Fillable CDID FDS SB Employee Packet Simplex 20210412

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CDID FDS SB Employee Packet Simplex 20210412

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Family‐DirectedServices
EMPLOYEEDATAFORM
Rev.01/02/2019
00840
EmployeeInformation
Name:
First Middle Last
PhysicalAddress:
Street Apt/Unit# City StateZipCode
MailingAddress:
(ifdifferentthanphysicaladdress)
Street/POBox Apt/Unit# City StateZipCode
Phone#:Home( ) Cell( )
Email:
Gender:MaleFemaleDateofBirth: SocialSecurity#: ‐ ‐
EmploymentRelationships
NameofParticipant(ChildReceivingServices):
NameofChild’sParent/Guardian:
Employee’srelationshiptoChild/Employer*:
YesNo–IamcurrentlyemployedbyanotherParticipantintheIdahoSelfDirectionProgram.
*ThechildreceivingservicesistheEmployerofRecord.Byprogramrule,theparent,stepparent,or
guardianoftheprogramrecipient(childnamedabove)isnotallowedtobeapaidemployeeintheFamily
DirectedServicesoption.
PleaseReadCarefully:Ifyoucompleteanemploymentagreementyoubecomeanemployeeofthe
Participant’sfamily.YouwillnotbeanemployeeofConsumerDirectCareNetwork.
_________________________________ ______________
EmployeeSignature Date
Please complete this Employee Data Form prior to printing.
This packet is designed for single-sided paper printing.
Clear Form
/
/
Family‐DirectedServices
NEWSUPPORTBROKERCHECKLIST
Rev.01/02/2020
00848
WelcometoConsumerDirectCareNetwork(CDCN)!
PleasecompletetheformsasindicatedinthelistsbelowandsubmittoCDCN.TheSupportBrokerisnot
approvedtobeginworkuntilallformshavebeenreviewedbyCDCN,andresultsoftheCriminal
Backgroundcheckhavebeenreceived.Uponapproval,CDCNwillnotifytheEmployerandissuethe
SupportBrokeranIDnumberforusewhensubmittingtimesheets.
Instructionsandadditionalinformationforcompletingtheseformsisavailableonlineat
www.consumerdirectid.com.
TheFamilyRepresentativeshouldcheckeachiteminthelistsbelowastheyarecompleted.
MandatoryForms‐allnewSupportBrokers
1. EmployeeDataForm
2. NewEmployeeChecklist(thisform)
3. I‐9Form‐AdditionalI‐9instructionsareavailableontheCDCNIdahowebsiteunderthe
Resourcestab
4. W‐4Employee’sWithholdingAllowanceCertificate(federal)
5. IDW‐4Employee’sWithholdingAllowanceCertificate(state)
6. PaySelectionForm‐Attachmentmayberequired,seeforminstructions
7. Participant‐SupportBrokerEmploymentAgreement
8. Medicaid‐SupportBrokerAgreement
MandatoryDocumentation‐allnewSupportBrokers
1. SupportBrokerQualificationsLetter
2. NoticeofClearanceLetter–CriminalHistoryCheck
Ihavereviewedtheseformsandagreethattheyarecompleteandreadable.

Parent/LegalRep.Signature Date PrintedName
DatesubmittedtoConsumerDirect:____/____/_____
/ /
SupportBrokerName EstimatedStartDate Child’sName
Instructions
f
orCompletingFormI‐9Section1
(Onorbeforeemployee’sfirstdayofworkforpay)
Employee:CompleteSection1ofFormI‐9.Thismustbedonenolaterthanyourfirstdayofworkforpay.
Pleaseprintclearly,andsignanddatewhenyouarefinished.Refertothenumberedexplanationsbelowfor
additionalinformation.
Employer:ReviewSection1,ensuringyouremployeehascompleteditproperly
.
Employee(steps1‐9)
Printyourfulllegalname:
Last,FirstandMiddleInitial.
Provideanyothernamesused,
suchasmaidenname.Enter
“N/A”ifyouhaveneverhad
anothername.
Printyourphysicaladdress.
