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									      West-Central Independent Living Solutions
  Personal Care Attendant (PCA) Application Checklist
In Order to Avoid Common Errors and thus Frustrating Processing Delays…
   The application page must be signed by the applicant on the back.

   The application page must be dated by the applicant on the back.
   The first blank on the front of the contract must be filled in with the consumer’s name.

   The second blank on the front of the contract must be filled in with the applicant’s name.

   The third blank on the front of the contract must be filled in with the consumer’s name.

   The contract must be signed by the applicant on the back.

   The contract must be dated by the applicant on the back.

   All paragraphs on the front of the policies and procedures must be initialed by the applicant.

   All paragraphs on the back of the policies and procedures must be initialed by the applicant.

   The policies and procedures must be signed by the applicant on the back.

   The policies and procedures must be dated by the applicant on the back.

   The policies and procedures must be signed by the consumer on the back.

   The policies and procedures must be dated by the consumer on the back.
   All applicable boxes in section B of the worker registration must be filled in.

   Evidence of the applicant’s social security number must accompany the worker registration.

   Section D of the worker registration must be signed by the applicant.

   Section D of the worker registration must be dated by the applicant.

   Section A of the employer background screening request must have the consumer’s info.

   Section B of the employer background screening request must have the applicant’s info.

   Section C of the employer background screening request must be signed by the consumer.

   Section C of the employer background screening request must be dated by the consumer.

   All applicable boxes in section 1 of form I-9 must be filled in with the applicant’s information.

   The applicant’s citizenship status must be attested on form I-9.
   The applicant must sign section 1 of form I-9.

   The applicant must date section 1 of form I-9.

                                                                                                       OVER ↺
Section 2 of form I-9 must be completed by WILS staff and WILS staff only.

            Applicant’s uncopied, unexpired documentation (see back of form I-9) must be shown to WILS staff.

            WILS staff will record title(s) of documentation.

            WILS staff will record issuer(s) of documentation.

            WILS staff will record number(s) of documentation.

            WILS staff will record expiration date(s) of documentation (if applicable).
            WILS staff will sign section 2.

            WILS staff will date section 2.

      On form W-4, the applicant’s marital status must be indicated.

      On form W-4, box 5 or box 7 must be filled in.

      The applicant must sign form W-4.

      The applicant must date form W-4.

      On form MO W-4, the applicant’s marital status must be indicated.

      On form MO W-4, box 5 or box 7 must be filled in.

      The applicant must sign form MO W-4.

      The applicant must date form MO W-4.
      The applicant’s name must be given on the pay election form.

      The applicant must select one of the electronic deposit options given on the pay election form.

If the applicant chooses Checking or Savings Account,

            A void check, saving deposit form, or bank letter must accompany the pay election form.

If the applicant chooses Paycard,

            The applicant’s physical address must be given on the pay election form.

            The applicant’s social security number must be given on pay election form.

            The applicant’s date of birth must be given on pay election form.

            The applicant’s phone number must be given on pay election form.

      The applicant must sign the pay election form.
      The applicant must date the pay election form.



                                                                                                      Rev. 2010-09-07
                       PERSONAL CARE ATTENDANT (PCA) APPLICATION
                          CDS Vendor: West-Central Independent Living Solutions
              PO Box 582, Warrensburg MO 64093, Phone: 660-747-2940, Toll Free: 800-460-6430

Personal Data
Name: First Middle Last                              Social Security Number: 000-00-0000
List All Names Ever Used By You:
List All Social Security Numbers Ever Used By You:
Address: (Mailing)
City:                                                State: MO            Zip:
Phone (primary):                                     Phone (alternate):
Have you been domiciled (resided) in Missouri for all of the past five years?         Yes         No
Are you at least 18 years old?       Yes       No    Do you have a valid driver’s license?        Yes       No
Do you have any criminal convictions, findings of guilt, pleas of guilty, or pleas of nolo contendere,
except for minor traffic offenses?      Yes         No
You are required to disclose this information on this application, please provide the details below:




Do you smoke?        Yes      No                Are you available to work over holidays?          Yes       No
Do you have any physical limitations that would prevent you from performing the essential duties of
the job? If yes, describe the physical limitation:


How did you learn about this position?
Are you related to the consumer you will be working for?          Yes      No If yes, how? Consumer's ...
Have you ever worked with persons with physical disabilities?            Yes     No
If yes, please explain types of disabilities and job duties:

Preferences and Availability
Do you prefer working with males, females, or either? Either
Indicate the hours of each day you are available: SUN:                           MON:
TUE:                  WED:                    THU:                FRI:                  SAT:
Please check (x) the following duties that you are willing to perform:
   BLADDER CARE            SHOPPING             HOUSECLEANING              GROOMING/MINOR HYGIENE
   BOWEL CARE              LAUNDRY              TRANSPORTATION             EQUIP. MAINTENANCE
   UNDRESSING              DRESSING             ROM EXERC ISES             BATH OR SHOWER
   MEDICATIONS             TRANSFERS            TURNING IN BED             MEAL PREPARATION
   MEAL CLEAN-UP           MEAL CONSUMPTION                 OTHER:
Would you like WILS to provide your contact information to (other) consumers?               Yes        No
If yes, where would you accept (more) work?
Employment History (most recent first)
Company name:
Address:
Dates employed:                                    Position held:
Duties:
Reason for leaving:                                Are you eligible for rehire?
If no, explain:
Company name:
Address:
Dates employed:                                    Position held:
Duties:
Reason for leaving:                                Are you eligible for rehire?
If no, explain:

Do you give permission to contact your previous employer(s)?         Yes     No

References
Please list three personal references not related to you.

Name:                                                               Relationship:
Address:                                                            Phone:

Name:                                                               Relationship:
Address:                                                            Phone:

Name:                                                               Relationship:
Address:                                                            Phone:


Comments:




I certify that answers given herein are true and complete to the best of my knowledge.

                                                                     11/14/2010
Signature of Applicant                                               Date


West-Central Independent Living Solutions accepts job applications for personal care
attendant positions as a service to consumers who may need PCAs and keeps these
applications on file for six months. Consumers establish working relationships with PCAs as
the PCAs’ employer. WILS is neither the employer nor an independent contractor for or with
consumers or PCAs. PCAs are responsible for negotiating working relationships w ith
individual consumers, including discussion of responsibility for payment of taxes, etc.
                    Medicaid                                    Services to be contracted by:
           Non-Public Entity OHCDS                        West-Central Inde pendent Living Solutions
      Organized Health Care Delivery System                      610 N Ridgeview Dr Ste B
       Home and Community Based Services                       Warrensburg MO 64093-9337
             Requested for Proposal                           (660) 422-7883 or (800) 236-5175


This contract is being issued between West-Central Independent Living Solutions and an attendant to be
employed by the Consumer named First Last.

The purpose of this contract is to allow consumers of West-Central Independent Living Solutions to
employ their own attendant(s). This contract between West-Central Independent Living Solutions and the
attendant (employee) employed by the consumer (employer) defines the terms and conditions under which
West-Central Independent Living Solutions (WILS) will make payment on behalf of the employer to the
employee.

1.   Parties to the contract:

     a. West-Central Independent Living Solutions (WILS).

     b. First Last, Attendant, hereinafter referred to as the employee.

2.   Other involved entities not party to the contract:

     a. The consumer of WILS hereinafter referred to as the employer.

3.   Explanation:

An Attendant employed in the home of, and working at the direction of, the person he or she supports, will
ordinarily not qualify under the Federal Fair Labor Standards Act (FLSA) as a self-employed independent
contractor. The attendant must, nearly always, be considered an employee. He or she will therefore need
to have payroll taxes withheld and paid on his or her behalf, including Social Security (FICA), and Federal
and State Unemployment Insurance. This contract is only for attendants that will be employees of the
consumer.

WILS, the fiscal intermediary, will write payroll checks to the attendants who are employed by the
consumers, withholding the necessary tax amounts, including employer's share, and withholding FICA
and Unemployment. WILS will withhold income taxes as well. With each payroll check or direct deposit
notice, the attendant will also receive an explanation of withholdings.

