common law employer (cle) enrollment packet · 2016. 11. 14. · cle training schedule odp payment...

Public Partnerships, LLC

PA ODP Program

7776 S Pointe Pkwy W, Suite 150

Phoenix, AZ 85044

Phone: 1-877-634-6805

TTY: 1-800-360-5899

Paperwork Fax: 1-855-405-7037

Paperwork E-mail: [email protected]

Website: www.publicpartnerships.com

Common Law Employer (CLE)

Enrollment Packet

Dear Participant/Common Law Employer:

Thank you for supporting self-direction in Pennsylvania.

You have received this packet because you or someone you care for is opting to self-direct their

services through the Office of Developmental Programs Vendor/Fiscal Employer Agent Financial

Management Services (VF/EA FMS) model. By completing the enclosed forms, YOU will

become the COMMON LAW EMPLOYER (CLE) and have the responsibility and authority to hire

Support Service Workers (SSW) to perform the services listed in the Participant’s Individual

Support Plan (ISP).

Public Partnerships, LLC (PPL) is the VF/EA that will support you by registering you as a common

law employer in Pennsylvania and enrolling your qualified Support Service Worker(s). Once

enrolled, PPL will begin making payments on your behalf, assume responsibility for managing

tax withholding and filings, and sending monthly statements that summarize service spending.

This packet contains all Required Common Law Employer enrollment paperwork, Instructions on

how to complete each required form, and Information that you should keep for your record.

See the Enrollment Packet Checklist on the next page for a list of enclosed forms. If you require

program materials in alternate print format (for example, Braille or large print) please contact

our Customer Service Center.

PPL and ODP are committed to providing you as much support as possible; however, we must

adhere to federal and state employment tax laws. Therefore, all Common Law Employer and

Support Service Worker documentation must be signed and returned to PPL before payments

are issued to your SSW(s).

We understand that these forms can be complicated, so please call us

toll-free at 1-877-634-6805 or e-mail us at [email protected].

Common Law Employer

Enrollment Packet Checklist

SETTING UP you up as a Common Law Employer

Please complete and submit the following forms to PPL immediately:

�� Common Law Employer Designation

�� Common Law Employer Agreement

�� IRS Form SS-4

�� IRS Form 2678

�� IRS Form 8821

�� Participant Directed Services Back-up Plan

�� Acknowledgement of Employer Skills Training

INFORMATION and INSTRUCTIONS for Common Law Employers:

Please keep the following information for your records:

�� Good to Serve Process

�� CLE Training Schedule

�� ODP Payment Schedule

�� Timesheet & Instructions

�� PPL Customer Service Quick Facts

�� Instructions for Common Law Employer Designation

�� Instructions for Common Law Employer Agreement

�� Instructions for IRS Form SS-4

�� Instructions for IRS Form 2678

�� Instructions for IRS Form 8821

�� Instructions Participant Directed Services Back-up Plan

�� Instructions Acknowledgement of Employer Skills Training

All required forms must be signed and returned to PPL

If you have any questions, please call PPL at 1-877-634-6805 or e-mail us at [email protected].

WHERE TO SEND FORMS:

FAX TO:

1-855-405-7037

E-MAIL TO:

MAIL TO:

[email protected]


PA ODP Program


Phoenix, AZ 85044

Common Law Employer InformationInformationInformationInformation

The Common Law Employer should read these and keep them for their

records.

Good to Serve Process

CLE Training Schedule

ODP Payment Schedule

Timesheet & Instructions

PPL Customer Service Quick Facts

Good to Serve Process Pennsylvania’s ODP VF/EA FMS Model

Su

pp

or

ts C

oo

rd

ina

tor

Pu

bli

c P

ar

tne

rs

hip

s

(PP

L)

Co

mm

on

La

w E

mp

loy

er

Su

pp

or

t S

er

vic

e

Wo

rk

er

SC meets with the Participant to discuss the Service model. If the Participant is interested, a New Participant Referral Form is forwarded to Public Partnerships, LLC (PPL).

PPL mails a Common Law Employer Packet and Support Service Worker (SSW) Packet to the CLE’s mailing address.

The Common Law Employer completes the CLE Enrollment Packet and

returns it to PPL.

The Support Service Worker completes the SSW Enrollment Packet and

returns it to PPL.

PPL reviews and processes CLE and SSW Enrollment Packets.

If there are errors with paperwork, PPL contacts the

Common Law Employer.

When the packets are complete, PPL sends a Good to Serve notification to the CLE and the Participant’s Administrative Entity.

Upon receiving the Good to Serve notification, the CLE may begin scheduling the

SSW to perform services.


PA ODP Program


Phoenix, AZ 85044

CLE Training Schedule

Fiscal Year 2015 – 2016

Public Partnerships, LLC (PPL) offers training the second and fourth Tuesday of each month. In general,

the trainings provide an in-depth review of the ODP VF/EA Employer Handbook; with topics including:

the role of the Common Law Employer, the role of Public Partnerships, important program rules, hiring

and supervising SSWs, and managing the Participant’s services.

Trainings begin at 6:00 PM EST

July 14, 2015 January 12, 2016

July 28, 2015 January 26, 2016

August 11, 2015 February 9, 2016

August 25, 2015 February 23, 2016

September 8, 2015 March 8, 2016

September 22, 2015 March 22, 2016

October 13, 2015 April 12, 2016

October 27, 2015 April 26, 2016

November 10, 2015 May 10, 2016

November 24, 2015 May 24, 2016

December 8, 2015 June 14, 2016

December 22, 2015 June 28, 2016

To join a training, call into the toll free conference line: 1.888.866.0650

Enter Access Code: 98449164#

**If you are unable to attend a Tuesday evening session, please call or e-mail us and we can set up a

time to talk.**

Please call us at 1-877-634-6805 or e-mail us at [email protected] if you have

any questions.