EnteringaPOBoxisnot
allowed.Enter“N/A”ifyou
havenoapartmentnumber.
Printyourdateofbirth
(mm/dd/yyyy).
PrintyourSocialSecurity
Number.
Printyouremailaddressor
print“N/A”ifyouchoosetonot
provideit.
Printyourtelephone
numberorprint“N/A”ifyou
choosetonotprovideit.
Checktheoneboxthat
bestdescribesyourcitizenship
orimmigrationstatusinthe
UnitedStates.
Signandprintthedateyou
completedtheform.Nolater
thanfirstdayofworkforpay.
Checktheboxthatindicates
whetherornotyouwere
assistedbyaprepareror
translator.
Note:Theseinstructionsareforinformationalpurposesonly.Refertopages1and2ofFormI‐9Instructionsfordetailedinformation.
Exam
p
le
123 Main St.
N
/
A
An
y
town
I
D
12345
X
Jane Doe
02/05/2017
D
oe
Jane
Q
N
/
A
X
03
/
13
/
1964
1 2 3
4
5
6
7
8
9
em
p
lo
y
ee@email.com
555
-
123
-
4
567
Instructions
f
orCompletingFormI‐9Section2
(Anytimeafteremployeehasacceptedjoboffer,butnolaterthan3daysafteremployee’sfirstdayofwork)
Employee:Presentoriginal,unexpireddocumentstoyouremployertoverifyyouridentityandauthorization
toworkintheUnitedStates.TheLISTOFACCEPTABLEDOCUMENTSisfoundaftertheFormI‐9.
Employer(FEINholder):ExaminethedocumentsyouremployeeprovidesandrecordtheminSection2.The
employeemustbepresentwhileyouexaminethem.Refertothenumberedexplanationsbelow
foradditionalinformation.
Employer(steps1‐10)
Printemployee’snamefrom
Section1:Last,First,andMiddleInitial.
Enterthenumberrepresenting
employee’scitizenshipstatuschecked
inSection1.
Examineeachdocumentandnote
thedetailsintheappropriateList
column.
onedocumentfromListA
OR
onefromListBandonefromListC
Onlyacceptunexpired,original
documents(nophotocopies).
Printthedateoftheemployee’s
firstdayofwork.
Signtheform.
Printthedateyousignedtheform.
Mustbecompletedandsignedwithin
3daysofemployee’sfirstdayofwork.
Ifnotpre‐populated,printyour
titleas“Employer.”
Printyourlastthenfirstname.
Printyourfirstandlastname.
Printphysicaladdresswhere
servicesareprovided:street,city,state
andzipcode.
Note:Theseinstructionsareforinformationalpurposesonly.Refertopages6through12ofFormI‐9Instructionsfordetailedinformation.
Doe
J
ane
Q
1
Driver’s License
S
ocial Securit
y
Card
02
/
05
/
2017
S
tate of Residence
S
SA
0
123
4
56789abcde
123-
4
5-
6
789
0
8
/
17
/
2020
N/
A
Ronald Smith
02/05/2017
Employer
Smith Ronald
Ronald Smith
500 Fictional St. Anytown ID 85018
Exam
p
le
SubmitformI‐9toConsumerDirectwiththeEmployeePacket
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
ŹSTART HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
03149
/
/
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
03150
Employer
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
00540
Form W-4
2021
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
a
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a
Give Form W-4 to your employer.
a
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
a
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly or Qualifying widow(er)
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld .....
a
TIP: To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
a
$
Multiply the number of other dependents
by $500 . . . .
a
$
Add the amounts above and enter the total here .............
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here .....................
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
F
Employee’s signature (This form is not valid unless you sign it.)
F
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2021)
02227
Form W-4 (2021)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you
will generally be due a refund. Complete a new Form W-4
when changes to your personal or financial situation would
change the entries on the form. For more information on
withholding and when you must furnish a new Form W-4,
see Pub. 505, Tax Withholding and Estimated Tax.