4.   Basis of Payment:

West-Central Independent Living Solutions will maintain funds to pay an agreed hourly rate for services
provided the employer by the employee. WILS will issue payroll to the employee on behalf of the
employer. Payment will be made only for services described and authorized in a Plan of Care agreed to by
the employer, Department of Senior and Disability Services and WILS. A copy of pertinent parts of this
plan will be made available to the employee. Units of service are 15-minute units. Any service units
provided within a month beyond the number of units authorized for that month and/or those ineligible for
reimbursement through Medicaid will not be payable under this contract and will be the responsibility of
the employer: First Last. Payment to the employee will be made only for services actually delivered by
the employee. The employee shall have qualifications and training to perform the duties described in the
consumer evaluation. Any service units provided before all requirements of this contract are completed
will not be payable.
5.   Method of Payment:

WILS will furnish the employer with documents authorizing payment of the services included in the Plan
of Care. These documents will specify maximum units and rates for payment and the time frames to which
these maximums apply. WILS will also furnish the employer with forms with which to document services
performed and time worked. The employee and employer shall be responsible for accurately recording the
units worked and services performed by the employee. This record, or timesheet, once approved by the
employer, becomes the basis for payment to the employee. Any falsification or other misrepresentation of
the information on this record will constitute fraud. All payments made as a result of inaccurate time sheet
information will be recouped from the employee and/or employer. Any apparent fraud could be referred to
law enforcement agencies. Payroll will be processed bi- weekly. At the end of each payroll period, the
employer will approve the timesheet completed by the e mployee, and then forward it to WILS. It must
reach WILS within four calendar days after the end of the payroll period to be included in the payment
process for that period. WILS will issue a paycheck to the employee. If WILS does not receive an
employee's approved timesheet within four calendar days after the end of the payroll period, those units
shall be paid on the earliest possible subsequent pay date. WILS will withhold all taxes, including the
employee's share of Social Security (FICA) and employee's income tax. WILS will also withhold all of the
employer's taxes, including the employer's share of FICA and both federal and state unemployment taxes.
WILS pays these tax amounts to the appropriate authorities, maintains records of all withholdings, and
furnishes the employee and employer with end of the year statements for filing with income tax returns,
etc. The employer must not supplement (make extra) payments to the employee outside of this contract.
The records maintained by WILS will be the official records of the employer/employee relationship that
will be reported to state and federal tax authorities. Both the employee and employer could be subjected to
prosecution for tax evasion if all earnings and taxes are not accurately reported to these taxing authorities.

6.   Conditions:

The quality, appropriateness and timeliness of services reimbursed through this contract shall be subject to
evaluation, through inspection or other means, by WILS. Furthermore, If Medicaid payments are involved
the Missouri Department of Social Services and the Federal Department of Health and Human Services
(the State and Federal Medicaid Agencies) shall also have the right to make such evaluation. The
employee understands and agrees that he or she is the employee of the cons umer (the employer), and shall
not represent himself/herself as an employee of the State of Missouri or WILS. The employee also
understands and agrees that this contract does not limit the employer from employing other attendants
within the terms of the employer's agreement with WILS. Finally, the employee understands and agrees
that this contract does not guarantee any number of units of work. Information shared with the employee
by the employer or WILS regarding the consumer shall be confidential. Payment does not include any
fringe benefits such as health insurance, sick leave, vacation, paid holidays, Workman's Compensation,
etc. Any liability related to accidents or injuries incurred by the employee while providing services are the
responsibility of the employer. The employee and employer shall set the conditions of employment, and
termination of employment for cause shall be the prerogative of the employer.

7.   Period of the Contract

All contracts with attendants shall be reviewed by WILS at the end of e ach year. Period of this contract is:
                                until termination.

8.   Signatures:

                                                                  11/14/2010
Attendant                                                         Date


WILS Representative                                               Date
          WEST-CENTRAL INDEPENDENT LIVING SOLUTIONS
                 CDS PERSONAL CARE ATTENDANT
                           POLICIES AND PROCEDURES

As a vendor for the Consumer Directed Services (CDS) program, West -Central
Independent Living Solutions (WILS) is responsible for providing case management and
processing accurate timesheets. In addition, WILS has a responsibility to inform you of
the laws, regulations and guidelines as they relate to the CDS program and the position
of Personal Care Attendant (PCA). Therefore, the following policies and procedures
have been outlined for you and by initialing each, you are acknowledging that you
understand, agree and will adhere to the content of such.


_____ The PCA is the employee of the consumer and never the employee of WILS, the
      Department of Health and Senior Services (DHSS) or the state of Missouri.
      Authority: 19 CSR 15-8.400 (4) (A) 4; Section 208.903 2 RSMo; and OHCDS
      contract.

_____ You can not begin working for the consumer until you have submitted a complete
      application, the background check results from FCSR have been received and
      do not indicate any negative results, and you are cleared on the EDL under all
      aliases and social security numbers used by you. Authority: 19 CSR 15-8.400
      (4) (A) 1; Section 208.918 (5) RSMo; DHSS Participation Agreement and DHSS
      VM-07-08.

_____ If the FCSR indicates you have negative results on your background check, you
      can not work for the consumer. You may apply for a Good Cause Waiver
      (GCW) which, if approved, would allow you to work for the consumer. Please
      note: this process may take up to a year. Authority: Section 208.909 RSMo and
      DHSS VM-07-04.

_____ By accepting the position of PCA, you become a mandated reporter and are
      required to notify DHSS of reports of abuse, neglect and/or exploitation. This
      obligation covers any circumstance where you have knowledge of an individual
      with a disability or who is elderly when their health, safety and/or welfare is at
      risk. The 24 hour hotline number for Elder Abuse & Neglect is 1-800-392-0210.
      Authority: 19 CSR 15-8.400 (4) (A) 2, and Sections 198.070, 208.912, and
      565.188 RSMo.

_____ PCA’s are urged to check the Missouri Sex Offender Registry to determine
      whether a consumer is on the registry. The website address is:
       http://www.mshp.dps.mo.gov/MSHPWeb/PatrolDivision/CRID/SOR/SORPage.html
      In addition, WILS will notify DHSS of any reports by PCA’s of any inappropriate
      contact by consumers. Authority: DHSS VM-06-10.

_____ WILS is responsible for processing inquiries and problems received from the
      consumer and PCA. Authority: 19 CSR 15-8.400 (4) (C) and section 208.918 (4)
      RSMo.
_____ PCA’s must meet the following qualifications: 1) Be at least 18 years old, 2) Be
      able to meet the physical and mental demands required to perform specific tasks
      required by a particular consumer, 3) Be emotionally mature and dependable, 4)
      Be able to handle emergency type situations, and 5) Not be the consumer’s
      spouse. Authority: 19 CSR 15-8.400 (4) (A) 3.

_____ WILS as a designated agent participates in E-Verify on behalf of our consumers.
      All PCA’s will go through the E-Verify process no later than the 3rd business day
      after they start work for pay. Authority: The E-Verify Program for Employment
      Verification Memorandum of Understanding for Designated Agents Article II C 4
      and E-Verify User Manual 3.2.1


_____ PCA’s must agree to maintain all aspects of the consumer’s confidentiality in
      order to protect their privacy rights. Medical diagnosis, health, personal and
      financial information about the consumer will not be shared with anyone. Breach
      of confidentiality is inappropriate, unethical and may be subject to civil remedies.
      Authority: 19 CSR 15-8.400 (4) (A) 3.

_____ Any person directly involved in the misappropriation of a consumer’s personal
      property or funds, or falsification of documents regarding delivery of services
      through the CDS program is guilty of a class A misdemeanor. Examples of
      Medicaid Fraud include, but are not limited to: forging the consumer’s signature,
      claiming more time than actually worked, overlapping work hours between two or
      more consumers, not performing tasks as outlined in the DA-3c (care plan), etc.
      Incidents will be reported to DHSS and Department of Social Services Division of
      Legal Services Investigation Unit. Authority: Sections 198.090 and 208.915
      RSMo and OHCDS contract.

_____ The consumer’s original timesheet must be completed daily and contain: the
      PCA’s name, the consumer’s name, dates and times of services delivered, types
      of activities performed by the PCA, both the PCA and consumer’s signatures
      which verify dates, times and activities are correct and the document is accurate.
      Failure to do so is non-compliance with the CDS program. Authority: 19 CSR
      15-8.400 (4) (I) 2; OHCDS contract, and DHSS VM-07-18.

_____ Services to the consumer may be discontinued if the PCA is not providing
      services as set forth in the Plan of Care and attempts to remedy the situation
      have been unsuccessful. Authority: Section 208.924 (6) RSMo.