PA ODP Program


Phoenix, AZ 85044

ODP Payment Schedule

Fiscal Year 2015 – 2016

Pay Period Timesheets Received

by:

Payroll Date

Start Date: Sunday End Date: Saturday Deadline: Tuesday Payroll: Friday

June 28, 2015 July 11, 2015 July 14, 2015 July 24, 2015

July 12, 2015 July 25, 2015 July 28, 2015 August 7, 2015

July 26, 2015 August 8, 2015 August 11, 2015 August 21, 2015

August 9, 2015 August 22, 2015 August 25, 2015 September 4, 2015

August 23, 2015 September 5, 2015 September 8, 2015 September 18, 2015

September 6, 2015 September 19, 2015 September 22, 2015 October 2, 2015

September 20, 2015 October 3, 2015 October 6, 2015 October 16, 2015

October 4, 2015 October 17, 2015 October 20, 2015 October 30, 2015

October 18, 2015 October 31, 2015 November 3, 2015 November 13, 2015

November 1, 2015 November 14, 2015 November 17, 2015 November 27, 2015

November 15, 2015 November 28, 2015 December 1, 2015 December 11, 2015

November 29, 2015 December 12, 2015 December 15, 2015 December 24, 2015

December 13, 2015 December 26, 2015 December 29, 2015 January 8, 2016

December 27, 2015 January 9, 2016 January 12, 2016 January 22, 2016

January 10, 2016 January 23, 2016 January 26, 2016 February 5, 2016

January 24, 2016 February 6, 2016 February 9, 2016 February 19, 2016

February 7, 2016 February 20, 2016 February 23, 2016 March 4, 2016

February 21, 2016 March 5, 2016 March 8, 2016 March 18, 2016

March 6, 2016 March 19, 2016 March 22, 2016 April 1, 2016

March 20, 2016 April 2, 2016 April 5, 2016 April 15, 2016

April 3, 2016 April 16, 2016 April 19, 2016 April 29, 2016

April 17, 2016 April 30, 2016 May 3, 2016 May 13, 2016

May 1, 2016 May 14, 2016 May 17, 2016 May 27, 2016

May 15, 2016 May 28, 2016 May 31, 2016 June 10, 2016

May 29, 2016 June 11, 2016 June 14, 2016 June 24, 2016

June 12, 2016 June 25, 2016 June 28, 2016 July 8, 2016

**Timesheets submitted after the Tuesday deadline will be paid on the Payroll Date of the next pay period**

2015 – 2016 Federal Holidays

• Friday July 3rd: Independence Day

• Monday September 7th: Labor Day

• Monday October 12th: Columbus Day

• Tuesday November 11th: Veterans Day

• Thursday November 26th: Thanksgiving Day

• Friday December 25th: Christmas Day

• Friday January 1st: New Year’s Day

• Monday January 18th: Martin Luther King, Jr. Day

• Monday February 15th: Presidents Day

• Monday May 30th: Memorial Day


PA ODP Program


Phoenix, AZ 85044

Page 1 of 4

PPL Web Portal Registration Instructions

How do I register online? This document will outline how to set up your Username and Password so

that you may begin using the PPL Web Portal to create timesheets and track payments. The process for

online registration is the same for both Participants/CLEs and Support Service Workers.

1. The first thing you should do is type in the web address provided below into your browser: (we

recommend saving this as a favorite¸ so that you don’t have to keep typing it in).

https://fms.publicpartnerships.com

2. A log in screen will appear. You will use this screen to log into the PPL Web Portal after you have

registered.

3. Click on the Sign Up hyperlink to the right of the Login button.

4. This will bring you to the New User Registration screen. It will ask you to choose your state.

of 4

5. Select PENNSYLVANIA from the drop down list.

6. After you select your state, two new data fields will appear: Program and Role. Select your

Program – PA DPW ODP.

7. Next, select your Role.

� If you are the Participant/Common Law Employer, select Participant.

� If you are the SSW, select Support Service Worker.

8. After you have selected your Role, click the NEXT button to continue on to registration.

of 4

9. You will be brought to the Step 2: Enter Credentials screen. You are now required to verify who

you are by completing the following three fields:

� PPL ID: This number has been generated by PPL and is unique to each Participant or

Support Service Worker in the program.

� Last Name: This is the Participant’s or Support Service Worker’s last name.

� D.O.B.: This is the Participant’s Date of Birth, which we have on file in our system already.

� PLEASE NOTE: Support Service Workers will be asked to enter their Social Security

Number instead of their Date of Birth. Again, we have this information already in

our system and this is used for identity verification.

10. Enter your information into the blanks and then click on NEXT.

� If the system is unable to verify your information, then the Participant’s or SSW’s

information may have been inaccurately entered at the time of enrollment. In order to

resolve this, call the PPL Customer Service Center and provide the Participant/SSW ID so

that we may verify the demographic information on file.

11. You will now be brought to the Step 3: User Information page. This is the page in which you will

actually register yourself as a user in the system.

of 4

12. You will be asked to enter the following information:

� Username: PPL suggests that you use the first letter of your first name and your last name.

Example: Chrissy Raftery = CRaftery

NOTE: If the username you select is already in use, you will need to choose a different

username.

� Password: Your password must be at least 6 characters long and contain at least 1

numerical character, 1 capitalized character, and 1 lower case character. Please be aware

that your password will be case sensitive.

� Confirm Password: Here, you need to retype the password you just created.

� E-mail Address: Your e-mail address is an optional field. PPL will use this e-mail address

to send information pertaining to your timesheets. PLEASE NOTE: If you provide an e-mail

address you will receive an e-mail confirmation of your username and password.

� Security Questions: You should choose three questions from the down menus. Put the

answers to these questions in the data fields next to the corresponding questions.

� If you ever need to change your username or password, these questions provide a

layer of security to protect your privacy.

13. If you are happy with all of your information hit the SUBMIT button.

Congratulations!

You are now registered and ready to log into the PPL Web Portal!


PA ODP Program


Phoenix, AZ 85044

Page 1 of 7

PPL E-Timesheet Instructions

Submitting timesheets electronically through the PPL Web Portal is the most effective way to log your

time. When a timesheet is submitted, all validations occur within seconds and the SSW receives an

immediate confirmation of timesheet acceptance or notification of any errors preventing submission.

Support Service Worker: How to Create and Submit an E-timesheet

1. Log into the PPL Web Portal using your username and password:

https://fms.publicpartnerships.com./

2. You will default onto the “Timesheet List” page. Click on “Support Service Worker View

Timesheet” in the Dark Green banner and you will see the “Create Timesheet” and “Search

Timesheet” options appear.

3. Select the option for “Create Timesheet,” by clicking on the words. You will be directed to the

“Participant Search” page. From here you will see a list of all the participants you work for:

4. Click on “Create Timesheet” next to the Participant you would like to submit time for.

of 7

5. You will be prompted to enter a Pay Period. The easiest way to do this is to click on the calendar

icon next to the empty box and choosing the date from the calendar that corresponds to the first

day worked that you would like to submit.