Exemption from withholding. You may claim exemption
from withholding for 2021 if you meet both of the following
conditions: you had no federal income tax liability in 2020
and you expect to have no federal income tax liability in
2021. You had no federal income tax liability in 2020 if (1)
your total tax on line 24 on your 2020 Form 1040 or 1040-SR
is zero (or less than the sum of lines 27, 28, 29, and 30), or
(2) you were not required to file a return because your
income was below the filing threshold for your correct filing
status. If you claim exemption, you will have no income tax
withheld from your paycheck and may owe taxes and
penalties when you file your 2021 tax return. To claim
exemption from withholding, certify that you meet both of
the conditions above by writing “Exempt” on Form W-4 in
the space below Step 4(c). Then, complete Steps 1(a), 1(b),
and 5. Do not complete any other steps. You will need to
submit a new Form W-4 by February 15, 2022.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to
additional taxes, such as Additional Medicare Tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also
be checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be
cut in half for each job to calculate withholding. This option
is roughly accurate for jobs with similar pay; otherwise, more
tax than necessary may be withheld, and this extra amount
will be larger the greater the difference in pay is between the
two jobs.
F
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. This step provides instructions for determining the
amount of the child tax credit and the credit for other
dependents that you may be able to claim when you file your
tax return. To qualify for the child tax credit, the child must
be under age 17 as of December 31, must be your
dependent who generally lives with you for more than half
the year, and must have the required social security number.
You may be able to claim a credit for other dependents for
whom a child tax credit can’t be claimed, such as an older
child or a qualifying relative. For additional eligibility
requirements for these credits, see Pub. 972, Child Tax
Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2021 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
00540
Form W-4 (2021)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 ..................... 1
$
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a ....................... 2a
$
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b .............................
2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c .......... 2c
$
3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. ..... 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) ......................... 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2021 itemized deductions (from Schedule A (Form 1040)). Such deductions
may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to
$10,000), and medical expenses in excess of 10% of your income ............ 1
$
2 Enter:
{
• $25,100 if you’re married filing jointly or qualifying widow(er)
• $18,800 if you’re head of household
• $12,550 if you’re single or married filing separately
}
........ 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater
than line 1, enter “-0-” .......................... 3
$
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information .... 4
$
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 ........... 5 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to
provide this information; your employer uses it to determine your federal income
tax withholding. Failure to provide a properly completed form will result in your
being treated as a single person with no other entries on the form; providing
fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We
may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
00540
Form W-4 (2021)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $190 $850 $890 $1,020 $1,020 $1,020 $1,020 $1,020 $1,100 $1,870 $1,870
$10,000 - 19,999
190 1,190 1,890 2,090 2,220 2,220 2,220 2,220 2,300 3,300 4,070 4,070
$20,000 - 29,999 850 1,890 2,750 2,950 3,080 3,080 3,080 3,160 4,160 5,160 5,930 5,930
$30,000 - 39,999
890 2,090 2,950 3,150 3,280 3,280 3,360 4,360 5,360 6,360 7,130 7,130
$40,000 - 49,999
1,020 2,220 3,080 3,280 3,410 3,490 4,490 5,490 6,490 7,490 8,260 8,260
