consumer directed community supports (cdcs) worker ...supports (cdcs) worker employment packet...
TRANSCRIPT
EN-230040-WEP-1.0
Consumer Directed Community Supports (CDCS)
Worker Employment Packet Welcome to self-direction and to Palco! This packet contains all the forms you need to enroll as a worker and begin providing services to your consumer. A worker is an individual the approved consumer wants to hire to conduct CDCS authorized services for them. Please follow all directions in this packet. You will not be paid for services until all forms are completed, Palco verifies all information, criminal checks, and clears you for hire, and you are notified that you are ready to provide service.
You must complete and return:
☐ Worker Intake ☐ IRS Form W-4
☐ Worker Information & Qualification ☐ W-4 MN
☐ U.S.CIS Form I-9 ☐ Pay Selection and Direct Deposit Agreement
☐ I-9 supporting documentation
☐ Supporting documentation for Direct Deposit
☐ Background Study Information Form ☐ Money Network Card (Optional)
☐ Payroll Information Worksheet
Failure to return these forms will delay enrollment. We encourage you to use the checklist above as a final review before you return the forms to Palco. The other documents, including information on how to complete forms, the payment schedule, Palco’s Notice of Privacy Practices, F.A. Q. and similar instructional forms, are for informational purposes only and do not need to be returned to Palco. Send completed paper forms to Palco at the address below.
Should you need any assistance during this process, please contact a friendly customer support representative at 1.866.710.0456 or [email protected].
We look forward to serving you!
Sincerely, The Palco Team
Fax: 501-821-0045
Email: [email protected]
Palco, Inc.
Attn: Enrollment P.O. Box 242930
Little Rock, AR 72223
Page 1 of 2 EN-230040-FAQ-1.0
Frequently Asked Questions
Palco serves individuals who participate in the self-directed model by providing various financial, customer support, and informational services. Below are frequently asked questions to help you understand our processes, your requirements, and how to receive assistance.
How do I complete forms if I am unable to sign? You may either sign with an X or a mark, then have a witness legibly sign the document on the line above the ‘witnessed by’. What if I need assistance in completing forms? Palco customer support agents can assist you in completing forms in this packet.
When can the worker begin providing services? Palco will notify the employer and the worker once all requirements for enrollment have been met. The date of this notification is the date work can begin. Any work performed prior to that date will not be paid by the program.
Can a worker provide services to multiple consumers? Yes. However, a worker must abide by all program rules, especially those regarding overlapping claims for payment of services.
What happens if a worker wants to work for another employer? Workers may be employed by as many employers as he or she would like. Each time he or she begins working for a new employer, a new worker packet must be completed, just like getting any new job. However, some requirements may be waived depending on the circumstances, such as providing a copy of Social Security cards or documentation related to receiving direct deposit. Generally, background checks can also transfer, but be sure to check with your program rules to make sure you understand all the requirements.
What happens if a worker stops providing services? Anytime a worker stops providing service, Palco must be notified via an Employment Separation Notice, which can be found on our website. Even after termination, workers should keep Palco aware of any changes in contact information throughout the year, so that we can send correspondence, such as W-2s, to the correct address.
How does a consumer change an employer? The Employer Information section on page 2 of the Consumer Intake and Designation of Employer form must be completed and signed by the Consumer or Witness and the Employer.
How does an employer change impact existing workers? Workers must re-complete some new hire forms, such as the I-9. Palco will notify you of the requirements. Be sure to complete any required forms so that your pay is not impacted.
Page 2 of 2 EN-230040-FAQ-1.0
Can someone correspond with Palco on my behalf? Federal and state privacy laws prevent Palco from disclosing personal information to unauthorized individuals. Palco will only correspond with workers about that worker’s particular account. Employers may receive all information about the worker’s accounts and information about the consumer necessary to carry out employer roles. Consumers have unlimited information on their account. Consumers may appoint an authorized user by completing an Authorized User Designation form.
How are timesheets submitted? Timesheets can be submitted by fax, by mail or email.
When does a worker submit timesheets? The Consumer/Employer is provided with a payroll schedule that shows the deadlines for submitting timesheets and scheduled paydays. The payroll schedule for specific programs can be found at palcofirst.com.