6. After selecting your pay period, you will be taken to the screen below. From here you will enter the

time you worked for the pay period.

7. Choose a day of the week that you worked, and enter a service for that day by clicking in the “Service”

drop down menu. You must pick a service for every day you worked; if you forget, the system will

notify you when you try to submit the timesheet.

of 7

8. Next, enter the Hours and Minutes you worked on that date.

� To select the time of day you started, click on the “Time In” dropdown.

� To select the time of day you ended click on the “Time Out” dropdown.

9. If you worked multiple shifts in one day select the “There are more hours” button and a new line

will appear.

10. When you have finished entering all of the days you worked in the pay period, scroll to the bottom

of the page and click on the “Next” button.

11. You will be taken to the “Confirm Timesheet” page. On this page you should review the timesheet

you entered for completeness and accuracy.

of 7

12. If the timesheet has an error you may scroll to the bottom of the page and click on the “Edit” button

to make the necessary changes.

13. After verifying that the timesheet is accurate, click on the checkbox next to the attestation

statement, acknowledging that the timesheet is accurate and truthful; the “Submit” button will

become available to select.

14. From here you have two options:

� You may click on the “Save My Work” button and save the timesheet, so that you may enter

time later in the work week; or

� You may click on the “Submit” button and submit it to the Common Law Employer for

approval.

15. After you have selected the “Submit” button, you will be directed to a confirmation page letting you

know that your timesheet has been updated and submitted for approval.

of 7

16. If there is a problem with your timesheet that would cause it to not be paid, then the PPL Web

Portal will not allow the timesheet to be submitted for approval until the problem is fixed. You may

contact our Customer Service Center if you have a question about a specific pend message.

Examples:

� Overlapping time

� Missing paperwork

� Missing SSW Rate

17. Once you have successfully submitted your timesheet for approval, it will be up to the Common Law

Employer to approve the timesheet. You may monitor the approval status by searching your

timesheets and reviewing the “Status.”

� When approved, the status will update from “Submitted” to “Approved.”

� Do not assume that if you submitted your timesheet it will be paid. Monitor the status of

your timesheet and/or remind your Common Law Employer to approve your timesheets in a

timely manner.

� Once in an “Approved” status, it will be sent to PPL for payment in the next pay cycle.

Common Law Employer: How to Approve/Reject an E-timesheet

1. Log into the PPL Web Portal using your username and password:

https://fms.publicpartnerships.com

2. You will default onto the “Timesheet List” page.

� Near the bottom of the page, the Common Law Employer will see action items assigned to

them, including any Submitted timesheets.

3. Click on the “Approve/Reject” button next to the timesheet you want to view.

of 7

4. A summary of the timesheet will be displayed. Review this for accuracy and completeness.

5. At the bottom of the page you will see the option to “Show printable version (PDF).” This button

allows you to print the timesheet so that you may keep a hardcopy for your records. You do not

need to print the timesheet if you don’t want to. Timesheets will always be maintained electronically

for your review.

6. If the Common Law Employer determines that that the timesheet is accurate, they may click on the

“Approve” button. They will be sent to a confirmation page, displaying that the timesheet is now

approved.

� Remember, PPL will not pay for timesheets that are not approved

� By approving the timesheet, it is automatically entered into the PPL Payroll system for

payment.

� When the timesheet status shows “PAID,” it means PPL has cut a check or processed a

direct deposit for that timesheet.

of 7

7. If the Common Law Employer determines that the timesheet is not correct, they can choose to

reject the timesheet.

� When a timesheet is rejected it is sent back to the Support Service Worker for correction

and review. The Support Service Worker will see the reasons entered for rejection and will

need to correct the timesheet.


PA ODP Program


Phoenix, AZ 85044

Page 1 of 4

PPL Paper Timesheet Instructions

PPL accepts paper timesheets by fax or mail. Timesheets are read by a machine (like the ones that read

standardized tests), so it is important that you fill out these timesheets clearly and completely.

Required Fields

All of these fields MUST be completed for the timesheet to be paid. This list corresponds to the

timesheet image above.

A. Participant Name: This is the name of the Participant receiving services. Please print the

Participant’s name clearly on the line.

B. Participant ID: This ID is generated by PPL and will start with the letter “C.”

C. Support Service Worker Name: This is the name of the Support Service Worker who is

providing services to the Participant for days worked on this timesheet.

D. Support Service Worker ID: This ID is generated by PPL and will start with the letter “E.”

of 4

E. Service Type: Enter the approved procedure code/service based on the Participant’s

Individual Support Plan (ISP). The PPL timesheet is single service; which means, if the Support

Service Worker provides multiple types of service, they will need to submit a separate timesheet

for each service.

F. Week 1 Begin Date: This is the first day of the pay period. Your pay schedule will list these

dates for you. Please enter the first day of the pay period on this line (even if you don’t start

work on this date).

G. Week 2 End Date: This is the last day of the pay period. Your pay schedule will list these dates

for you. Please enter the last day of the pay period on this line (even if your last date worked for

the pay period was before this date).

H. Time In: Enter the time the Support Service Worker started working.

I. Time Out: Enter the time the Support Service Worker finished working.

J. AM/PM: Fill in the circle indicating if the Support Service Worker worked in the AM or PM.

K. Date of Support Service Worker Signature: This should be the date that the Support

Service Worker reviewed and signed the timesheet.

L. Support Service Worker Signature: Signature of the Support Service Worker who provided

service on the dates worked.

M. Date of Common Law Employer Signature: This should be the date that the Common Law

Employer reviewed and signed the timesheet.

N. Common Law Employer Signature: Signature of the Common Law Employer who reviewed

and approved the timesheet.

Special Situations

1. Working overnight: When you work overnight, you must complete one line for work you did before

midnight and another line for work you did after midnight.

For example, say you worked overnight Friday night from 9:00 PM to 6:00 AM. Enter the start time

as 9:00 PM, as seen below. Enter the end time for that day as 11:59 PM. Now, you did not finish

working at 11:59 PM, you just finished working on Friday at that time. Enter the rest of your time on

Saturday, as seen below, from 12:00 AM to 6:00 AM.

2. Many SSWs work with someone multiple times in a day. You can enter two different in and out

times on one timesheet, but you must enter each on a separate line. If you need to enter more than

two in and out times for the same day, you will need to move onto a second timesheet for the same

pay period.

of 4

For example, say you started working for Chrissy at 9:00 AM. You helped her until 10:05 AM. You

left to run an errand, came back at 11:15 AM, and stayed until 12:30 PM. You would enter one line

for each time you were providing services as shown below.