                                                              11/14/2010
PERSONAL CARE ATTENDANT/EMPLOYEE                              DATE


CONSUMER/EMPLOYER                                             DATE


WILS STAFF                                                    DATE
                   MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES                                                  FCSR USE ONLY
                   FAMILY CARE SAFETY REGISTR Y
                   WORKER REGISTRATION
PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)

     CHILD CARE WORKER ($10.00)                   PERSONAL CARE WORKER($10.00)                                VOLUNTARY REGISTRANT ($10.00)
     ELDER CARE WORKER ($10.00)                   RECIPIENT OF STATE OR FEDERAL FUNDS ($10.00)                FOSTER PARENT ( NO FEE)

SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NA ME                                               FIRST NAME                    MIDDLE NAME                        MAIDEN NAME


Last                                                     First                         Middle
PRIOR NAMES USED



SOCIAL SECURITY NUMBER     (ATTACH COPY OF SOCIAL SECURITY CARD)      DATE OF BIRTH            GENDER                     TELE PHONE NO.   (optional)
                                                                                                      MALE
000-00-0000                                                                                           FEMALE
MAILING ADDRESS
STREE T ADDRESS OR POST OFFICE BOX                                 CITY                                 STA TE      ZIP CODE            COUNTY


(Mailing)                                                                                               MO
HOME ADDRESS (if different than m ailing address)
STREE T ADDRESS                                                    CITY                                 STA TE      ZIP CODE            COUNTY


                                                                                                        MO
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPL OY ER NAME                                                    CONTACT PERSON                       PHONE NUMBER




ADDRESS                                                            CITY                                 STA TE      ZIP CODE


                                                                                                        MO
SECTION D: AUTHORIZATION TO REL EASE BACKGROUND SCREENING INFORMATION
The infor mation provided is complete and accurate to the best of my know ledge. I understand it is unlaw ful to w ithhold or falsify inf or mation
required on this form. I grant my per mission for the Missouri Department of Health and Senior Services (DHSS) to obtain a ny and all background
infor mation author ized by law to process this request. Further more, I authorize the Missouri Department of Health and Senior Services to release
the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any related bac kground infor mation to the requestor of the FCSR for
employ ment purposes only, as provided in §210.921, subsection 1, subdiv isions (1) and (2), RSMo. For purposes of the FCSR, ― employ ment
purposes‖ includes direct employer/employee relationships, pros pective employer/employee relationships, and screening and interview ing of
persons or facilities by those persons contemplating the placement of an individual in a child care, elder car e or personal c are setting. I understand
that if I dispute the infor mation contained in the FCSR I have the right to appeal the accuracy in the tr ansfer of infor mation to the FCSR w ithin thirty
(30) days of receiving the r esults of the background screening deter mination.

NOTICE: The FCSR may choose to deposit the check enc losed electronically as an A CH debit entry to your designated bank account. I
understand that my signature below authorizes my Financ ial Institution to deduct this pay ment from my account. In the event that DHSS or its
subcontractor, is unable to secure f unds from your account or you provide insufficient or inaccurate information regarding your account, your
obligation to the DHSS w ill r emain unpaid and further collection action may be taken by the DHSS or its subcontractor, includ ing, but not limited to,
returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)                                                              DATE


                                                                                                     11/14/2010


IMPORTANT
    Individuals are required to register one time only.
    Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
    Read back of form for instructions and information on registrant notification and appeal rights
    Send completed registration form, copy of Social Security card and required fee to:

                      Missouri Department of Health and Senior Servic es
                      Attn: Fee Receipts
                      P.O. Box 570
                      Jefferson City, MO 65102

MO 580-2421 (FP)
WHAT IS THE FAMILY CARE SAFETY REGISTRY?
The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provide s
families and other employers with a method to obtain background screening information. The Registry, through various state agencies,
offers several resources to screen child care, elder care and personal care workers and child care and elder care providers:

1.    State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol
2.    Child abuse/neglect records, maintained by the Department of Social Services
3.    The Employee Disqualification List, maintained by the Department of Health and Senior Services
4.    The Employee Disqualification Registry maintained by the Department of Mental Health
5.    Child care facility licensing records, maintained by the Department of Health and Senior Services
6.    Foster parent, residential care facility, and child placing agency licensing records, maintained by Department of Social Services
7.    Residential living facility and nursing home licensing records, maintained by the Department of Health and Senior Services

WHO HAS TO REGISTER?
An y person hired on or after January 1, 2001, as a child care worker or elder care worker, or hired on or after January 1, 2002 as a
personal care worker, as defined in §210.900, subsection 2, RSMo, is required to make application for registration in the Fam ily Care
Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration
form to the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and
volunteers from non-State and/or Federally regulated entities are NOT REQUIRED to register with the FCSR.

HOW DO I COMPLETE THE REGISTRATION FORM?
Section A: Type of Worker - Check one box that best describes your worker category. A "voluntary registrant" is a person who is not
mandated to register with the Family Care Safety Registry pursuant to §210.900 to §210.936, RSMo.
Section B: Identifying Data for Background Screening - List your current name, maiden name, all prior names used, Social Security
number, date of birth, gender, home address, and mailing address. You must provide yo ur Social Security number pursuant to
§210.906.2, RSMo Supp. 1999. This identifying information, including Social Security number, will be used for internal ident ification
purposes and to conduct background screenings for the resource information listed i n paragraph one above.
Section C: Current Employer Information (If Applicable) - If you are currently employed by or are seeking employment with a child care
or elder care provider, please list the facility name, owner/operator, telephone number and facili ty address. If you are a foster parent, a
voluntary registrant, or receive state or federal funds for child care or elder care services, leave this section blank.
Section D: Authorization to Release Background Check Information - Sign and date the registration form. Your signature will authorize
the Family Care Safety Registry to conduct the background screening outlined in §210.903.2, RSMo and to provide the informati on to
requestors for ―employment purposes‖, as provided in §210.921.1, RSMo.

WHERE DO I SEND MY REGISTRATION FORM?
Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of He alth
and Senior Services, Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102. If you have questions, please call the
Registry using the toll-free telephone number, 1-866-422-6872.

WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND CHECK?
After the background screening has been completed, you will be notified in writing of the results that wi ll be recorded in the Family Care
Safety Registry. You will also be notified in writing each time background screening information is provided. The notification will
contain the name and address of the person who made the request and the background information disclosed. The person making the
request will be informed that information will be released for employment purposes only as defined pursuant to §210.921.1, RS Mo.
Any person using Registry information for any other purpose is guilty of a class B m is demeanor. In addition, state agencies
can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and
address of the person calling, and determines that the request is for employment or reg ulatory purposes. To ensure you receive these
notifications, it will be important for you to notify the Family Care Safety Registry when you have a change in your mailing address. You
can send address changes to Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102.

WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND CHECK?
Pursuant to §210.912, RSMo, you have the right to appeal the information transferred onto the Family Care Safety Registry. Yo ur right
to appeal is limited only to the accuracy in the transfer of information from the state agency that maintains the background information
and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal needs to be f iled in
writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O. Box 570, Jefferson City, MO, 65102,
within 30 days of receiving the results of the background screening determination. An administrative appeal shall be set wit hin 30 days
of the filing of the appeal and a decision shall be made within 60 days. This right to appeal is in addition to any other appea l rights
granted by state law.

WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY?
Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. A Registry worker will
first confirm whether the person in question is registered. If the person is registered, the Registry worker will then discl ose whether the
person's name is listed in any of the background checks pursuant to §210.903, subsection 2, RSMo, and if so, which one. Specific
information will only be disclosed by the Registry upon receipt of a written request from the caller.


MO 580-2421 (FP)
                   MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
                   FAMILY CARE SAFETY REGISTR Y
                   EMPLOYER BACKGROUND SCREENING REQUEST
PLEASE TYPE OR PRINT CLEARLY
SECTION A: EMPLOYER INFORMATION
BUSINESS NAME                                                    CONTACT PERSON

First Last
MAILING ADDRESS                                                  CITY                                               STA TE           ZIP CODE             COUNTY

                                                                                                                    MO                                    (select one)
LICENSE NUMBER                                                   LICENSING AGENCY                                                    TELE PHONE NUMBER


SECTION B: EMPLOYEE IDENTIFYING DATA
                 LAST NAME                                FIRST NAME                  MI                  SOCIAL SECURITY NO.                      DATE OF BIRTH
1
       Last                                     First                                 MI            000-00-0000
2

3

4

5

6

7

8

9

10

SECTION C: REQUEST FOR EMPLOY EE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I
certify that my request for background information on the individuals listed in Section B is for employment purposes only. For purposes of the Family Care Safety
Registry, ―employment purposes‖ includes direct employer-employee relationships, prospective employer-employee relationships, and screening and interviewing of
persons or facilities by those persons contemplating the placement of an individual in a child -care, elder care or personal care setting. I have read and understand the
following: 1) Registry information provided consists only of information relative to the state of Missouri and does not include information from other states or information
that may be available from other states; 2) any person who uses the information obtained from the Family Care Safety Registry for any purpose other than that
specifically provided for in sections 210.900 to 210.936, RSMo, is guilty of a class B misdemeanor; and 3) when any Registry information is disclosed pursuant to
section 210.921.1(2), RSMo, the Department of Health and Senior Services will notify the registrant of the name and address o f the person making the request.
SIGNATURE OF EMPLOY ER (REQUIRED IN INK)                                                                               DATE