How will I know a timesheet was received and approved? Palco Customer Support representatives are available to assist you with verifying the status of your timesheet.
What if a worker doesn’t receive the funds on the scheduled payday? For direct deposited payments, please allow sufficient time for the pay to deposit into your account. We recommend allowing 24 hours after payday for the deposit. For paper checks, if you have not received within 5 days, please contact at 1.866.710.0456 or email to [email protected].
Will the Worker receive a W-2 at year-end? W-2s are available January 31. If receiving the W-2 by mail, please allow one week for delivery. All workers receive a W-2. Workers who earn less than the annual domestic service threshold, per IRS Pub. 15 (Circular E), will also receive a refund of over collected FICA. The consumer/employer consushould encourage their workers to make sure that the correct address and direct deposit information is current with Palco prior to this date, even if the worker is no longer working.
How do I change my information with Palco? The fastest and easiest method is to log into your account and change your information. Otherwise, you must complete the appropriate form and mail or fax it to Palco. All forms are found at palcofirst.com. For name and contact information changes, complete a Change of Information form and attach documentation to show proof of name change which can be driver’s license, divorce degree or marriage license. For withholding changes, complete an IRS W-4, or Payroll Information Worksheet. To change payment information, complete a Direct Deposit Authorization. For any other changes, contact Palco customer support.
How can Palco be contacted? Palco Customer Support representatives are available Monday through Friday, 8:00 a.m. to 5:00 p.m. CST, except state holidays. You may reach us by phone at 501.604.9936 or toll free at 1.866.710.0456, email to [email protected], fax to 501.821.0045 or mail to P.O. Box 242930, Little Rock, AR 72223. Palco has a range of translator and interpreter services at your request.
EN-000000-NPP-1.0
Notice of Privacy Practices
Palco may receive and create records concerning your medical and individually identifiable information (“PHI”) and is required to maintain the privacy and security of your PHI. Please read this notice carefully. If you have questions or concerns, contact the Palco Privacy Officer at [email protected]. Palco will only use and disclose your information as allowed by law and as described below: • Help manage the health care treatment you receive. We may disclose your information to provide
treatment and administer services, including performing assessments, issuing workers’ compensation and administering similar programs, and recommending services in some situations. We may disclose information to others who implement your health services. We may correspond with you and/or your designated representative (e.g., surrogate employer or authorized user). All emailed correspondence from Palco is encrypted and secure. By emailing Palco with your personal email account, you accept the risk that your correspondence may not be encrypted, nor secure.
• Run our business, including payment for and administration of your health services. We may use and disclose your information to receive and issue payment on your behalf and bill Medicaid, Medicare, Managed Care Organizations, the Veterans Administration, or other bodies, as required by your program.
• Comply with federal and state law, including investigations by the United States Department of Health and Human Services (U.S. DHHS) and law enforcement. Palco is required by law to comply with investigations by regulatory bodies and issues involving national security. Palco may be required to disclose your information to coroners and other officials at your death.
• Respond to legal actions and health oversight, such as lawsuits or quality assurance reviews. Palco may be required to respond to requests, including discovery, subpoenas, audits, and other legal or regulatory matters.
You have the right to: • Authorize the use and disclosure of your PHI for reasons not authorized by federal or state law.
Palco will seek your approval to disclose PHI for reasons not required at law, and you may reject disclosure. • Receive this notice of privacy practices. You can request a copy of this notice or view the posting at
palcofirst.com, in enrollment packets, and in program manuals, as applicable. Palco can change the terms of this notice at any time. Changes will apply to all of your medical records. Direct complaints to the Privacy Officer or the U.S. DHHS.
• Review and receive copies of your records and a list of disclosures. Requests must be on a Request for Sensitive Records. We will provide you with a copy or summary within 10 days of receiving your request. We may charge a reasonable, cost-based fee for collection of the records, including postage and labor. Palco may reject some requests if required by law.
• Request amendments to your records. Requests must be on a Request to Amend Sensitive Information. We will provide you with a copy or summary or a rejection within 15 days of receiving your request.
• Request information in an alternate format or restrict access on your records. Requests must be in writing on a Request for Additional Privacy. We will provide you with a copy or summary within 15 days of receiving your request. We may reject or terminate the request in certain limited cases and will notify you of rejections and terminations.