General Suggestions

• Time worked for 24-Hour Respite may only be entered on paper timesheets.

• Fill in the timesheet clearly. Your Common Law Employer will need to be able to read the

timesheet clearly or your payment may be delayed.

• Fill in all the required fields. You will not be paid unless all of the fields are filled in.

• Use dark ink.

• Use separate timesheets for different Participants.

• Do not round time. Write the Exact time. Our systems will round your time for you.

• If you make a mistake, use a new timesheet; do not use Whiteout.

24-Hour Respite: How to Create and Submit Timesheets

When a Support Service Worker works a 24-Hour Respite shift, there are special instructions for

completing the timesheet.

� 24-Hour Respite may only be submitted on paper timesheets, at this time.

� The SSW should complete one line for their entire shift, even if it goes overnight or crosses over

to a new pay period.

� 24-Hour Respite shifts must be between 16.25 hours and 24.00 hours in length; no more and no

less.

It is very important that each unit of 24 hour respite you want paid be entered on its own unique line.

Typical Overnight Shift

If the SSW works a 24-Hour Respite shift that begins 7:00 PM Monday night, and finishes at 7:00 PM

Tuesday night, then time would be entered as seen below. Remember, 24-Hour Respite shifts must be

between 16.25 hour and 24.00 hours in length.

of 4

Overnight Shift that Crosses Pay Periods

If a shift begins on the last Saturday of a pay period, and ends on the beginning Sunday of the next pay

period, then you should include the entire shift on the line for the Saturday it begins on.

For example, if the SSW begins working on the last Saturday of the pay period at 10:00 AM and finishes

his/her shift at 10:00 AM Sunday morning, then the timesheet would include the entire shift in one line,

on Saturday, for a total of 24.00 hours.

Obtaining Timesheets

You can download copies of the timesheets online at www.publicpartnerships.com. Click on “Who We

Serve,” select Pennsylvania from the map of the United States, and click on the PA ODP Program; a link

for Timesheets is beneath the “Program Materials” header.

Where to Send Timesheets

Fax to: 1.855.838.6850 Mail to:


PA ODP Program


Phoenix, AZ 85044

Questions? We’re here to help. Call our Customer Service Center at 1-877-634-6805.

#CNSMRServed

#CNSMRServed

Support Service Worker Signature:Date (mm/dd/yyyy):

/ / 2 0

Begin: Sunday (mm/dd/yyyy) / / 2 0

:

Week 1

Fri

Sun

Moni

Tue

Wed

Thu

Sat:

::::::::::::

End: Saturday (mm/dd/yyyy) / / 2 0Week 2

Fri

Sun

Mon

Tue

Wed

Thu

Sat

Common Law Employer Signature:Date (mm/dd/yyyy):

/ / 2 0

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM AM PM AM PM AM PM

Participant ID:

C

Support Service Worker ID:

EParticipant: (Last Name, First Name)

Support Service Worker: (Last Name, First Name)

FAX to 1-855-838-6850

* USE BLACK INK, PRINT ONE CHARACTERPER BOX, TRY NOT TO TOUCH THE LINES!!!

By signing below, I certify that I have provided the services to the participant during thetimes described on this timesheet.

By signing below, I certify that the participant has received the hours of service asreported above.

CORRECTINCORRECT

Sub-Total HoursTime Out AM/PMTime In AM/PM Sub-Total HoursTime Out AM/PMAM/PMTime In

Total Hours for Week 1: : Total Hours for Week 2: :

::::::::::::::

::::::::::::::

::::::::::::::

::::::::::::::

::::::::::::::

* SUBMIT YOUR TIMESHEET ONLINE! GO TOHTTP://FMS.PUBLICPARTNERSHIPS.COM FOR FAST, SECURE, REAL-TIMEVALIDATION

Service Code:

W -PUBLIC PARTNERSHIPS, LLC SUPPORT SERVICE WORKER TIMESHEET (Financial Management Services PA DPW ODP)

2200

7

2200

7


PA ODP Program


Phoenix, AZ 85044

PPL Customer Service Quick Facts

Our Customer Service Center can help with questions about enrollment, timesheets, and many other

topics concerning the Pennsylvania ODP Participant Directed Model of Service.

How to Contact Us

Telephone:

E-mail:

TTY:

1-877-634-6805

[email protected]

1-800-360-5899

Timesheet Fax:

Paperwork Fax:

Paperwork E-mail:

1-855-838-6850

1-855-405-7037

[email protected]

Hours of Operation

Monday – Friday:

Saturday:

8:00 AM to 8:00 PM

9:00 AM to 1:00 PM

Busy, or on the go?

E-mail us at [email protected]. Our customer service team will quickly respond to your e-mail and

you may read our reply when it’s convenient for you.

Need Timesheets, Mileage Logs, or Enrollment Forms?

Visit our website at www.publicpartnerships.com. You can access forms by selecting “Who We Serve,”

selecting Pennsylvania from the map of the United States, and then choosing the PA ODP program.

Want to check the status of your timesheet?

We have two great and easy-to-use options available to you:

� Visit the PPL Web Portal at https://fms.publicpartnerships.com. It’s an excellent tool to check

the status of your timesheet, get a real-time report on the balance of service authorizations, and

to view and re-print pay stubs.

� Call our Automated Timesheet Reporting system:

1. Dial 1-877-634-6805

2. Press 1 for English or Press 2 for Spanish

3. Press 1 to check the Status of a Timesheet

4. Press 1 if you’re a SSW or Press 2 if you’re a Common Law Employer

5. You’ll be prompted to enter your ten (10) digit phone number and the last four (4) digits

of your social security number.

Please call us at 1-877-634-6805 or e-mail us at [email protected] if you have

any questions.

Common Law Employer RequiredRequiredRequiredRequired Forms

Please complete these required forms and return them to PPL as soon as

possible. Refer to the InstructionInstructionInstructionInstructions for help with these forms.

Common Law Employer Designation

Common Law Employer Agreement

IRS Form SS-4

IRS Form 2678

IRS Form 8821

PDS Back-up Plan

Acknowledgement of Employer Skills Training


Designation

Common Law Employer Designation Page 1 of 2

In the VF/EA FMS model, the Participant can serve as their own Common Law Employer (CLE), or may

designate a surrogate to serve in this role. The Participant and/or their legal agent and the surrogate, if

applicable, should complete this form, understand their responsibilities, and sign and date the second

page.