PRINT EMPLOY ER NAME

First Last
                                                                  ATTENTION EMPLOYERS
The Family Care Safety Registry provides basic background screening information upon initial request. Employers have the rig ht to request specif ic
information regarding the findings identified in the background screening. Chapter 210.921, RSMo., requires request for spec ific information to be submitted
in w riting. Section D serves as the written request for specific information w hen information is identified in the background of the individuals identified in
Section B above.
SECTION D: REQUEST FOR SPECIFIC INFORMATION
I request that specific information be provided to me in the event that the background screening performed upon the individuals identified in Section B of this form
indicates that there is information identified in any of the sources checked by the Family Care Safety Registry. I understan d that this information is to be used for
employment purposes only and anyone using the information for any purpose other than that specifically provided in sections 210.900 to 210.936, RSMo., is guilty of a
class B misdemeanor.
SIGNATURE OF EMPLOY ER (REQUIRED IN INK)                                                                               DATE



IMPORTANT                               Background screening inform ation is provided at no cost.
                                        If you have questions on how to complete this form , contact 1-866-422-6872 (toll-free)
                                        Send completed form to:
                                                   Missouri Department of Health and Senior Servic es
                                                   Fee Receipts Unit
                                                   P.O. Box 570
                                                   Jefferson City, MO 65102-0570
                                                   FAX: (573) 522-6981
MO 580- 2422 (12-01)
WHAT IS THE FAMILY CARE SAFETY REGISTRY?
The Family Care Safety Registry, administered by the Missouri Department of Health and Senior Services, p rovides families and other
employers with a method to obtain background screening information. The Registry, through various state agencies, offers se veral
resources to screen child-care, elder-care and personal care workers and child-care and elder-care providers:

1.    State criminal background checks conducted by the Missouri State Highway Patrol
2.    Child abuse/neglect records, maintained by the Division of Family Services
3.    The Employee Disqualification List, maintained by the Division of Senior Services
4.    The Employee Disqualification Registry maintained by the Department of Mental Health
5.    Child-care facility licensing records, maintained by the Department of Health and Senior Services
6.    Foster parent, residential care facility, and child placing agency licensing re cords, maintained by Division of Family Services
7.    Residential living facility and nursing home licensing records, maintained by the Division of Senior Services

WHO HAS TO REGISTER?
An y person hired on or after January 1, 2001, as a child -care worker or elder-care worker, or hired on or after January 1, 2002 as a
personal care worker, as defined in §210.900, subsection 2, RSMo, is required to make application for registration in the Fam ily Care
Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration
form to the Department of Health and Senior Services without good cause, as determined by the department, is guilty of a
class B misdemeanor.

WHAT IS THE PURPOS E OF THE EMPLOYER BACKGRO UND S CREENING REQUEST FORM?
Employers may use the Employer Background Screening Request form to obtain background screening information on employees who
have completed registration for to the Family Care Safety Registry. The form may take the place of cal ling the Registry's toll-free
telephone line as outlined in section 210.921, RSMo. The background screening information is provided at no cost. The regis trant will
be notified in writing each time a background screening request is made. The written noti fication will include the name and address of
the employer as well as the information provided to the requestor.

HOW DO I COMPLETE THE EMPLOYER BACKGROUND SCREENI NG REQUEST?
Section A: Employer Information – List employer's identifying information.
Section B: Employee Identifying Data – List the full name, social security number, and date of birth, of employees whose applications
for registration have been or are being submitted to the Family Care Safety Registry for processing
Section C: Request for Employee Background Screening Information – Employer must sign and date the Employer Background
Screening Request in ink. The employer’s signature certifies that the request for background information for employees liste d in
Section B is for employment purposes. The employer’s signature also certifies the employer understands Registry information provided
consists only of information relative to the state of Missouri and does not include information from other states; any person who uses
the information obtained from the Registry for any purpose other than employment purposes is guilty of a class B misdemeanor; and
when Registry information is disclosed, the Department of Health and Senior Services will notify the registrant of the name and address
of the person making the request.
Section D: Request for Specific Information – Employers have the right to request specific information regarding the findings of
identified in any of the sources checked by the Registry. The request must be submitted in writing and the employer can use this
section to submit the request by adding a signature in the space provided.

HOW DO I SUBMIT THE EMPLOYER BACKGROUND SCREENI NG REQUEST?
The Employer Background Screening Request may be submitted by either mail or FAX.

WHEN WILL BACKGROUND SCREENING RESULTS BE KNOWN?
The requestor will be notified, in writing, of the results of the background screening performed by the Family Care Safety Re gistry. If
the requestor contacts the Registry using the toll-free access line, 1-866-422, 6872, the employer will be provided the results while on
the phone. The registrant will also be notified in writing each time a background screening request is made. The written no tification will
include the name and address of the individual making the request as well as the information provided to the requestor.

WHAT IS THE PENALTY FOR MISUSING REGISTRY INFORMATION?
Information maintained by the Family Care Safety Registry can be disclosed for employment purposes only. Employment purposes
includes direct employer-employee relationships, prospective employer-employee relationships, and screening and interviewing of
persons or facilities by those persons contemplating the placement of an individual in a child - or elder-care setting. Any person who
uses the information obtained from the Registry for any purpose other than employment purposes is guilty of a c lass B
misdemeanor.

MO 580- 2422 (08/07)
                                                                                                                              OM B No. 1615-0047; Expires 08/31/12

Department of Homeland Security                                                                                                 Form I-9, Employment
U.S. Citizenship and Immigration Services                                                                                       Eligibility Verification
Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DIS CRIMINATION NOTICE: It is illegal to discriminate against work-authorized indi vi duals. Empl oyers CANNOT
specify which document(s) they will accept from an empl oyee. The refusal to hire an indi vi dual because the documents have a
future expiration date may also constitute illegal discriminati on.
Section 1. Empl oyee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name: Last                                                 First                                 Middle Initial     Maiden Name
Last                                                             First                                            MI
Address (Street Name and Number)                                                                       Apt. #             Date of Birth (month/day/year)


City                                                     State                                         Zip Code           Social Security #
                                                         MO                                                               000-00-0000
                                                                                I attest, under penalty of perjury, that I am (check one of the following):
I am aware that federal l aw provi des for
                                                                                       A citizen of the United States
imprisonment and/or fines for false statements or
use of false documents in connection wi th the                                         A noncitizen national of the United States (see instructions)
completi on of this form.                                                              A lawful permanent resident (Alien #)
                                                                                       An alien authorized to work (Alien # or Admission #)
                                                                                       until (expiration date, if applicable - month/day/year)
Employee's Signature                                                              Date (month/day/year)         11/14/2010
Preparer and/ or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
         Preparer's/Translator's Signature                                               Print Name


           Address (Street Name and Number, City, State, Zip Code)                                                      Date (month/day/year)



Section 2. Empl oyer Review and Verification (To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, an d
expiration date, if any, of the document(s).)
                   List A                     OR                List B                    AND                       List C
Document title:
Issuing authority:

Document #:
       Expiration Date (if any):
Document #:

       Expiration Date (if any):
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above -named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
(month/day/year) _______________ and that to the best of my knowledge the employee is authorized to work in the United S tates. (S tate
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative                 Print Name                                                T itle


Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)                                     Date (month/day/year)
           First Last , %WILS, 610 N Ridgeview Dr Ste B, Warrensburg MO 64093-9337
Section 3. Updating and Reverification (To be completed and signed by employer.)
A. New Name (if applicable)                                                                                 B. Date of Rehire (month/day/year) (if applicable)


C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.

          Document Title:                                                Document #:                                Expiration Date (if any):
l 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 presente d
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative                                                                 Date (month/day/year)


                                                                                                                                         Form I-9 (Rev. 08/07/09) Y Page 4
                                       LISTS OF ACCEPTABLE DOCUMENTS
                                                     All documents must be unexpired