• Be notified in case of a breach of your sensitive information. You will be notified within 60 days by the Privacy Officer.
• Choose someone to act on your behalf with regard to your records. You must complete the appropriate forms and information to designate Authorized Users in order for those individuals to communicate with Palco on your behalf.
EN-230040-BWS-1.0
PALCO BI-WEEKLY PAYMENT SCHEDULE
Minnesota CDCS Program
Fiscal Year 2019
Pay Period
Timesheets Due to Palco by 12:00 p.m.
Payment Date
Start Date End Date Deadline Paid On March 31, 2019 April 13, 2019 April 16, 2019 April 26, 2019
April 14, 2019 April 27, 2019 April 30, 2019 May 10, 2019
April 28, 2019 May 11, 2019 May 14, 2019 May 24, 2019
May 12, 2019 May 25, 2019 May 28, 2019 June 7, 2019
May 26, 2019 June 8, 2019 June 11, 2019 June 21, 2019
June 9, 2019 June 22, 2019 June 25, 2019 July 5, 2019
June 23, 2019 July 6, 2019 July 9, 2019 July 19, 2019
July 7, 2019 July 20, 2019 July 23, 2019 August 2, 2019
July 21, 2019 August 3, 2019 August 6, 2019 August 16, 2019
August 4, 2019 August 17, 2019 August 20, 2019 August 30, 2019
August 18, 2019 August 31, 2019 September 3, 2019 September 13, 2019
September 1, 2019 September 14, 2019 September 17, 2019 September 27, 2019
September 15, 2019 September 28, 2019 October 1, 2019 October 11, 2019
September 29, 2019 October 12, 2019 October 15, 2019 October 25, 2019
October 13, 2019 October 26, 2019 October 29, 2019 November 8, 2019
October 27, 2019 November 9, 2019 November 12, 2019 November 22, 2019
November 10, 2019 November 23, 2019 November 26, 2019 December 6, 2019
November 24, 2019 December 7, 2019 December 10, 2019 December 20, 2019
December 8, 2019 December 21, 2019 December 23, 2019 January 3, 2020
December 22, 2019 January 4, 2020 January 7, 2020 January 17, 2020
EN-230040-IWF-1.0
Instructions for Worker Forms
Please use the instructions below to complete the attached Palco forms in order to become a worker through the self-directed program.
The Worker Intake is used to enroll the worker in the program and associate him or her with the consumer and employer. Complete the entire form. Sign and date the highlighted fields on page 2. Please make sure your employer signs and dates the highlighted fields on page 2 as well.
The Worker Information & Qualification notifies you of your duties associated with being a worker on the CSG program. Please read this form carefully to make sure that you understand and will comply with the information therein. Complete the Worker Information box at the top of page 1. Sign and date the highlighted fields on page 2.
The Payroll Information Worksheet is used to determine any exemptions you qualify for in order for Palco to calculate the proper payroll and payroll tax for you and your employer.
☐ Complete all fields in the Required Information section.
☐ Select the reason for completing the form.
☐ Complete Part A.
☐ Please select the option that most closely relates to your relationship.
☐ Complete Part B.
☐ Please select the option that most closely relates to the living arrangement.
☐ Sign and date the page.
The IRS Form W-4 tells Palco how you would like us to calculate and withhold federal income taxes from your paycheck.
□ Complete Box 1 with your name and full address.
□ Write your Social Security Number in Box 2.
□ Make the appropriate selection in Box 3.
□ Select Box 4 if appropriate.
□ Include the total number of dependents you would like to claim in Box 5.
□ Indicate any additional dollar amount to be withheld each pay cycle in Box 6.
□ If you claim any exemption, will write EXEMPT in Box 7.
□ Sign and date the bottom of the form.
The W-4MN is to be used when an employee claims exempt from Minnesota withholding or claims more than 10 allowances on their W-4 Form.
The Pay Selection and Direct Deposit Authorization Agreement is used to inform Palco how you would like to be paid. Please select one of the two choices (Direct Deposit or Money Network Services). If you select the Direct Deposit option please follow the instructions on the form. If you choose to enroll in the Money Network Services option please include the Money Network Services Employee Pay Selection Record Form. Sign and date the bottom of the forms.