Participant’s Name:

Common Law Employer’s Name:

Address:

Address 2:

City: State: Zip Code:

Phone: E-mail:

Common Law Employer Designation:

is designated to serve as the Common Law Employer

Name of Common Law Employer

for in the VF/EA FMS model.

Name of Participant

Common Law Employer’s Relationship to the Participant: (Check one box)

� Self (Participant)

� Spouse of Participant

� Parent of Participant � Sibling of Participant

� Child of Participant � Friend of the Participant

� Other (Please Specify): __________________


Designation

Common Law Employer Designation Page 2 of 2

CLE Responsibilities and Attestation:

I understand and agree with my role as a Common Law Employer. I understand that my appointment as

Common Law Employer may be revoked at any time by the Participant, myself, or the Office of

Developmental Programs (ODP).

I understand as a Common Law Employer, I cannot receive payment for performing the Common Law

Employer role. I also cannot receive payment for any services funded through the Consolidated or

Person/Family Directed Support (P/FDS) Waivers that I provide to the Participant with the exception of

Transportation Mile reimbursement.

I understand that PDS must be provided in accordance with the authorized Individual Support Plan (ISP).

As a surrogate, I agree that I will make decisions regarding PDS services on the Participant’s behalf.

Once appointed to be the Common Law Employer, I am responsible to do the following:

• Maintain compliance with federal and state regulations, ODP policy bulletins and the approved

waivers noted above, as applicable.

• As much as possible, make the decisions the Participant would make if the Participant made the

decisions.

• Accommodate the Participant, to the extent necessary, so that the Participant is included to the

extent possible in all decisions that affect the Participant.

• Give due consideration to all information including the recommendations of other interested

and involved parties.

I understand and agree with my responsibilities as the Common Law Employer. I understand and agree

with my responsibilities as they relate to participating in the PDS program and enrolling with Public

Partnerships, LLC. If I am a surrogate, I understand and agree with my responsibilities and will act on

behalf of the Participant who designated me as the Common Law Employer.

Signatures:

Participant’s Name

Participant’s or Participant’s Legal Guardian/Power of Attorney Signature Date

Common Law Employer’s Name

Common Law Employer’s Signature Date


Agreement

Common Law Employer Agreement V1.0 Page 1 of 4

I understand that participating in the VF/EA FMS model means that the Common Law Employer (CLE)

has the ability to exercise decision-making authority over some or all of the services and supports as

authorized in the Individual Service Plan (ISP). The CLE accepts the responsibility for managing the PDS

services and supports and is, therefore, recognized as the legal employer of the qualified Support

Service Worker(s) (SSW) hired to provide the Participant – Directed Services (PDS).

PARTICIPANT’S INFORMATION

First Name: Last Name:

Address:

Address 2:

City:

State: Zip Code:

COMMON LAW EMPLOYER’S INFORMATION

First Name Last Name:

Address:

Address 2:

City:

State: Zip Code:

Common Law Employer Requirements

The Participant or surrogate, when appointed by the Participant, must meet the following criteria in

order to be the Common Law Employer:

• Be at least 18 years of age or older.

• Must attest in writing that they have no convictions reported as per the Older Adult Protective

Services Act (OAPSA) [35 P.S. §10225.101 et. seq. and 6 PA. Code Chapter 15], and when service

a child under 18, conduct child abuse clearances as per the Child Protective Services Law (CPSL)

[23 Pa. C.S. Chapter 63].

• Be a resident of Pennsylvania for two (2) calendar years immediately preceding the date of

request to become a Common Law Employer.


Agreement


o If the Common Law Employer has not been a Pennsylvania resident for the previous two

(2) years or is not currently a resident, the Common Law Employer must attest in writing

that they have no convictions reported in the Federal Criminal History Record from the

Federal Bureau of Investigation (FBI), in addition to the Criminal History Record from the

State Police.

• Participates in required training sponsored by ODP and Public Partnerships, LLC.

• Enters into and maintain compliance with all agreements related to the VF/EA FMS model.

• Agrees to perform all the tasks outlined in the Responsibilities Section.

• Agrees to work with the Supports Coordinator (SC) to develop and revise the Participant’s ISP as

needed and required.

• Agrees to participate in SC monitorings at the required frequency and location outlined in the

approved Waivers.

• Agrees to work with the Supports Broker when the Supports Broker service has been authorized

on the Participant’s ISP.

Common Law Employer (CLE) Responsibilities

1. Enroll with Public Partnerships, LLC and complete the required documents.

2. Agree to manage the authorized participant-directed service in accordance with the Common

Law Employer Agreement.

3. Recruit, interview, and hire qualified SSWs.

4. Verify qualifications of SSWs and vendors prior to the person or entity rendering a waiver-

funded participant-directed service.

5. Complete and submit required qualified SSW documents to Public Partnerships, LLC for

processing.

6. Maintain an employment/qualification file on each qualified SSW and qualified vendor.

7. Verify ongoing qualifications for the SSWs, both regularly scheduled and emergency back-up

SSWs, as needed per ODP Waiver requirements and timelines established in the approved

Waiver.

8. Once the SSW is qualified, the CLE and the qualified SSW must sign the Support Service Worker

(SSW) Agreement form and submit it to Public Partnerships, LLC.

9. Update any changes in qualified SSW information and submit the required information to the

Public Partnerships, LLC.

10. Negotiate the wage and optional benefit allowance for qualified SSWs within the ODP

established wage ranges and complete and sign the Support Service Worker Rate Sheet, and

submit the rate sheet to the SC for processing.

11. Negotiate and explain to a qualified vendor that the vendor will be reimbursed at the cost of the

goods charged to the general public and in accordance with the authorized ISP.

12. Obtain bids or estimates and secure qualified vendors.

13. Explain to individuals providing mileage that mileage is a vendor payment for an SSW or a non-

SSW and is paid at the mileage reimbursement rate established by ODP in accordance with the

approved Waiver.


Agreement


14. Sign the Request for Vendor Payment Form, when appropriate to do so.

15. Develop and implement emergency back-up plans which include qualified SSWs or natural

supports to cover the hours when a regularly scheduled qualified SSW does not report to work.

16. Determine the work schedule of qualified SSWs up to a maximum of 40 hours per week based

on the services authorized in the ISP.