$50,000 - 59,999 1,020 2,220 3,080 3,280 3,490 4,490 5,490 6,490 7,490 8,490 9,260 9,260
$60,000 - 69,999
1,020 2,220 3,080 3,360 4,490 5,490 6,490 7,490 8,490 9,490 10,260 10,260
$70,000 - 79,999
1,020 2,220 3,160 4,360 5,490 6,490 7,490 8,490 9,490 10,490 11,260 11,260
$80,000 - 99,999 1,020 3,150 5,010 6,210 7,340 8,340 9,340 10,340 11,340 12,340 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,930 7,130 8,260 9,320 10,520 11,720 12,920 14,120 15,090 15,290
$150,000 - 239,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,230 16,190 16,400
$240,000 - 259,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,270 17,040 18,040
$260,000 - 279,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,870 14,870 16,870 18,640 19,640
$280,000 - 299,999
2,040 4,440 6,500 7,900 9,230 10,470 12,470 14,470 16,470 18,470 20,240 21,240
$300,000 - 319,999 2,040 4,440 6,500 7,940 10,070 12,070 14,070 16,070 18,070 20,070 21,840 22,840
$320,000 - 364,999
2,720 5,920 8,780 10,980 13,110 15,110 17,110 19,110 21,190 23,490 25,560 26,860
$365,000 - 524,999
2,970 6,470 9,630 12,130 14,560 16,860 19,160 21,460 23,760 26,060 28,130 29,430
$525,000 and over
3,140 6,840 10,200 12,900 15,530 18,030 20,530 23,030 25,530 28,030 30,300 31,800
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $440 $940 $1,020 $1,020 $1,410 $1,870 $1,870 $1,870 $1,870 $2,030 $2,040 $2,040
$10,000 - 19,999
940 1,540 1,620 2,020 3,020 3,470 3,470 3,470 3,640 3,840 3,840 3,840
$20,000 - 29,999 1,020 1,620 2,100 3,100 4,100 4,550 4,550 4,720 4,920 5,120 5,120 5,120
$30,000 - 39,999
1,020 2,020 3,100 4,100 5,100 5,550 5,720 5,920 6,120 6,320 6,320 6,320
$40,000 - 59,999
1,870 3,470 4,550 5,550 6,690 7,340 7,540 7,740 7,940 8,140 8,150 8,150
$60,000 - 79,999 1,870 3,470 4,690 5,890 7,090 7,740 7,940 8,140 8,340 8,540 9,190 9,990
$80,000 - 99,999
2,000 3,810 5,090 6,290 7,490 8,140 8,340 8,540 9,390 10,390 11,190 11,990
$100,000 - 124,999
2,040 3,840 5,120 6,320 7,520 8,360 9,360 10,360 11,360 12,360 13,410 14,510
$125,000 - 149,999 2,040 3,840 5,120 6,910 8,910 10,360 11,360 12,450 13,750 15,050 16,160 17,260
$150,000 - 174,999
2,220 4,830 6,910 8,910 10,910 12,600 13,900 15,200 16,500 17,800 18,910 20,010
$175,000 - 199,999
2,720 5,320 7,490 9,790 12,090 13,850 15,150 16,450 17,750 19,050 20,150 21,250
$200,000 - 249,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$250,000 - 399,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$400,000 - 449,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,910 21,220 22,520
$450,000 and over
3,140 6,250 8,830 11,330 13,830 15,790 17,290 18,790 20,290 21,790 23,100 24,400
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $820 $930 $1,020 $1,020 $1,020 $1,420 $1,870 $1,870 $1,910 $2,040 $2,040
$10,000 - 19,999
820 1,900 2,130 2,220 2,220 2,620 3,620 4,070 4,110 4,310 4,440 4,440
$20,000 - 29,999 930 2,130 2,360 2,450 2,850 3,850 4,850 5,340 5,540 5,740 5,870 5,870
$30,000 - 39,999
1,020 2,220 2,450 2,940 3,940 4,940 5,980 6,630 6,830 7,030 7,160 7,160
$40,000 - 59,999
1,020 2,470 3,700 4,790 5,800 7,000 8,200 8,850 9,050 9,250 9,380 9,380
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,850 11,050 11,250 11,520 12,320
$80,000 - 99,999
1,880 4,280 5,710 7,000 8,200 9,400 10,600 11,250 11,590 12,590 13,520 14,320
$100,000 - 124,999
2,040 4,440 5,870 7,160 8,360 9,560 11,240 12,690 13,690 14,690 15,670 16,770
$125,000 - 149,999 2,040 4,440 5,870 7,240 9,240 11,240 13,240 14,690 15,890 17,190 18,420 19,520
$150,000 - 174,999
2,040 4,920 7,150 9,240 11,240 13,290 15,590 17,340 18,640 19,940 21,170 22,270
$175,000 - 199,999
2,720 5,920 8,150 10,440 12,740 15,040 17,340 19,090 20,390 21,690 22,920 24,020
$200,000 - 249,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$250,000 - 349,999
2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$350,000 - 449,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,900 25,200
$450,000 and over 3,140 6,840 9,570 12,160 14,660 17,160 19,660 21,610 23,110 24,610 26,050 27,350
00540
EFO00307 12-15-2020 Page 1 of 2
Form ID W-4
(PSOR\HH¶V:LWKKROGLQJ$OORZDQFH&HUWL¿FDWH
Complete Form ID W-4 so your employer can withhold the correct amount of state income tax from
your paycheck. Sign the form and give it to your employer. Use the information on the back to
calculate your Idaho allowances and any additional amount you need withheld from each paycheck.