                LIST A                                             LIST B                                      LIST C

   Documents that Es tablish Both                        Documents that Es tablish                  Documents that Es tablish
     Identi ty and Employment                                   Identi ty                           Empl oyment Authorization
           Authorizati on                    OR                                              AND
1. U.S. Passport or U.S. Passport Card            1. Driver's license or ID card issued by     1. Social Security Account Number
                                                     a State or outlying possession of the        card other than one that specifies
                                                     United States provided it contains a         on the face that the issuance of the
                                                     photograph or information such as            card does not authorize
2. Permanent Resident Card or Alien                  name, date of birth, gender, height,         emp loyment in the United States
   Registration Receipt Card (Form                   eye color, and address
   I-551)                                                                                      2. Cert ification of Birth Abroad
                                                                                                  issued by the Department of State
                                                  2. ID card issued by federal, state or
                                                                                                   (Form FS-545)
3. Foreign passport that contains a                  local govern ment agencies or
   temporary I-551 stamp or temporary                entities, provided it contains a
   I-551 printed notation on a machine-              photograph or information such as
                                                     name, date of birth, gender, height,      3. Cert ification of Report of Birth
   readable immig rant visa
                                                     eye color, and address                       issued by the Department of State
                                                                                                   (Form DS-1350)
4. Emp loy ment Authorization Docu ment           3. School ID card with a photograph
   that contains a photograph (Form
   I-766)                                         4. Voter's registration card                 4. Original or certified copy of birth
                                                                                                  certificate issued by a State,
5. In the case of a nonimmigrant alien            5. U.S. M ilitary card o r draft record         county, municipal authority, or
   authorized to work for a specific                                                              territory of the United States
   emp loyer incident to status, a foreign                                                        bearing an official seal
                                                  6. Military dependent's ID card
   passport with Form I-94 or Form
   I-94A bearing the same name as the
                                                  7. U.S. Coast Guard Merchant Mariner         5. Native A merican tribal docu ment
   passport and containing an                        Card
   endorsement of the alien's
   nonimmigrant status, as long as the            8. Native A merican tribal docu ment
   period of endorsement has not yet
   expired and the proposed                       9. Driver's license issued by a Canadian     6. U.S. Citizen ID Card (Fo rm I-197)
   emp loyment is not in conflict with               government authority
   any restrictions or limitations
   identified on the form                                                                      7. Identificat ion Card for Use of
                                                        For persons under age 18 who
                                                                                                  Resident Citizen in the United
                                                           are unable to present a
6. Passport from the Federated States of                                                          States (Form I-179)
                                                           document listed above:
   Micronesia (FSM) or the Republic of
   the Marshall Islands (RMI) with                10. School record or report card             8. Emp loy ment authorization
   Form I-94 or Form I-94A indicat ing                                                            document issued by the
   nonimmigrant ad mission under the              11. Clin ic, doctor, or hospital record         Depart ment of Ho meland Security
   Co mpact of Free Association
   Between the Un ited States and the
                                                  12. Day-care or nursery school record
   FSM or RM I



  Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M -274)
                                                                                                           Form I-9 (Rev. 08/07/09) Y Page 5
Form W-4 (2010)                                                  Complete all worksheets that apply. However,
                                                                 you may claim fewer (or zero) allowances. For
                                                                 regular wages, withholding must be based on
                                                                                                                                  dividends, consider making estimated tax
                                                                                                                                  payments using Form 1040-ES, Estimated Tax
                                                                                                                                  for Individuals. Otherwise, you may owe
Purpose. Complete Form W-4 so that your                          allowances you claimed and may not be a flat                     additional tax. If you have pension or annuity
employer can withhold the correct federal income                 amount or percentage of wages.                                   income, see Pub. 919 to find out if you should
tax from your pay. Consider completing a new                                                                                      adjust your withholding on Form W-4 or W-4P.
Form W-4 each year and when your personal or                     Head of household. Generally, you may claim
financial situation changes.                                     head of household filing status on your tax                      Tw o earners or multiple j obs. If you have a
                                                                 return only if you are unmarried and pay more                    working spouse or more than one job, figure
Exemption from withholding. If you are exempt,                   than 50% of the costs of keeping up a home for                   the total number of allowances you are entitled
complete only lines 1, 2, 3, 4, and 7 and sign the               yourself and your dependent(s) or other                          to claim on all jobs using worksheets from only
form to validate it. Your exemption for 2010                     qualifying    individuals.    See Pub.   501,                    one Form W-4. Your withholding usually will be
expires February 16, 2011. See Pub. 505, Tax                     Exemptions, Standard Deduction, and Filing                       most accurate when all allowances are
Withholding and Estimated Tax.                                   Information, for information.                                    claimed on the Form W-4 for the highest
                                                                                                                                  paying job and zero allowances are claimed on
Note. You cannot claim exemption from                            Tax credits. You can take projected tax credits                  the others. See Pub. 919 for details.
withholding if (a) your income exceeds $950 and                  into account in figuring your allowable number
includes more than $300 of unearned income (for                  of withholding allowances. Credits for child or                  Nonresident alien. If you are a nonresident
example, interest and dividends) and (b) another                 dependent care expenses and the child tax                        alien, see Notice 1392, Supplemental Form W-
person can claim you as a dependent on his or her                credit may be claimed using the Personal                         4 Instructions for Nonresident Aliens, before
tax return.                                                      Allowances Worksheet below. See Pub. 919,                        completing this form.
                                                                 How Do I Adjust My Tax Withholding, for
Basic instructions. If you are not exempt,                       information on converting your other credits into                Check your w ithholding. After your Form W-
complete the Personal Allowances Worksheet                       withholding allowances.                                          4 takes effect, use Pub. 919 to see how the
below. The worksheets on page 2 further adjust                                                                                    amount you are having withheld compares to
your withholding allowances based on itemized                    Nonw age income. If you have a large amount                      your projected total tax for 2010. See Pub.
deductions, certain credits, adjustments to income,              of nonwage      income, such as interest or                      919, especially if your earnings exceed
or two-earners/multiple jobs situations.                         dividends, consider making estimated tax                         $130,000 (Single) or $180,000 (Married).

                                            Personal Allowances Worksheet (Keep for your records.)



                        {                                                                                                                                               }
A    Enter ―1‖ for yourself if no one else can claim you as a dependent ......................................................................................... A
                           ● You are single and have only one job; or
B    Enter “1” if:         ● You are married, have only one job, and your spouse does not w ork; or                                                            ... B
                           ● Your w ages from a second job or your spouse’s w ages (or the total of both) are $1,500 or less.
C Enter ―1‖ for your spouse. But, you may choose to enter ―-0-‖ if you are married and have either a w orking spouse or
     more than one job. ( Entering ―-0-‖ may help you avoid having too little tax w ithheld.) ........................................................ C
D Enter number of dependents (other than your spouse or yourself) you w ill claim on your tax return ................................... D
E    Enter ―1‖ if you w ill file as head of household on your tax retur n (see conditions under Head of household above) .......... E                                         Enter ―1‖ if
      (Note. Do not include child support pay ments. See Pub. 503, Child and Dependent Care Ex penses, for details.)
F    Enter ―1‖ if you have at least $1,500 of child or dependent care expenses for w hich you plan to claim a credit ................. F
G Child Tax Credit ( including additional child tax credit). See Pub. 972, Child Tax Credit, for more infor mation.
     ● If y our total income w ill be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if y ou hav e three or more eligible children.
     ● If your total income w ill be betw een $61,000 and $84,000 ($90,000 and $119,000 if married), enter ―1‖ for each eligible




                    {
     child plus ―1‖ additional if you have six or more eligible children.                                                                                            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 0
For accuracy,             ● If you plan to itemize or c laim adjustments to income and w ant to reduce your w ithholding, see the Deductions
com plete all             and Adjustments Worksheet on page 2.
w orksheets               ● If y ou hav e more than one job or are married and y ou and y our spouse both w ork and the combined earnings from all jobs ex ceed
that apply.               $18,000 ($32,000 if married), see the Tw o-Earners/Multiple Jobs Worksheet on page 2 to av oid hav ing too little tax w ithheld.
                          ● If neither of the above situations applies, stop here and enter the number from line H on line 5 of For m W-4 below .


     - - - - - - - - - - - - - - - Cut here and give Form W-4 to your em ployer. Keep the top part for your records. - - - - - - - - - - - - - - -

                                                      Employee’s Withholding Allowance Certificate                                                                              OMB No. 1545-0074

Form    W-4
Department of the Treasur y
                                    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.                                                   10
Internal Revenue Ser vice
    1 Ty pe or print y our first name and middle initial.        Last name                                                         2     Your social security number

    First MI                                                      Last                                                                 000                      00                  0000
    Home address (number and street or rural route)                                             3
                                                                                                         Single         Married        Married, but withhold at higher Sing le rate.
                                                                                                Note. If married, but legally separated, or spouse is a nonresident alien, check the “ Single” box .

    City or town, state, and ZIP code                                                           4
                                                                                                    If your last name differs from that shown on your social security card,
          MO                                                                                    check here. You must call 1-800-772-12 13 for a replacement card.

    5 Total number of allow ances you are claiming (from line H above or from the applicable w orksheet on page 2)                                      5
    6 Additional amount, if any, you w ant w ithheld from each paycheck................................................................................ 6
    7 I claim exemption from w ithholding for 2010, and I certify that I meet both of the follow ing conditions for exemption.
      ● Last year I had a right to a refund of all federal income tax w ithheld because I had no tax liability and
      ● This year I expect a refund of all federal income tax w ithheld because I expect to have no tax liability.
        If you meet both conditions, w rite ―Exempt‖ here ...........................................................................              7
Under penalties of perjury , I declare that I hav e examined this certif icate and to the best of my knowledge and belief , it is true, correct, and co mplete.