17. Schedule SSW’s work schedule to ensure required and authorized services are provided and

overtime will not occur.

18. Determine the tasks/activities the qualified SSW or natural support person will perform

including how and when to perform service-related tasks/activities, in accordance with the

authorized ISP and ODP service definitions.

19. Orient and train qualified SSWs as per the qualification criteria and service definition

requirements included in the approved Waivers and ISP.

20. Ensure that the ODP Progress Notes form is completed by you, qualified SSWs or vendors, and

that the form documents that all services delivered support the ISP outcomes.

21. Review, approve, and sign the qualified SSW timesheets and vendor invoices and submit them

to Public Partnerships, LLC for processing in accordance with its payment cycle or schedule and

in accordance with PA Department of Labor & Industry standards.

22. Provide supervision to all qualified SSWs and emergency back-up SSWs, natural supports

person, and vendors.

23. Terminate qualified SSWs for just cause and notify Public Partnerships, LLC of the dismissal of

qualified SSWs.

24. Track utilization of authorized services and associated funds to ensure qualified SSWs and

vendors provide participant-directed services in accordance with the authorized ISP.

25. Notify and discuss with the SC any changes in a Participant’s need that may require a team

meeting and/or revision to the ISP.

26. Notify the SC and the VF/EA FMS organization when the CLE suspects or is aware of issues of

Medicaid fraud or financial abuse related to the delivery of the Participant’s PDS.

27. In accordance with ODP policy on reportable incidents, report any reportable incidents to the

SC.

28. Respond to surveys regarding the Participant’s or surrogate’s satisfaction with the VF/EA FMS

organization.

29. Participate in required orientation and trainings offered by Public Partnerships, LLC or ODP

related to the VF/EA FMS model.

30. Enter into and maintain compliance with all standard agreements with the Public Partnerships,

LLC and ODP.

31. Prepare and report on ISP outcomes and progress achieved during ISP meetings.

32. Participant in remediation, training, and termination processes as established and directed by

ODP.


Agreement


Attestation

By signing below, I attest that I have read this Common Law Employer Agreement in its entirety. As a

condition of enrolling and participating in the VF/EA FMS model, I understand that I must complete,

sign, and return this form to Public Partnerships, LLC who is under contract with the Office of

Developmental Programs (ODP). I attest that I understand my responsibilities as a Common Law

Employer (CLE) and agree to abide by the CLE terms and conditions. I further understand and agree that

violation of any of the terms and/or conditions of this agreement may result in corrective action

including termination of this agreement.

Common Law Employer Name:

Common Law Employer Signature: Date:

Application for Employer Identification Number Form SS-4 EIN

(Rev. January 2010) (For use by employers, corporations, partnerships, trusts, estates, churches,government agencies, Indian tribal entities, certain individuals, and others.)

OMB No. 1545-0003

Department of the TreasuryInternal Revenue Service

Legal name of entity (or individual) for whom the EIN is being requested

1

Executor, administrator, trustee, “care of” name

3

Trade name of business (if different from name on line 1)

2

Mailing address (room, apt., suite no. and street, or P.O. box)

4a

Street address (if different) (Do not enter a P.O. box.)

5a

City, state, and ZIP code (if foreign, see instructions)

4b

City, state, and ZIP code (if foreign, see instructions)

5b

County and state where principal business is located

6

Name of responsible party

7a

Estate (SSN of decedent)

Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.

9a

Partnership

Plan administrator (TIN)

Sole proprietor (SSN)

Farmers’ cooperative

Corporation (enter form number to be filed) ©

Personal service corporation

REMIC

Church or church-controlled organization

National Guard

Trust (TIN of grantor)

Group Exemption Number (GEN) if any ©

Other nonprofit organization (specify) ©

Other (specify) ©

9b

If a corporation, name the state or foreign country(if applicable) where incorporated

Changed type of organization (specify new type) ©

Reason for applying (check only one box)

10

Purchased going business

Started new business (specify type) ©

Hired employees (Check the box and see line 13.)

Created a trust (specify type) ©

Created a pension plan (specify type) ©

Banking purpose (specify purpose) ©

Other (specify) ©

12

11

Closing month of accounting year

Date business started or acquired (month, day, year). See instructions.

15 First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid tononresident alien (month, day, year) ©

Household

Agricultural

13 Highest number of employees expected in the next 12 months (enter -0- if none).

17 Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

18 Has the applicant entity shown on line 1 ever applied for and received an EIN? Yes No

Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.

Designee’s telephone number (include area code)

Date ©

Signature ©

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form SS-4 (Rev. 1-2010)

Typ

e o

r p

rint

cle

arly

.

Cat. No. 16055N

Foreign country

State

Designee’s fax number (include area code)

© See separate instructions for each line.

( )

( )

© Keep a copy for your records.

Compliance with IRS withholding regulations

SSN, ITIN, or EIN

7b

Other

Applicant’s telephone number (include area code)

Applicant’s fax number (include area code)

( )

( )

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

Name and title (type or print clearly) ©

ThirdPartyDesignee

Designee’s name

Address and ZIP code

Federal government/military Indian tribal governments/enterprises

State/local government

If you expect your employment tax liability to be $1,000or less in a full calendar year and want to file Form 944annually instead of Forms 941 quarterly, check here.(Your employment tax liability generally will be $1,000or less if you expect to pay $4,000 or less in totalwages.) If you do not check this box, you must fileForm 941 for every quarter.

Is this application for a limited liability company (LLC) (or a foreign equivalent)?

No

Yes

8a

If 8a is “Yes,” enter the number ofLLC members ©

8b

If 8a is “Yes,” was the LLC organized in the United States?

8c

No

Yes

14

Check one box that best describes the principal activity of your business.

16 Construction Real estate

Rental & leasing Manufacturing

Transportation & warehousing Finance & insurance

Health care & social assistance Accommodation & food service Other (specify)

Wholesale-agent/broker Wholesale-other

Retail

If “Yes,” write previous EIN here ©

If no employees expected, skip line 14.

Form 2678(Rev. October 2012)

Employer/Payer Appointment of AgentDepartment of the Treasury — Internal Revenue Service

OMB No. 1545-0748

Use this form if you want to request approval to have an agent file returns and make deposits or payments of employment or other withholding taxes or if you want to revoke an existing appointment.

• If you are an employer or payer who wants to request approval, complete Parts 1 and 2 and sign Part 2. Then give it to the agent. Have the agent complete Part 3 and sign it.