If you plan to itemize deductions, use the worksheet at tax.idaho.gov/w4.
Withholding Status
Check the “A” box (Single) if you’re:
• Single with one job or single with multiple jobs
• Filing as head of household
Check the “B” box (Married) if you’re:
• 0DUULHG¿OLQJMRLQWO\ZLWKRQHMREDQG\RXUVSRXVHGRHVQ¶WZRUN
• A qualifying widow(er)
Check the “C” box (Married, but withhold at Single rate) if you’re:
• 0DUULHG¿OLQJMRLQWO\DQGERWKSHRSOHZRUNRU\RXKDYHPXOWLSOHMREV
• 0DUULHG¿OLQJVHSDUDWHO\
Form ID W-4
(PSOR\HH¶V:LWKKROGLQJ$OORZDQFH&HUWL¿FDWH
WITHHOLDING STATUS (see information above)
A
(Single)
B
(Married)
C
(Married, but withhold at Single rate)
1. Total number of Idaho allowances you’re claiming ...........................................................................
2. Additional amount (if any) you need withheld from each paycheck (Enter whole dollars) ...............
Your Social Security number (required)
<RXU¿UVWQDPHDQGLQLWLDO Last name
Current mailing address
City State ZIP Code
Under penalties of perjury, I declare that to the best of my knowledge and belief I can claim the number of withholding
allowances on line 1 above.
Your signature Date
10221
1. Total number of allowances you’re claiming.
Enter the number of children in your household age 16 or under as of December 31, 2021. If you have no qualifying children,
HQWHU³´,I\RXU¿OLQJVWDWXVZLOOEHKHDGRIKRXVHKROGRQ\RXUWD[UHWXUQDGG³´WRWKHQXPEHURITXDOLI\LQJFKLOGUHQDon’t
claim allowances for you or your spouse. You can claim fewer allowances but not more.
If you’re married, claim your allowances on the W-4 for the highest-paying job for the most accurate withholding. If you’re
PDUULHG¿OLQJMRLQWO\RQO\RQHRI\RXVKRXOGFODLPWKHDOORZDQFHV7KHRWKHUVKRXOGFODLP]HURDOORZDQFHV
If you work for more than one employer at the same time, you should claim zero allowances on your W-4 with any employer
other than your principal employer.
Write Exempt on line 1 if you meet both of the following conditions:
• Last year I had no Idaho income tax liability and
• This year I expect to have no Idaho income tax liability
Nonresident Aliens
Exempt income. If you’re a nonresident alien and all your income is exempt from withholding, write “Exempt” on line 1.
Exempt income from a treaty. If a treaty exempts a portion of your income from withholding, complete federal Form 8233 to
FODLP\RXUWUHDW\EHQH¿WVDQGFRPSOHWHWKH,GDKR:WRZLWKKROGRQLQFRPHWKDW¶VQRWH[HPSWE\\RXUWUHDW\
Idaho taxable income. If you’re a nonresident alien and have Idaho taxable income, do all of these:
1. Check the “Single” withholding status box regardless of your martial status.
2. Enter 0 on line 1.
3. Using the Pay Period table below, enter the additional amount of income tax to be withheld for each pay period on
line 2. Exception: If you’re a student or business apprentice from India, report $0 on line 2.
Pay Period Table
If your pay period is: Weekly Biweekly Semimonthly Monthly
Enter this amount on line 2: $17 $33 $36 $72
The withholding table calculations for employers include the standard deduction. Because nonresident aliens
don’t qualify for the standard deduction, the Pay Period table helps ensure that employers withhold enough.