Em ployee’s signature
(For m is not valid unless you sign it.)                                                                                                     Date  11/14/2010
    8   Employ er’s name and address (Employ er: Complete lines 8 and 10 only if sending to the IRS.)                 9 Office code (optional)     10 Employer identification number (EI N)


For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                                    Cat. No. 10220Q                                           Form    W-4 (2010)
Form W-4 (2010)                                                                                                                                                                                        Page     2
                                                                     Deductions and Adjustments Worksheet
 Note. Use this w orksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
  1    Enter an estimate of your 2010 itemized deductions. These include qualifying home mortgage interest,
       charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and




                     {                                                                                               }
       miscellaneous deductions ....................................................................................................................................   1           $
                     $11,400 if married filing jointly or qualifying w idow (er)
  2 Enter:           $8,400 if head of household                                                                 ..................................................... 2           $ 11400
                     $5,700 if single or married filing separately
  3 Subtract line 2 from line 1. If zero or less, enter ―-0-‖ ............................................................................................             3           $
  4 Enter an estimate of your 2010 adjustments to income and any additional standard deduction. ( Pub. 919) ..                                                         4           $
  5 Add lines 3 and 4 and enter the total. ( Include any amount for credits from Wor ksheet 6 in Pub. 919                                                              5           $ 0.00
  6 Enter an estimate of your 2010 nonw age 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 $3,650 and enter the r esult here. Dr op any fraction ..........................................                                    8           0
  9 Enter the number from the Personal Allow ances Worksheet, line H, page 1 ......................................................                                    9           0
 10 Add lines 8 and 9 and enter the total here. If you plan to use the Tw o-Earners/Multiple Jobs Wor ksheet,
     also enter this total on line 1 below . Otherw ise, stop here and enter this total on For m W-4, line 5, page 1                                                  10               0

                                Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
  Note. Use this w orksheet 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 abov e if y ou used the Deductions and Adjustments Worksheet).............. 1                                               0
   2 Find the number in Table 1 below that applies to the L OWEST paying job and enter it here. How ever, if
     you are married filing jointly and w ages from the highest paying job are $65,000 or less, do not enter more
     than ―3.‖ ..................................................................................................................................................................... 2 0
   3 If line 1 is m ore than or equal to line 2, subtract line 2 from line 1. Enter the result here ( if zero, enter ―-0-‖)
     and on For m W-4, line 5, page 1. Do not use the rest of this w orksheet............................................................. 3
  Note. If line 1 is less than line 2, enter ―-0-‖ on For m W-4, line 5, page 1. Complete lines 4–9 below to figure the additional
            w ithholding amount necessary to avoid a year-end tax bill.
   4 Enter the number from line 2 of this w orksheet .......................................................                                4         0
   5 Enter the number from line 1 of this w orksheet .......................................................                                5         0
   6 Subtract line 5 from line 4 ....................................................................................................................................... 6             0
   7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here ............................ 7                                                          $ 550
   8 Multiply line 7 by line 6 and enter the result here. This is the additional annual w ithholding needed ................ 8                                                         $ 27.00
   9 Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paid
      every tw o w eeks and you complete this form in December 2009. Enter the resu lt here and on For m W-4,
      line 6, page 1. This is the additional amount to be w ithheld from each paycheck ............................................... 9                                               $
                                                 Table 1                                                                                              Table 2
         Married Filing Jointly                                           All Others                                  Married Filing Jointly                                 All Others
 If wages from LOWEST             Enter on               If wages from LOWEST             Enter on             If wages from HI GHEST     Enter on           If wages from HI GHEST              Enter on
 paying job are —                 line 2 above           paying job are —                 line 2 above         paying job are —           line 7 above       paying job are —                    line 7 above

        $0   -     $7,000   -             0                     $0   -    $6,000   -              0                  $0   - $65,000           $550                  $0   - $35,000                   $550
     7,001   -     10,000   -             1                  6,001   -    12,000   -              1              65,001   - 120,000            910              35,001   -    90,000                  910
    10,001   -     16,000   -             2                 12,001   -    19,000   -              2             120,001   - 185,000           1,020             90,001   - 165,000                   1,020
    16,001   -     22,000   -             3                 19,001   -    26,000   -              3             185,001   - 330,000           1,200            165,001   - 370,000                   1,200
    22,001   -     27,000   -             4                 26,001   -    35,000   -              4             330,001   and over            1,280            370,001   and over                    1,280
    27,001   -     35,000   -             5                 35,001   -    50,000   -              5
    35,001   -     44,000   -             6                 50,001   -    65,000   -              6
    44,001   -     50,000   -             7                 65,001   -    80,000   -              7
    50,001   -     55,000   -             8                 80,001   -    90,000   -              8
    55,001   -     65,000   -             9                 90,001   - 120,000     -              9
    65,001   -     72,000   -            10                120,001   and over                    10
    72,001   -     85,000   -            11
    85,001   -    105,000   -            12
   105,001   -    115,000   -            13
   115,001   -    130,000   -            14
   130,001   -   and over                15

 Pr ivacy Act and Paper wor k Reduction Act Notice. We ask for the information on this form to                      Y ou are not required to prov ide the inf ormation requested on a f orm that is
 carry out the Internal Revenue laws of the Unit ed States. Internal Revenue Code sections                     subject to the Paperwork Reduction Act unless the f orm display s a v alid OMB
 3402(f)(2) and 6109 and t heir regulations require you to provide this information; y our employer            control number. Books or records relating to a f orm or its instructions must be
 uses it to determine your federal income tax withholding. Failure to provide a properly complet ed            retained as long as their contents may become material in the administration of
 form will result in your being treated as a single person who claims no withholding allowances;               any Internal Rev enue law. Gen erally , tax returns and return inf ormation are
 providing fraudulent information may subject you to penalties. Routine uses of this information               conf idential, as required by Code section 6103.
 include giving it to t he Department of Justice for civil and cri minal litigation, to cities, states, t he        The av erage time and expenses required to complete and file this f orm will
 District of Columbia, and U.S. commonwealt hs and possessions for use in administering their tax              v ary depending on indiv idual circumstances. For estimated av erages, see the
 laws, and using it in the National Directory of New Hires. We may also disclose this information to           instructions f or y our income tax return.
 other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal               If y ou hav e suggestions f or making this f orm simpler, we would be ha ppy to
 laws, or to federal law enforcement and intelligence agencies to combat terrorism.                            hear f rom you. See the instructions f or y our income tax return.
                 MISSOURI DEPARTMENT OF REVENUE TAXATION DIVISION
                 P.O. BOX 3340                                                                                                                     This certificate is for income tax w ithholding
                 JEFFERSON CITY, MO 65105-3340                                                                               MO W-4                and child support enforcement purposes only .
                 FAX:(573) 526-8079                                                                                          (REV. 09-2008)        PL EASE TYPE OR PRINT .
                 EMPLOYEE’S WITHHOLDI NG ALLOWANCE CERTIFI CATE
FULL NAME                                                                                         SOCIAL SECURITY NUMBER                                                   SINGLE
                                                                                                                                                   FILING
                                                                                                                                                                           MARRIED
                                                                                                                                                   STATUS
First Middle Last                                                                                 000-00-0000                                                              HEAD OF HOUSEHOLD
HOME ADDRESS (NUMBER AND STREE T OR RURAL ROUTE)                                                  CITY OR TOWN, STATE AND ZIP CODE

                                                                                                         MO
1.     ALLOWANCE FOR YOURSELF: Enter 1 for yourself if your filing status
       is single, married, OR head of household ................................................................................................              1                                 0
2.     ALLOWANCE FOR YOUR SPOUSE: Does your spouse work?                        Yes        No...................................................
       If YES, enter 0. If NO, enter 1 for your spouse...........................................................................................             2                                 0
3.     ALLOWANCE FOR DEPENDENTS: Enter the number of dependents you will claim on your tax return. Do not claim
       yourself or your spouse or dependents that your spouse has already claimed on his or her Form MO W-4.......................                            3

4.     ADDITIONAL ALLOWANCES: You may claim additional allowances if you itemize your deductions or have other state tax
       deductions or credits that lower your tax. Enter the number of additional allowances you would like to claim.....................                      4

5.     TOTAL NUMBER OF ALLOWANCESYOU ARE CLAIMING: Add Lines 1 through 4 and enter total here .......................                                         5
6.     ADDITIONAL WITHHOLDING: If you expect to have a balance due (as a result of interest income, dividends, income from
       a part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each
       pay period. To calculate the amount needed, divide the amount of the expected balance due by the number of pay periods
       in a year. Enter the additional amount to be withheld each pay period here ..........................................................                  6     $
7.     EXEMPT STATUS: If you had a right to a refund of ALL of your Missouri income tax withheld last year because you had NO
       tax liability and this year you expect a refund of ALL Missouri income tax withheld because you expect to have NO tax
       liability, write “EXEMPT” on Line 7. See information below.............................................................................                7
Under penalties of perjury , I certify that I am entitled to the number of withholding allo wances claimed on this certificate, or I am entitled to claim exempt status.
EMPL OY EE’S SIGNATURE (Form is not v alid unless y ou sign it.)                                  DATE

                                                                                                 11/14/2010
EMPL OY ER’S NAME                                                                                FEDERAL EMPLOY ER IDENTIFICATION NUMBER


EMPL OY ER’S ADDRESS                                                                             MISSOURI TA X IDENTIFICATION NUMBER



            NOTICE TO EMPLOYER: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the: Missouri Department of Revenue, P.O. Box 3340,
           Jefferson City, MO 65105-3340 or fax to (573) 526-8079. For additional information regarding new hire reporting, please v is it www.dss.mo.gov/cse/newhire.htm.