Page 1 of 2 EN-230040-AWI-1.0
Worker Intake
Complete this form entirely to begin the enrollment process as a worker in the MN Consumer Directed Community Supports (CDCS) program. Completion of this form does not constitute a hiring by the employer.
WORKER INFORMATION
First Name Middle Name Last Name
Social Security Number Email Date of Birth (mm/dd/yyyy)
Gender
☐ Male
☐ Female
Is the worker-applicant related to the consumer by blood or marriage?
☐ No ☐ Yes. I am the consumer’s: _____________________________ (specify relationship)
Do you share a residence with the consumer?
☐ No ☐ Yes. Please specify who owns or rents the residence: _________________________
Physical Address (Street Address, Including Apt. #)
City State Zip County
Mailing Address (Street Address, Including Apt. #) – if different than the physical address
City State Zip County
Phone1 Phone2 Preferred Method of Communication
☐ Email ☐ Mail
☐ Phone / Voicemail
CONSUMER INFORMATION
Full Name SSN
Program
CDCS
Page 2 of 2 EN-230040-AWI-1.0
How would you like to continue the enrollment process?
☐
Receive a packet via email.
☐ Receive a paper packet via mail.
____________________________ ___________________________ Worker Printed Name Employer Printed Name ____________________________ ___________________________ Worker Signature Employer Signature
_______________________________ ______________________________
Date Date
Page 1 of 2 EN-230040-WIQ-1.0
Worker Information & Qualification
As a worker in self-direction, you must agree to the following terms of employment:
You understand that the consumer, or his or her surrogate, is your employer. Neither Palco, nor program/state administrators, is your employer.
This position is paid as an employee and not as an independent contractor.
This document does not create an anticipation, nor a contract, of employment.
To adhere to all federal, state, local, and program laws, regulations, policies, and requirements throughout your employment. This includes staying current on information provided to me about the program throughout your employment.
To accurately complete all enrollment documentation to ensure that you meet the program’s eligibility requirements for providing services and is not prohibited in any manner from providing services.
That your employment is contingent upon many factors, including successful completion and/or passing of required background checks, training, and/or credentialing.
To report any changes in your ability to deliver services, including changes in your background history or qualifications required to perform services under this program.
Being paid for services through the program is contingent upon the consumer’s eligibility for the program. Once eligibility terminates, you may no longer be paid through this program.
Your employer is responsible for payment of services for activities not authorized in or exceeding the limitations established by the budget.
Funds to pay for services are from public sources, and financial accountability and liability applies to the use of the funds. You understand that submitting false or fraudulent timesheets or submitting timesheets for tasks other than those approved on the authorized budget will be reported to the appropriate authorities for investigation and possible prosecution as fraud.
That medical and personal information and data about the consumer and the worker is confidential. You have read and agree to Palco’s Privacy Practices.
That neither Palco nor program/state administrators are responsible or liable for any negligent acts, work-related injuries, or omissions by me, the employer, consumer, other workers or service providers, or authorized representatives.
To report all critical incidents relating to the consumer’s health, safety, and welfare, including suspicion of fraud, abuse, or neglect.
You certify that you are at least 18 years of age. You give your permission for Palco to run federal and state Office of Inspector General Medicaid exclusion checks and to share the results with your employer, state and program administrators, and others who may be involved in the consumer’s care through this program. You understand that your employment is based on the outcome of these checks and that you cannot provide
WORKER INFORMATION
Full Name ID/Last 4 of SSN
Page 2 of 2 EN-230040-WIQ-1.0
services, nor receive payment, until Palco has notified you that you have been cleared to do so. You hereby release your employer, Palco, and his/her agents from any and all liability, claims and/or demands, of whatever kind, related to the compilation or preparation of the checks hereby authorized.
☒ Office of Inspector General Medicaid exclusion check.
☒ U.S. CIS e-verify system.
☒ Minnesota Department of Human Services Background Study.
By signing below, you acknowledge that you have read this agreement and accept responsibility as a worker in self-direction, understand their responsibilities and duties associated with that role, and will comply with program policies and requirements. The information provided herein is true and accurate to the best of your knowledge. You further understand and agree that violation of this agreement will result in termination.