2. Additional amount, if any, you need withheld from each paycheck.
,I\RX¶UHVLQJOHRUPDUULHG¿OLQJVHSDUDWHO\DQGKDYHPRUHWKDQRQHMREDWDWLPH, complete the worksheet below to
calculate any additional amount you need withheld from each paycheck.
1.
Other than your primary job, how many jobs do you expect to have at the
same time during 2021? (Don’t count your primary job.) .....................................................................
2. Multiply the number on line 1 by $12,400 ............................................................................................
3.
Enter an estimate of your 2021 income from other jobs
(not including your primary job) ...........................................................................................................
4. Enter the smaller of lines 2 or 3 ..........................................................................................................
5.
If you completed the itemized deduction worksheet for Idaho (tax.idaho.gov/w4), enter the
number from line 4. Otherwise, enter “0” ............................................................................................
6. Multiply the number on line 5 by $2,960..............................................................................................
7. Subtract line 6 from line 4 ...................................................................................................................
8.
Multiply line 7 by 6.925% (.06925). This is the additional amount you need to
withhold annually ................................................................................................................................
9.
Divide the amount on line 8 by the number of your remaining pay periods
in 2021. Enter the number on line 2 of the W-4 as the additional amount
you need withheld from each paycheck .............................................................................................
Contact us:
In the Boise area: (208) 334-7660 | Toll free: (800) 972-7660
Hearing impaired (TDD) (800) 377-3529
tax.idaho.gov/contact
EFO00307 12-15-2020 Page 2 of 2
Form ID W-4 (continued)
00540

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Rev.04/05/2021
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Iffundsaredepositedtomyaccountinerror,oranimproperpaymentismade,Iauthorize
CDCNtodebitmyaccounttocorrecttheerror.Ifmyaccountcannotbedebitedduetoclosure
orinsufficientbalance,thenCDCNmaywithholdfuturepaymentsuntiltheerroneousdeposited
amountsarerepaid.
Imayreceiveapapercheckwhilemyselectedmethodofpayisbeingsetup.
ImustsubmitanewPaySelectionFormtoCDCNifIwishtochangemyDirectDepositoption.

EmployeeSignature Date
/
/
Sign up for the
Wisely
®
Pay card today!
It’s a reloadable prepaid pay card that’s yours to keep
no matter where you work.
1
There’s no fee to sign up,
and there’s no credit check to get the Wisely Pay card
because it’s not a credit card.
2
Enjoy these great benefits when you
activate your Wisely Pay card account.
No Charge for Direct Deposit — Get paid up
to 2 days early
4
for your pay and other sources of
income.
5
A no-fee
6
upgrade is required.
7
Shop and Pay Bills — In stores, by phone, or
online, everywhere Visa debit cards are accepted
and where Debit Mastercard is accepted.
3
Pay with a single touch anywhere Apple Pay
®
,
Samsung Pay
®
, or Google Pay
™
is accepted.
Safe and Secure — Balance is protected
from fraud if the card is lost or stolen, and is
FDIC insured.
8
Manage your Money — Save for a rainy day, plan
your budget, and track your spending to boost
your financial wellness with myWisely
®
app.
9
1
Adding funds from other sources requires additional cardholder identification verification.
2
Wisely Pay is not a credit card and does not build credit.
3
Additional terms and third-party fees may apply.
4
You must opt into early direct deposit on myWisely.com/pay or myWisely mobile app. Early direct deposit of funds is not guaranteed and is
subject to payer’s support and the timing of payer’s payment instruction. Faster-funding claim is based on a comparison of our policy of making
funds available upon our receipt of payment instruction with the typical banking practice of posting funds at settlement. Please see full disclosures
on myWisely.com or myWisely app. Please allow up to 3 weeks for funds to be loaded to the card after initial setup of direct deposit to your card.
5
Please allow up to 3 weeks for your pay to be loaded to the card after initial setup of direct deposit to your card.
6
While this feature is available at no additional charge, certain other transaction fees and costs, terms, and conditions are associated with the use of
this Card. See the cardholder agreement for more details.
7
Additional verification required and may not be available to all cardholders.
8
You must notify us immediately and assist us in our investigation if your card is lost or stolen or you believe someone is using your card without
your permission.
