sticker, and current proof of automobile insurance as
required by the State of Louisiana may not transport individuals in connection with their
employment responsibilities.

Issued: May 7,2072 Pa'gel of 2

 7. The provider/employee acknowledges that the funds used to pay the employee are Medicaid
fundi and that the submission of false information on time records may subiect the employee
to criminal action, in addition to repayment of any funds.
B. The provider/employee acknowledges that federal income tax withholding Medicare, social
secuiity, and Louisiana state income tax withholding [as applicable) shall be withdrawn from
the employee's wages per state and federal laws,
g. The provider/employee agrees to complete the required training as specified in the Self-
Direction Manual.
10. The provider/employee understands and agrees that he/she will not be paid for providing any
services unless he/she has completed the required training and his/her training certifications
are current and on file with Acumen Fiscal Agenl
11. The provider/employee understands and acknowledges that any work in excess of forty [40)
hours per week will be paid at a straight time rate.
12. The provider/employee understands and acknowledges that work performed in excess of the
authorized amount or service limits will not be paid by the Louisiana Department of Health
and Hospitals orAcumen Fiscal Agent
13. The provider/employee agrees to provide only the services authorized in the participant's Plan
of Care. The provider/employee agrees that his/her duties must be consistent with the service
specifications for the seryice he/she provides, as specified in the Self-Direction Manual.
14. The provider/employee agrees to complete progress notes each time he/she provides a paid
service, as specified in the Self-Direction Manual.
15. Upon requeig the provider/employee agrees to provide information regarding the service for
wtrictr payment was made to the Louisiana Department of Health and Hospitals or its designee.
16. The provider/employee agrees to maintain all information regarding the employer,
participant, his/her family, in a confidential manner.
f Z. the provider/employee agrees to immediately notiff a person designated by the employer of
any medical emergency, illness, or visit to a physician.
18, If you zuspect an adult between the ages of 18 and 60 or a person under 18 who has been
tegaty declared an adult has been abused or mistreated, you are required to report it to the
Adult Protection Services at 1-800-898'4910.
19. If you suspect an adult who is age 60 or older and has been abused or mistreated, you are
reiuired to report to the Elderly Protective Services at 1.800-259'4990 fif calling from within
Louisianal or at L-225-342-2297 (if calling from outside of Louisiana)
20. The proviier/employee agrees to report all critical incidents, as specified in the Self-Direction
Manual, to the participant's support coordinator.
21. The provider/employee understands and acknowledges that employment is contingent upon
the employerrs participation in the Self-Direction option,

My signature on this document verifies my aclnowledgement and agreement to follow the policies and
pio.u"durur of the Self-Direction option and policies and procedures of the program under which
services are provided.

fuuul )o*N Date

Provider/Employee Signature

Issued: May 7,2012 Page2 of2

 /
Statement of Understandins of Tasks

By siguing below, I verify that QcraldtrY. Gabrid (employee) is able to

complete the tasks on the participant's Plan of Care. This statement is to cover any type of
individualized taining that the participant may require.

Employer/Legally party/Authorized Representative (Printed)

n/p/pz 3
Responsible Representative Signature Date

LANOW/ROW
Rev 3/15/201 1