Note. This appointment is not effective until we approve your request. See the instructions for filing Form 2678 on page 3.

• If you are an employer, payer, or agent who wants to revoke an existing appointment, complete all three parts. In this case, only one signature is required.

For IRS use:

Part 1: Why you are filing this form... (Check one)

You want to appoint an agent for tax reporting, depositing, and paying. You want to revoke an existing appointment.

Part 2: Employer or Payer Information: Complete this part if you want to appoint an agent or revoke an appointment.

1 Employer identification number (EIN) —

2 Employer’s or payer’s name (not your trade name)

3 Trade name (if any)

4 Address

Number Street Suite or room number

City State ZIP code

5 Forms for which you want to appoint an agent or revoke the agent’s appointment to file. For ALL

employees/ payees

For SOME employees/

payees (Check all that apply.)

Form 940, 940-PR (Employer's Annual Federal Unemployment (FUTA) Tax Return)*Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return) Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural Employees) Form 944, 944(SP) (Employer’s ANNUAL Federal Tax Return) Form 945 (Annual Return of Withheld Federal Income Tax) Form CT-1 (Employer’s Annual Railroad Retirement Tax Return) Form CT-2 (Employee Representative's Quarterly Railroad Tax Return)

*Generally you cannot appoint an agent to report, deposit, and pay taxes reported on Form 940, Employer's Annual Federal Unemployment (FUTA) Tax Return, unless you are a home care service recipient.

Check here if you are a home care service recipient, and you want to appoint the agent to report, deposit, and pay FUTA taxes for you. See the instructions.

I am authorizing the IRS to disclose otherwise confidential tax information to the agent relating to the authority granted under this appointment, including disclosures required to process Form 2678. The agent may contract with a third party, such as a reporting agent or certified public accountant, to prepare or file the returns covered by this appointment, or to make any required deposits and payments. Such contract may authorize the IRS to disclose confidential tax information of the employer/payer and agent to such third party. If a third party fails to file the returns or make the deposits and payments, the agent and employer/payer remain liable.

✗ Sign your name here

Date / /

Print your name here

Print your title here

Best daytime phone

Now give this form to the agent to complete. ■▶

For Paperwork Reduction Act Notice, see the instructions. IRS.gov/form2678 Cat. No. 18770D Form 2678 (Rev. 10-2012)

Form 8821 (Rev. October 2012)

Department of the Treasury Internal Revenue Service

Tax Information Authorization ▶ Information about Form 8821 and its instructions is at www.irs.gov/form8821.

▶ Do not sign this form unless all applicable lines have been completed. ▶ To request a copy or transcript of your tax return, use Form 4506, 4506-T, or 4506T-EZ.

OMB No. 1545-1165

For IRS Use Only Received by:

Name

Telephone

Function

Date

1 Taxpayer information. Taxpayer must sign and date this form on line 7. Taxpayer name and address (type or print) Taxpayer identification number(s)

Daytime telephone number Plan number (if applicable)

2 Appointee. If you wish to name more than one appointee, attach a list to this form. Name and address CAF No.

PTIN Telephone No. Fax No. Check if new: Address Telephone No. Fax No.

3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information for the tax matters listed on this line. Do not use Form 8821 to request copies of tax returns.

(a) Type of Tax

(Income, Employment, Payroll, Excise, Estate, Gift, Civil Penalty, etc.) (see instructions)

(b) Tax Form Number

(1040, 941, 720, etc.)

(c) Year(s) or Period(s)

(see the instructions for line 3)

(d) Specific Tax Matters (see instr.)

4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 . . . . . . ▶

5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked): a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing

basis, check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Note. Appointees will no longer receive forms, publications and other related materials with the notices.b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . ▶

6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

To revoke this tax information authorization, see the instructions.

7 Signature of taxpayer. If signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute this form with respect to the tax matters and tax periods shown on line 3 above.

▶ IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

▶ DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

Signature Date

Print Name Title (if applicable)

PIN number for electronic signature

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 11596P Form 8821 (Rev. 10-2012)

Participant Directed Services

(PDS) Back-up Plan

PDS Back-up Plan Page 1 of 2

Participant Information:

Participant’s Name:

Common Law Employer’s Name:

Back-up Coverage Information:

Please, check one box and fill in the Back-up’s information.

� Qualified SSW � Natural Support � Traditional Provider

Back-up’s Name:

Address:

City:

State: Zip Code:

Phone Number:

Services and Availability:

Indicate the service (by code) to be covered, as well as the days and times the back-up person is

available. Service, Day, and Time must be filled out in order for this form to be marked as complete.

Service Day Time

Participant Directed Services

(PDS) Back-up Plan

PDS Back-up Plan Page 2 of 2

Back-up’s Responsibilities:

Indicate the responsibilities that the Back-up is responsible for in supporting the ISP.

Attestation:

I understand and agree with my role and responsibilities as the Back-up supports person for the

Participant in the VF/EA FMS model of Participant Directed Services (PDS). In the event a regularly

scheduled SSW is unable to provide the authorized services to the participant, I will provide the services

as the designated back-up supports coverage person as indicated on this plan. I understand that PDS

must be provided in accordance with the participant’s approved and authorized Individual Support Plan

(ISP). I also understand that my acceptance of this responsibility as a PDS back-up person may be

revoked at any time by the Participant, the Common Law Employer, or the Office of Developmental

Programs (ODP).

Back-up’s Signature: Date:

Common Law Employer’s Signature: Date:

Acknowledgement of

Employer Skills Training

Acknowledgment of Employer Skills Training Page 1 of 1

Participant Information

Participant First Name Participant Last Name

Common Law Employer Information

Common Law Employer First Name Common Law Employer Last Name

Address

Address 2

City State Zip Code Phone

Acknowledgment of Employer Skills Training

My signature below attests that I have received, reviewed, and understand the program rules and

employer responsibilities outlined in the ODP VF/EA Employer Handbook and have received employer

skills training from Public Partnerships, LLC (PPL).

Common Law Employer Name Common Law Employer Signature Date

Common Law Employer InstructionsInstructionsInstructionsInstructions

Please read through these Instructions while completing the RequiredRequiredRequiredRequired

forms.