________________________ ________________________ ______________ Worker Printed Name Worker Signature Date
Page 1 of 2 EN-230040-PIW-1.0
Payroll Information Worksheet
As a self-direction worker, your payroll tax withholdings are subject to special tax rules, and your residency may impact your benefits under labor laws. Completing this form accurately will ensure that your taxes and benefits are calculated properly.
Select the following box that applies:
☐ This form is part of your first-time enrollment with Palco.
☐ You are already enrolled with Palco and need to change your information due to the following reason(s) (select all that apply):
☐ New employer
☐ Change in relationship to existing employer
☐ Change in residence
☐ Reached age 18 or age 21
☐ Other:________________________________________
Part A: FICA Exemption Determination. Depending on your age or relationship to your employer, you may be exempt from FICA (Social Security and Medicare) taxes. If you do not meet an exemption, FICA will be withheld. Should you not meet the annual IRS domestic service wage threshold for the current tax year, your FICA will be refunded to you in January of the following year, and your W-2 will reflect that no FICA was withheld. Select the appropriate response:
☐ Non- Exempt, none of the selections apply.
☐ Exempt, I am the spouse of my employer.
☐ Exempt, I am the child of my employer and am under 21.
☐ Exempt, I am under 18 and a student.
☐ Exempt, I am the parent of my employer. My employer does not have a minor dependent, who requires personal care due to a mental or physical condition, living in their home, and my employer is not widowed, divorced, or married to an individual who cannot care for the minor dependent due to mental or physical condition of their own.
REQUIRED INFORMATION
Worker Name ID
Consumer/Employer Name Consumer(s) For Whom You Provide Care
Page 2 of 2 EN-230040-PIW-1.0
Part B: DOL Home Care Exclusion Qualification. Per the United States Department of Labor (DOL) your employer is not required to pay you for hours worked beyond 40 per week in some cases.
☐ Yes, I live at my employer’s residence at least 5 days per week.
☐ No, I don’t live at my employer’s residence at least 5 days per week.
If any of the information in this document changes at any time, please complete a new document and submit to Palco immediately. Failure to notify Palco may result in a tax bill to you. Palco is not responsible for incorrectly calculating or withholding pay due to your failure to complete and submit a new Payroll Information Worksheet. By signing below, you certify that the information in this document is correct and understand that you have the burden to notify Palco immediately of any changes in this information, and you hold Palco harmless for any incorrect information supplied herein. _______________________________ Worker Printed Name
_______________________________ Worker Signature
______________________________ Date
Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.
General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.
You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider
using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.
Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.
Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4Department of the Treasury Internal Revenue Service
Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
20191 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 filing separately, check “Married, but withhold at higher Single rate.”
4 If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card. ▶
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of employment
10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)
Section 2 — Exemption from Minnesota withholding
CompleteSection2ifyouclaimtobeexemptfromMinnesotaincometaxwithholding(see Section 2 instructions for qualifications).Ifapplicable,checkoneboxbelowtoindicatethereasonwhyyoubelieveyouareexempt:
ImeettherequirementsandclaimexemptfrombothfederalandMinnesotaincometaxwithholding.
EventhoughIdidnotclaimexemptfromfederalwithholding,IclaimexemptfromMinnesotawithholdingbecauseIhadnoMinnesotaincometaxliabilitylastyear,IreceivedarefundofallMinnesotaincometaxwithheld,ANDIexpecttohavenoMinnesotaincometaxliabilitythisyear.
MyspouseisamilitaryservicememberassignedtoamilitarylocationinMinnesota,mydomicile(legalresidence)isinanotherstate,ANDIaminMinnesotasolelytobewithmyspouse.Mystateofdomicileis .
IamanAmericanIndianlivingandworkingonareservation.
IamamemberoftheMinnesotaNationalGuardoranactivedutyU.S.militarymemberandclaimexemptfromMinnesotawithholdingonmymilitarypay.
IreceiveamilitarypensionorothermilitaryretirementpayascalculatedunderTitle10,1401through1414,1447through1455,and12733andclaimexemptfromMinnesotawithholdingonthisretirementpay.