9
Standard text message fees and data rates may apply.
The Wisely Pay Mastercard
®
is issued by Fifth Third Bank N.A., Member FDIC, or MetaBank
®
, N.A., Member FDIC, pursuant to license by Mastercard
International Incorporated. The Wisely Pay Visa
®
is issued by Fifth Third Bank N.A., Member FDIC, or MetaBank
®
, N.A., Member FDIC, pursuant to a
license from Visa U.S.A. Inc. ADP and the ADP logo are registered trademarks of ADP, Inc. Wisely, myWisely, and the Wisely logo are registered trademarks
of ADP, Inc. Apple, the Apple logo, and Apple Pay are registered trademarks of Apple Inc. App Store is a service mark of Apple Inc., registered in the
U.S. and other countries. Google Pay, Google Play, and the Google Play logo are trademarks of Google LLC. Samsung Pay is a registered trademark of
Samsung Electronics Co., Ltd. All other marks are the property of their respective owners. Copyright © 2020 ADP, Inc. All rights reserved.
WiselyCard_Poster_V4 Rev. Aug 2020
Revised 11/09/2015 Page 1 of 3
01248
PARTICIPANT-SUPPORT BROKER EMPLOYMENT AGREEMENT
This agreement is hereby made between a Participant of the
Participant’s Name
Family-Directed Community Supports (FDCS) Option, a Medicaid option administered by the Department of
Health and Welfare (department), and a Support Broker.
Support Broker’s Name
The participant wants to hire the support broker for services under the FDCS Option. In exchange, the
support broker wants to be paid for the services provided to the participant. Both parties understand and
agree that payment is made through a fiscal employer agent (FEA), using Medicaid monies and based on
time sheets submitted by the support broker and approved by the employer, who is the participant.
To these mutual purposes, the parties promise and agree as follows:
1. Support broker services are to be provided in accordance with “Participant-Support Broker Agreement,”
and the FDCS rules, according to the Idaho Administrative Procedures Act (IDAPA) 16.03.13,
“Consumer-Directed Services.”
2. The support broker is hired to help the participant, and assumes no responsibility for the Participant’s
conduct.
3. That the Support Broker is an employee of the Participant and not an employee of the FDCS Option or
the FEA, and agree that the Support Broker is not entitled to, nor will make claim for any employee
benefits from the FDCS Option or the FEA, including but not limited to, worker’s compensation,
disability, life insurance, or health insurance.
4. The Support Broker will take all actions necessary to become the Participant’s employee, and to maintain
the employment relationship by submitting necessary documents to the FEA, including:
A “Support Broker Letter of Approval” from the Department.
A Completed W-4, I-9, and other IRS required forms.
A completed criminal history check, including clearance in accordance with IDAPA 16.05.06,
"Criminal History and Background Checks”.
A copy of this agreement.
Participant approved time sheets that record the hours the support broker worked.
5. The Support Broker will provide all required support broker duties outlined in Subsection 136.02 of
IDAPA 16.03.13, “Consumer-Directed Services” and, as mutually agreed upon with the Participant, the
optional support broker duties outlined in Subsection 136.03 of IDAPA 16.03.13, “Consumer-Directed
Services.”
6. The Support Broker’s wage is not to exceed $18.72 per hour. It is mutually understood that any overtime
hours or services not described in the Participant’s “Family-Directed Community Supports Support and
Spending Plan,” or described elsewhere in this agreement, are not covered by or paid through this
agreement.
Revised 11/09/2015 Page 2 of 3
01249
7. Terms and conditions of work (job duties). Effective Date: .
☐ Please check this box if employer is requiring the support broker to specifically document
activities that support billable time in writing in a manner agreed upon between the employer and the
support broker and identified in the “other” section of the agreement.
Service or Task
Identify the activity that will be completed under each
service or task.