                                                                —EMPLOYEE INFORMATION—
                   YOU D O NOT P AY M ISSOURI INCOME TAX ON ALL OF THE INCOME YOU EARN!
                               Visit www.dor.mo.gov to try our online withholding calculator.

Deductions and exemptions reduce the amount of your taxable income. For m MOW-4 is completed so you can have as much “take-home pay” as possible
with- out an income tax liability due to the state of Missouri when you file your return. Deductions and exemptions reduce the amou nt of your taxable income. If
your income is less than the total of your personal exemption plus your standard deduction, you should mark “EXEMPT” on Line 7 above. The following
amounts of your annual Missouri adjusted gross income will not be taxed by the state of Missouri when you file your individua l income tax return.
                         Single                                            Married Filing Combined                                                  Head of Household
      $2,100 — personal exemption                                    $ 4,200 — personal exemption                                               $ 3,500 — personal exemption
      $5,700 — standard deduction                                    $11,400 — standard deduction                                               $ 8,350 — standard deduction
      $7,800 — Total                                                 $15,600 — Combined Total (For both spouses)                                $11,850 — Total

      + $1,200 for each dependent                                    + $1,200 for each dependent                                                + $1,200 for each dependent
      + up to $5,000 for federal tax                                 + up to $10,000 for federal tax                                            + up to $5,000 for federal tax


                                                                              Items to Remember:
     If your filing status is married filing combined and your spouse works, do not                  If you have more than one employer, you should claim a smaller number or no
      claim an exemption on Form MO W-4 for your spouse.                                               allowances on each Form MO W-4 filed with employers other than your principal
     If you and your spouse have dependents, please be sure only one of you                           employer so the amount withheld will be closer to your amount of total tax.
      claim the dependents on your Form MO W-4. If both spouses claim the                             If you itemize your deductions, instead of using the standard deduction, the amount
      dependents as an allowance on Form MO W-4, it may cause you to owe                               not taxed by Missouri may be a greater or lesser amount.
      additional Missouri income tax when you file your return.
MO 860- 1598 (09-2008)
PAY ELECTION FORM
WILS has elected to offer the benefit of electronic deposit to all employees! Electronic deposit is the most convenient, secure and
affordable way to be paid. Those employees who currently have a bank relationship will use the existing account to receive electronic
deposit. Those employees without a bank account are offered the Skylight paycard. The Skylight paycard is available to ever yone
regardless of credit history or prior inability to obtain a bank account with electronic deposit and successful applicant verification.
CONVENIENT – No more special trips to work on your day off to pick up your check and no more waiting in long lines to get your check
cashed. Your money is in your account by 9am ET on payday morning. With a Skylight paycard, you can receive text message alerts of your
current balance and recent deposits.1
AFFORDABLE – Avoid check cashing and money order fees. Skylight account pricing is based on the transactions you make, with many
transactions available for free.
SECURE – Your money is safe in your account and available when you need it. If you lose your card, Skylight will send you a replacement!2
UNIVERSAL – Request a second card or open a sub-account and send money around the world or around the block. 3 Skylight offers
unlimited free transfers between cards. An additional cardholder is able to access the money you transfer by using the card you authorize
at ATMs and retail locations.
To sign up for either your bank direct deposit OR a Skylight paycard, please complete this form and return it to Payroll. (Please place a
check mark next to your option).
 NAME (Last, First, Middle Initial)
 Last, First MI
 PHYSICAL ADDRESS (Street Address, City, State, Zip)
      ,       MO
 SOCIAL SECURITY NUMBER                                DATE OF BIRTH (MM/DD/YYYY)                              PHONE NUMBER (PRIMARY)
                000-00-0000

Select the option for your paycheck to be deposited.

 ELECTRONIC DEPOSIT OPTIONS:
            CHECKING OR SAVINGS
            ACCOUNT DIRECT DEPOSIT*                                                         PAYCARD DIRECT DEPOSIT
     NAME OF FINANCIAL INSTITUTION                                                   ACCOUNT NUMBER


     PHONE NUMBER OF FINANCIAL INSTITUTION                                           CARD NUMBER


     BANK ROUTING NUMBER                                                             FINANCIAL INSTITUTION


     BANK ACCOUNT NUMBER                                                             ROUTING NUMBER




 *PLEASE A TTACH A C OPY OF A VOIDED CHECK, SAVINGS DEPOSIT FORM OR BA NK LETTER TO THIS FORM FOR ROUTING AND ACCOUNT VE RIFICATION.

My signature below grants authorization to deposit 100% of my wages into the account listed above. This includes authorization to correct
any entries made in error. This authorization will remain in effect until I give a written 10 day notice to cancel it.
 EMPLOYEE SIGNATURE                                                                DATE
                                                                                   11/14/2010


1 User must register for Online Banking and activate subscription to text message alerts. Standard text message/other charges by individual cell phone may apply.
2 Consult your fee schedule for additional details.
3 With successful identity verification.
SELECTED TERMS AND CONDITIONS GOVERNING
THE SKYLIGHT ONE PREPAID PAYROLL CARD
(Effective January 1, 2009)

T he Skylight ONE Prepaid Payroll Card is a consumer-purpose Prepaid Card issued by Elan Financial                   4. Fun din g Your Card: T his Card has been issued to receive electronic payroll deposits. Aside from these
Services, Inc. for Skylight Financial, Inc. Your Prepaid Payroll Card, which may or may not feature a Visa®          deposits, only wire transfers, Mone yGram® E xpressPaymen ts® [limited to $1,000.00 per transaction and a
logo, accesses a special Prepaid Account that has been opened on your behalf by Skylight Financ ial, Inc.            maximum of $1,000.00 per we ek, Monda y through Sunday) and U.S. Postal Mone y Orders payable to
You are authori zed to use the P repaid Pa yroll Ca rd to access the funds in such Prepaid Account, subject to       Skylight with clear instructions to credit your ca rd numbe r will be accept ed for funding the card balance.
the terms of this Agre ement. T he Prep aid Payroll Card cannot be used to access any other chec king or
savings account, and it is not a credi t card.                                                                       5. Your Lia bility for U nau th orized Tra nsacti ons: T ell us AT ONCE if you believe your Ca rd or PIN h as
                                                                                                                     been lost or stolen. T elephoning toll -free at 800-279-5066 is the best way of keeping you r possible losses
In this Agreement, "Prepaid Payroll Card " o r "Ca rd" an eithe r mean the P repaid Payroll Card issued by Elan      down. You could lose all the money on your Card. If you tell us within 2 business days you can lose no more
Financial Services or the Visa Prepaid Payroll Card issued by Elan Financial Services under license from             than $50 if someone used your Card without your permission. If you do N OT tell us within two business days
Visa USA, lnc. ("Visa"), both in c onnection with Skylight Financials Prepaid Payroll Card Prog ram (the             after you lea rn of the loss or theft of your Ca rd and we can p ro ve we could have stopped someon e from
"Prog ram"). "You " and "your" mean the pe rson to whom a Prepaid Payroll Card is issued in connection with          using your Card without your permission if you had told us, you could lose as much as $500. You will not be
the Program. "Skylight", "us ", "we " and "our" mean Skylight Financial, Inc., the c ompany that sponsors the        liable for unautho rized use that occurs af ter you notify us of t he loss, theft o r una uthori zed use o f your
Prepaid Payroll Card P rogra m, in connection with WILS. "Elan Financial Services" means Elan Financial              Card(s).
Services, Inc. which issues the Prepaid Payroll Card. "WILS" means the company that has funded the
Prepaid Account that enables you to access your Prepaid Payroll Account balance.                                     6. Error Resol uti on Notice: In case of erro rs or questions about your Card, or if you think an error h as
                                                                                                                     occurred in you r Card please contact us immediately at:
You will be deemed to ha ve accepted yo ur C ard and to ha ve agreed to the t erms and conditions of this            Phone:     800-279-5 066
Cardholder Ag reement (the "Agree ment") if you do an y of th e following: (a) request and receive th e Ca rd; (b)   Mail:      PO Box 46 7428, Atlanta GA 31146-74 28
sign the back of the Card; (c ) activate the Card; o r (d) use the Card.                                             E-mail:    contact@skylight.net