W-4MN
(Rev.12/17)
2018 Minnesota Employee Withholding Allowance/Exemption Certificate
Employees: Givethecompletedformtoyouremployer.
Employers IfyouarerequiredtosendacopyofthisformtotheDepartmentofRevenue(see instructions),youmustentertheemployerinformationbelowandmailthisformto:MinnesotaRevenue,MailStation6501,St.Paul,MN55146-6501.(Incompleteformsareconsideredinvalid.)A $50 penalty may be assessed for each required Form W-4MN not filed with the department.Keepacopyforyourrecords.
Employee’ssignature Date Daytimephone
I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for filing a false withholding allow-ance/exemption certificate.
EmployeesYoumustcompleteandgivethisformtoyouremployerifyoudoanyofthefollowing:• ClaimfewerMinnesotawithholdingallowancesthanyourfederalallowances• Claimmorethan10Minnesotawithholdingallowances• WantadditionalMinnesotataxwithheldfromyourpayeachpayperiod• ClaimtobeexemptfromfederalwithholdingorclaimtobeexemptfromMinnesotawithholdingDonotcompletethisformifyouareclaimingthesamenumberofMinnesotaallowancesasfederalandthenumberclaimedis10orless.
Employee’sfirstnameandinitial Lastname Employee’sSocialSecuritynumber
Permanentaddress Marital status (check one box)
City State ZIPcode Married Married,butwithholdathigherSinglerate
Single;Married,butlegallyseparated;or Spouseisanonresidentalien
Employees: Read instructions on back, complete Section 1 OR Section 2, sign and give the completed form to your employer. (Do not complete both Section 1 and Section 2. Completing both sections will make the form invalid.)
Section 1 — Determining Minnesota allowances CompleteSection1ifyouclaimfewerMinnesotaallowancesthanyourfederalallowances,AND/ORifyouwantadditionalMinnesotawithhold-
ingdeductedeachpayperiod.
1 TotalnumberoffederalallowancesclaimedonfederalFormW-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 TotalnumberofMinnesotaallowances(line 2 cannot be more than line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 AdditionalMinnesotawithholdingyouwantdeductedeachpayperiod . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $
Nameofemployer FederalemployerIDnumber(FEIN) MinnesotataxIDnumber
Address City State ZIPcode
Questions? Website:www.revenue.state.mn.us.Email:[email protected]:651-282-9999or1-800-657-3594.
EN-230040-DDD-1.0
Pay Selection and Direct Deposit Authorization Agreement
HOW WOULD YOU LIKE TO BE PAID?
Payment Selection: (please check only one box)
☐ Direct Deposit ☐ Money Network Services*
*If you choose the Money Network Services Option, Palco will enroll you with our partners at First Data: Money Network Services. You will need to sign an additional Money Network Services Form to enroll.
Request Type (check one):
☐ New Account Setup ☐ Change in Existing Account ☐ Cancellation
DIRECT DEPOSIT ACCOUNT INFORMATION
Account Holder’s Full Name ID or Last 4 of SSN
Financial Institution Routing Number Account Number
Type of Account (select one): ☐ Checking ☐ Savings ☐ Pre-paid card
REQUIRED The following validating documentation is attached:
☐ Voided check with account holder name printed on the check.
Check cannot be a temporary check.
OR
☐ Official documentation from financial institution listing account holder name, account, and
routing number. This includes letters from banks and paperwork from pre-paid cards. I authorize Palco, Inc. to initiate deposits and debit entries for the purpose of correcting an erroneous deposit to the account indicated herein. In the event Palco is unable to initiate debit entries, I authorize the repayment to Palco from future amounts owed to me. I understand Palco is not responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. I understand that it is my responsibility to verify the crediting of funds by my financial institution prior to initiating debits against my account. I understand the risks of sharing an account with others, including my employer or worker. Palco is not responsible for any charges I incur from my financial institution. Any changes to my account must be submitted to Palco immediately. This authorization will remain in full force and effect until Palco has received written cancellation in such time and in such manner as to afford Palco and all appropriate financial institutions a reasonable opportunity to act on it. ________________________________________ Printed Name
________________________________________ _____________________________ Signature Date
09/15/2016