Service
Code
Number of
hours per
year needed
to perform
this task
Wage
per hour
Annual Cost
Person centered planning participation includes:
SBS
SB2
SB3
X
=
$
Sub Total
Developing the written Support and Spending Plan
includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer to review and monitor the budget
includes:
SBS
SB2
SB3
X
=
$
Sub Total
Submitting the employer satisfaction documentation to
the department as requested includes:
SBS
SB2
SB3
X
=
$
Sub Total
Participating in the quality assurance process with the
department includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer with the annual re-determination
process includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer to meet participant
responsibilities includes:
SBS
SB2
SB3
X
=
$
Sub Total
Criminal History Check Waiver Process (example:
complete waiver form, education and counseling to
participant and circle of support, assist with detailing
rationale for waiver and identifying how health and
safety will be protected).
SBS
SB2
SB3
X
=
$
Sub Total
Other: Give details of job duties:
SBS
SB2
SB3
X
=
$
Sub Total
Total Cost of Annual Support:
$
Revised 11/09/2015 Page 3 of 3
01250
The support broker agrees not to provide or bill for services until:
An authorized “Support and Spending Plan” has been submitted to the FEA.
The signed “Employment Agreement” has been submitted to the FEA.
The signed “Medicaid-Support Broker Agreement” has been submitted to the FEA.
Medicaid funding can only pay for services that are provided. Under the provision of this
agreement, the employee cannot bill for holiday, vacation, or sick time taken. Overtime hours
are not allowed.
The provisions of this agreement represent the entirety of the agreement between the parties. It
may be amended only in writing with both parties consenting with their signatures. It is
mutually understood that this is employment at will. Either party can terminate the relationship
without cause with 30 days notice. This agreement can be terminated immediately at any time
by the participant due to unsatisfactory support broker performance.
Participant Signature
Date
Legal Guardian Signature (if applicable) Date
Support Broker Signature Date
Revised 11/09/2015 Page 1 of 1
00869
MEDICAID-SUPPORT BROKER AGREEMENT
This agreement is hereby made between the Family-Directed Community Supports Option,
a Medicaid Option administered by the Department of Health and Welfare (the
Department), and ___________________________________, a Support Broker.
The Support Broker acknowledges that even though he/she is the employee of a
participant in the Family-Directed Community Supports Option, the Department, through
the Fiscal Employer Agent, is the source of payment for the Support Broker’s wages for
services performed under the Family-Directed Community Supports Option. Because of
the unique relationships of the participant, the Department, and the Fiscal Employer Agent,
the Support Broker acknowledges and agrees to the following:
1. That the Support Broker is a provider under the Idaho Medicaid Family-Directed
Community Supports Option.
2. To promptly notify the Fiscal Employer Agent, of any change of address or other
Support Broker contact information.
3. To accept, as payment in full for all Family-Directed Community Supports services,
payments made by the Fiscal Employer Agent, and will make no additional charge except
as allowed by the Medicaid Option.
4. To provide all Support Broker services according to the Participant-Support Broker
Employment Agreement and all duties and responsibilities in accordance with the rules
pertaining to the Support Broker contained in Idaho Administrative Procedures Act
(IDAPA) 16.03.13, “Consumer-Directed Services.”
5. To protect the confidentiality of personal and health information relating to the
participant and his participation in the Medicaid Family-Directed Community Services
Option, and to release that information only on request of the participant or as otherwise
allowed by law.
6. The Support Broker acknowledges that they are an employee of the participant and not
an employee of the Department or the Fiscal Employer Agent, and agrees that the Support
Broker is not entitled to, nor will make claim for, any employee benefits from the
Department or the Fiscal Employer Agent, including worker’s compensation, disability, life
and/or health insurance.
The provisions of this agreement represent the entirety of the agreement between the
parties. It may be amended only in writing with all parties consenting by their signature.
Support Broker Signature Date
The information provided in this document is for informational purposes only and not for the purpose of
providing legal, accounting, or tax advice. The information and services ADP provides should not be
deemed a substitute for the advice of any such professional. Such information is by nature subject to
revision and may not be the most current information available. ADP, the ADP logo and Always
Designing for People trademarks of ADP, Inc. Copyright © 2020 ADP, Inc. adp.com
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CDID FDS SB Employee Packet Simplex 20210412

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Completed 26 August 2021

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