You must sign the signature panel on the back of the card to ma ke it valid. Whether you sign the C ard o r not      Busine ss Da ys/ Ho urs: Mo nday through F riday 8:3 0am - 5:30pm (Eastern T ime). Holidays are n ot included.
does not limit your responsibility for transactions as defined in t hese T erms and Conditions.                      You may also contact the Custome r Ca re Cente r bet ween 7 am and 1 am ET Monda y th rough Frida y and on
                                                                                                                     Saturday a nd Sunda y between 7 am and 11:3 Oprn ET .
For a full explanation of your rights and obligations regarding use of the card, please review the Rules and
Regulations booklet pro vided in you r new account kit.                                                              We must allow you to re port a n error until 60 da ys after t he ea rlier of the date you electronically access your
                                                                                                                     account, if the error could b e viewed in your electronic history, or t he date we sent the FIRST written history
1. Ge neral In for mati on: You acknowledge and agree that you do no t ha ve if deposit, checking or other           on which the erro r appea red. You ma y re quest a written history of your t ransactions at any time b y contacting
account with Skylight Financial or Elan Financial Services. However; for ref erence purposes only, your              us at the information pro vided abo ve. You will need to tell us:
current a vailable Prepaid balance ma y be refe rred to herein as the P repaid Pa yroll Account. T he fun ds         (1) You r name and Card num ber
stored on the Card a re FDI C Insured. Ho weve r, you will not be paid interest or any other ea rnings on the        (2) Wh y yo u believe the re is an erro r, and the dollar am ount invol ve d.
funds allocated to your Ca rd.                                                                                       (3) App roximately when the e rro r too k place.

T he Card allows electronic access to the balance on your Ca rd; it is not a credit card.                            If you tell us orally, we will require that you send us your complaint or question in w riting within 10 business
                                                                                                                     days. We will determine whether an error occurred within 10 business days after we hear from you and will
2. Usin g Your Card: Subject to both Elan Fi nancial Services' satisfaction of its obligations as a Visa Member      correct any error prom ptly. If we need more time, howe ver; we ma y take up to 4S days to investigate your
and the type of Prepaid Pa yroll Progra m you h ave, you ma y use your Card as follows:                              complaint or question. If we decide to do this, we will credit you within 10 business days for the amount you
(1) You may use your Card only aft er activation. T he C ard and Personal Identification Number (PIN) are            think is in error, so that you will have the money during the time it takes us to complete our investigation. If
    provided fo r your use and protection. You ag ree that you will: (a) Not disclose the PIN nor record it on the   we ask you to put you r complaint or question in writing and we do not receive it within 10 business days, we
    Card or othe rwise make it available to any unautho rized pe rson(s); (b ) Use the Card, the PIN an d any        may not give you pro visional credit. Fo r e rro rs involving new Cards, point -of-sale, o r fo reign-initiated
    terminal as instructed; (c) Promptly n otify us of an y loss or theft of the C ard o r PIN.                      transactions, we ma y ta ke up to 90 days t o investigate you r complaint or question. Fo r a new Card, we m ay
(2) Using your Ca rd and selected PIN, you ma y withdraw cash from AT Ms bea ring the logos featured on              take up to 20 business days to credit you for t he amount you think is in error. We will tell you the results
    your Ca rd. You ma y also use your Card to pu rchase goods and services at merchant locations. Some              within three business days after completing our investigation. If we decide that there was no error, we will
    merchants may allow you to use your Card for cash-back on purchases. You ma y change you r PIN,                  send you a w ritten explanation. You ma y as k for copies of the documents that we used in our investigation.
    check your balance and transaction activity and initiate other customer service requests by calling the
    toll-free Ca rdholder Se rvices number indicated on the back of your Card or pro vided to you on you r card      7. Visa's Zero lia bility Pr ogram: Visa Cardholde rs, have complete liability protection for all Card
    carrier. You ma y also use you r Ca rd to access funds anywhe re debit card t ransactions are accepted,          transactions that take place on Visa's Network. Should someone steal you r Ca rd numbe r while shopping,
    such as domestic and international automatic teller machines (AT M), purchases at pa rticipating retail          online or off, you pa y nothing fo r the frau dulent activity. If fraudulent activity is notic ed on your Card, you
    merchants that accept debi t cards for point-of-sale (POS), pre-autho rized direct payments (ACH Debits)         must promptly repo rt it. T he Zero Liability policy covers all of your Card t ransactions processed over the Visa
    and transfe rs between yo ur Cards to othe r financial institutions. Some of these services may n ot be          network:. AT M and non -Visa-branded PI N tra nsactions are hot cove red unde r the Zero Liability policy. Under
    available at all terminals.                                                                                      this program, we will extend a pro visional credit for you r losses from unauthorized use of you r Visa Card
(3) In addition, Visa Cards ma y be used anywhere V isa debit cards a re accepted. Othe r funds disbursement         within five business days of notification of the loss.
    methods for Visa Card holders include Signature-based pu rchases, ove r-the -counter cash ad vances, mail
    order/telephone orde r (MOT O), Internet purchases, and transfe rs from your Card to other financial             8. Skyli gh t Priv acy Polic y: S kylight Financial, Inc. and Elan Financial Services' Privacy Policy sets forth
    institutions.                                                                                                    Skylight's Privacy Policy and describes the practices that Skylight Financial, Inc. and Elan Financial Services,
                                                                                                                     Inc. will follow with respect to certain nonpublic personal information collected from users of the Card. Elan
3. Limi tati ons: Limitation on the Dollar Amount of T ransfers : You m ay use you r Ca rd to withdraw up to         Financial Services is the issuer of the Visa and Non-Visa Cards under the Cardholder Agree ment between
$1,000.00 each calendar da y at any participating AT M o r P OS te rminal. Some AT M own ers ma y ha ve limits       you an d WILS. Neither Skylight Financial nor Elan Financial Services is affiliated with WILS. Please contact
lower than this amount to be dispensed at one time f rom their machine. T he withdrawal limit starts at 3:31pm       WILS directly if you would like a cop y of WILS' p rivac y policy. S kylight Fina ncial provided you with a cop y of
Eastern T ime each calendar da y a nd ends at 3:30pm Eastern T ime the next calendar d ay. T ransactions will        the privacy policy when the Card is issued to you. And you will receive a new copy at least once a year
be charged at the rate described in your Fee Schedule p rinted on you r card carrie r. Som e AT M owne rs            thereafter. You should re view this privacy policy and retain a copy of it for you r records.
impose an additional transaction fee unrelated to our fees and charges. T hese charges will be assessed to
your Card.




  TRANSACTION DESCRIPTION                          FEE              COMMENTS                                             TRANSACTION DESCRIPTION                        FEE               COMMENTS
  Enrollment Fee                                   FREE             One-time f ee. May be paid by                        Money Transf ers - Wire                        $25.00
                                                                    employ er.
                                                                                                                         Stolen Card Replacement                        $7.00             One each 12 months is free.
  Monthly Fee – Primary Account                    FREE
                                                                                                                         Deliv ery:
  Monthly Fee – Additional Card                    $3.00                                                                  Regular Mail                                  FREE
  Balance Inquiry v ia IVR                         FREE
                                                                                                                          Ov ernight                                    Extra
  Domestic ATM:
                                                                                                                          USPS Priority Mail 2-3 day                    Extra
   Withdrawal                                      $1.50            One each pay period is free.
                                                                                                                         Insuff icient Funds – Paid                     $25.00
   Balance Inquiry / Attempt                       $1.00
                                                                                                                         Insuff icient Funds – Returned                 $25.00
                           1
  International ATM:                                                                                                     Stop Pay ment                                  $25.00
   Withdrawal                                      $1.50
                                                                                                                         Statement v ia Web                             FREE
   Balance Inquiry / Attempt                       $1.00
                                                                                                                         Paper Statement / Statement                    $5.00
  Domestic POS – PIN Based:                                                                                              Reprints
   Purchase                                        FREE                                                                  Account Closing Fee                            $10.00
   Purchase Attempt                                FREE                                                                  Inactiv ity Fee                                $5.00             Assessed after 30 day s of
                                                                                                                                                                                          continuous inactiv ity.
  Signature-base d Purchase                        FREE
  Money Transf ers – Card-to-Card:
   Via Web                                         FREE
                                                                                                                     1     Funds dispensed in local curr ency . Sky light charges a f ee of 1% of the dollar
   Via IVR                                         FREE                                                                    amount of each transaction made in countries other than the United States.
   Via Liv e Customer Support                      FREE                                                                    Consult y our terms and conditions f or additional details.

								
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