Instructions for Common Law Employer Designation

Instructions for Common Law Employer Agreement

Instructions for IRS Form SS-4

Instructions for IRS Form 2678


Instructions for PDS Back-up Plan

Instructions for Acknowledgment of Employer Skills

Training


PA ODP Program


Phoenix, AZ 85044

Instructions for CLE Designation

Instructions for Common Law Employer Designation

What is the purpose of this form?

This form designates who will be

serving as the Common Law Employer

in the VF/EA FMS model. The

Participant may service as their own

Common Law Employer (CLE), or may

designate a surrogate to serve in this

role.

How do I complete this form?

Page One (1):

• Fill in the Participant’s name and

the Common Law Employer’s

information near the top of the

page.

• Designate the Common Law

Employer by filling in the CLE’s

name and the Participants name in

the middle of the page

• Check one box to record the

Common Law Employer’s

relationship to the Participant

(e.g., Self, Sibling, Parent, etc.).

Page Two (2):

• Read through the Responsibilities and Attestation.

• The Participant or their Legal Guardian/Power of Attorney must sign and date the bottom of the

page.

• The Common Law Employer must sign and date the bottom of the page.

Who needs to sign?

Both the Common Law Employer and Participant must sign this form. If the Participant has a Legal

Guardian or Power of Attorney, they may sign in their place.


PA ODP Program


Phoenix, AZ 85044

Instructions for CLE Agreement

Instructions for Common Law Employer Agreement


This form serves as an attestation that

the Common Law Employer

understands his/her role and

responsibilities. It is a requirement for

enrollment in the VF/EA FMS model.


Page One (1):

• Fill in the Participant’s

information.

• Fill in the Common Law

Employer’s information.

Pages Two (2) and Three (3):

• Read through the Requirements

and Responsibilities.

Page Four (4):

• The Common Law Employer prints

their name, signs, and dates the

form.

Who needs to sign?

ONLY the Common Law Employer may sign this form. If the Participant is acting as their own Common

Law Employer and requires a Guardian or Power of Attorney to sign on their behalf, then documentation

must be provided to PPL that shows proof of the Guardianship or Power of Attorney.


PA ODP Program


Phoenix, AZ 85044




This form tells the IRS that you are going

to be an employer and is used to obtain

an Employer Identification Number (EIN)

from the IRS. This EIN is used to identify

an employer when filing employment tax

returns and depositing employer

withholding taxes to the IRS.

Why isn’t my address listed on lines

4a and 4b

Lines 4a and 4b ask for the mailing

address to be attached to this employer

account. As your fiscal agent, PPL does

not burden you with IRS paperwork. By

establishing PPL’s address as the mailing

address on your employer account, PPL

ensures that you will not receive IRS

paperwork relating to this program at

your home.

What fields need completed?

PPL pre-populates this form for your

convenience. You only need to sign and

date the Signature and Date line at the bottom of the page.

Who needs to sign?





PA ODP Program


Phoenix, AZ 85044




This form lets the IRS know that you give

PPL permission to withhold taxes from

your employee’s paychecks and deposit

taxes with the IRS. With this form, you

delegate the employer tax responsibility

to PPL.

If I appoint PPL as my agent with IRS

Form 2678, what is PPL able to do?

IRS Form 2678 only allows PPL to

withhold taxes from your employee’s

paychecks and deposit those taxes to the

IRS. This form is only recognized by the

IRS; other tax agencies do not recognize

this form. The 2678 does not authorize

us to perform any other tax

responsibilities.



convenience. You only need to sign and

date the Signature and Date fields near

the bottom left of the page.

What liability does PPL take on when I sign the IRS Form 2678?

IRS Form 2678 subjects PPL to all provisions of law, including penalties that the employer incurs. When

you authorize PPL as your agent with IRS Form 2678, PPL is responsible by law for correctly representing

you. PPL incurs any penalties for misfiling your employer taxes.

Who needs to sign?





PA ODP Program


Phoenix, AZ 85044




This form allows PPL to discuss your

employer withholding account with

the IRS. It does not allow our

representatives to sign any

documents.

Will PPL be able to discuss my

personal tax account with the IRS?

NO. Public Partnerships will only be

able to discuss the employer tax forms

listed in section 3b. PPL will never be

able to be able to obtain any personal

income tax information.

I make all decisions about my life.

If I sign this form, what decisions

can PPL make for me?

This form only lets PPL talk and write

to the IRS. PPL cannot make decisions

about your personal life.



convenience. You only need to sign and date the Signature and Date fields near the bottom left of the

page.

Who needs to sign?





PA ODP Program


Phoenix, AZ 85044

Instructions for PDS Back-up Plan

Instructions for Participant Directed Service Back-up Plan


This form is used to document your

back-up strategy and ensure that the

Participant receives services in the

event of emergency or when a

qualified SSW does not show up to

provide services.

Back-up coverage can be filled by

another qualified SSW, Natural

Support, or a Traditional Provider.

The CLE and Participant should discuss

the available back-up coverage

options with the Supports Coordinator

(SC) prior to completing this form.


Page One (1):

• Fill in the Participant’s name and

Common Law Employer’s name at

the top of the page.

• Check off a box to indicate the

type of Back-up Coverage and

then fill in the Back-up Coverage’s

information.

• At the bottom of the page, fill in the

Service (H&C, Respite, Companion, etc.), Day(s) of the week available, and Time(s) available.

Page Two (2):

• Fill in the responsibilities that the Back-up is responsible for.

• Both the Back-up and the CLE sign and date the form.

Who needs to sign?

Both the individual acting as the Back-up support and the Common Law Employer must sign this form. If

the Participant is acting as their own Common Law Employer and requires a Guardian or Power of

Attorney to sign on their behalf, then documentation must be provided to PPL that shows proof of the

Guardianship or Power of Attorney.


PA ODP Program


Phoenix, AZ 85044

Instructions for Acknowledgement of Employer Skills Training

Instructions for Acknowledgement of Employer Skills Training


This form is used to document that the

Common Law Employer (CLE) has

received the ODP VF/EA Employer

Handbook and that they’ve received

employer skills training from Public

Partnerships, LLC (PPL).

Refer to the CLE Training Schedule

located in the Information section of

this packet for a schedule of over the

phone employer skills training sessions.


• Fill in the Participant’s First and

Last name at the top of the page.

• Fill in the Common Law Employer’s

information in the middle of the

page.

• The Common Law Employer prints

their name, signs, and dates the

bottom of the page.

Who needs to sign?




common law employer (cle) enrollment packet · 2016. 11. 14. · cle training schedule odp payment...

Documents