Employee packet

Fiscal Solutions

This packet contains a variety of documents for you to complete and a few helpful resources. We encourage you to keep a copy of these resources for future reference. Your employer’s Independent Support Broker (ISB) will go over the documents with you.

Please use the following tips when filling out the documents: • Only use black ink to prevent delays in the processing of your documents. • Avoid using a pencil or gel pen because your responses will be hard to read, especially if the documents are faxed or scanned. • The highlighted areas of this packet indicate where a response is required.

When all the documents are complete, please email them to Veridian Fiscal Solutions at ccoiowa@veridiancu.org.

If email is not an option for you, please submit your documents in one of the following ways:

Fax - (319) 236-6785, Attn: Consumer Choices Option

Mailing address – Veridian Fiscal SolutionsConsumer Choices Option P.O. Box 4502Waterloo, IA 50704

Instructions

470-4227 (7/07)

IOWA DEPARTMENT OF HUMAN SERVICES

REQUEST & ACKNOWLEDGEMENT TO CONDUCT REGISTRY AND RECORD CHECK I understand and acknowledge that the Iowa Department of Human Services (hereinafter “Department”) is required by

statute to conduct Child Abuse Registry, Dependent Adult Abuse Registry, Sexual Offender Registry checks and

DCI/FBI Criminal History Record checks for specific categories of persons who have direct contact with the

department's clients or provide Department approved services for the Department’s clients and herby request the

Department conduct such a Registry and Record check regarding me.

Nothing within this form shall be construed as a guarantee to have direct contact with the Department's clients or

provide Department approved services for the Department’s clients.

SEXUAL OFFENDER REGISTRY

I hereby request and give permission to the Department to conduct a Sexual Offender Registry check. I further give

permission to the Department to conduct such a registry check at any time while I have direct contact with the

department's clients or provide Department approved services for the Department’s clients.

Signature Date

CHILD ABUSE REGISTRY

I hereby request and give permission to the Department to conduct a Child Abuse Registry check. I further give

permission to the Department to conduct such a registry check at any time while I have direct contact with the

department's clients or provide Department approved services for the Department’s clients.

Signature Date

DEPENDENT ADULT ABUSE REGISTRY

I hereby request and give permission to the Department to conduct a Dependent Adult Abuse Registry. I further give

permission to the Department to conduct such a registry check at any time while I have direct contact with the

department's clients or provide Department approved services for the Department’s clients.

Signature Date

CRIMINAL HISTORY RECORD

I hereby request and give permission to the Department to conduct a DCI and FBI Criminal History Record check. I

further give permission to the Department to conduct such a registry check at any time while I have direct contact with

the department's clients or provide Department approved services for the Department’s clients.

Signature Date

INFORMATION REQUIRED FOR REGISTRY AND RECORD CHECK

PLEASE TYPE or PRINT LEGIBLY

Last Name First Name Middle Name Maiden Name (if applicable)

Alias (if applicable) Alias (if applicable) Alias (if applicable) Alias (if applicable)

Consumer Choices Option (CCO)

Date of Birth Gender Social Security Number (###-##-####) Reason for Check

Address Address 2

City State ZIP

For DHS Employees, Volunteers, or Contractors only: Position:

Institution: Serv. Area: CSCMR: Cent. Off.:

cco_3/16

Background check information disclosure form

An employee or individual vendor of a Consumer Choices Option (CCO) member must pass a background check before he/she can begin work. Veridian Fiscal Solutions will submit the required forms to complete this check. This information is requested on behalf of the CCO member so Veridian can pay an employee or individual vendor with Medicaid funds. Once Veridian receives the required forms, they will be submitted to run the check. The background check can be run at any time after the forms have been signed.

Information will be taken from the following:

The Single Contact Repository which includes: o Iowa’s Criminal History and Sex Offender Registry (Department of Public Safety,

Division of Criminal Investigation) o Central Abuse Registry for Child and Dependent Adult Abuse (Department of

Human Services)

Medicaid Exclusion Checks which may include: o Social Security Number verifications, exclusion from federal

contracts/subcontracts and non-financial assistance and benefits, exclusion of individuals or entities from participation in Medicare, Medicaid, or Federal Health Care Programs, and other state or federal government exclusion lists as required by regulation.

Veridian may share the information in these reports with the CCO member, his/her Independent Support Broker (ISB), his/her Managed Care Organization and other designated entities.

Veridian may ask the employee or individual vendor to provide additional information if there are findings and will ask for a response by a deadline. If Veridian does not receive the additional information by the date requested, the application to work with the CCO member will be denied.

If there is a finding in the report that would prevent the employee or individual vendor from working with the CCO member, Veridian will send the employee or individual vendor a copy of the report and contact information for the reporting agency. An employee or individual vendor should not start working with the CCO member until he/she has been informed by the CCO member or ISB that he/she has passed the background check.

cco_3/16

Background check information disclosure form

Member name:

Medicaid number:

I have read and understand the Background Check Information Disclosure Form. By signing below, I authorize Veridian Fiscal Solutions and its contractors to obtain the background check information and share the findings with my CCO member, Independent Support Broker, Managed Care Organization and designated entities. I understand that it is my responsibility to notify my CCO member immediately if I am convicted of a crime or become excluded from payment in a Medicaid program. I understand that information contained in the background check may be covered under the Fair Credit Reporting Act (FCRA). I understand that I may request additional information about the nature and scope of any background check report and a summary of my rights under FCRA at any time.

(Please print) Employee/vendor name: First name Middle name Last name

Maiden name/business name or other names used

Street address City State Zip

/ / / / Date of birth Social Security number

Employee/vendor signature

Statement of relationship of employee to employer

Are you related to the employer? ____ Yes ____ No

If you answered “Yes” above, please choose one of the following to describe your relationship to the employer:

____ Parent working for child____ Child working for parent____ Spouse____ Other Please describe: ________________________________

_______________________ _______________________Employee name (print) Employee signature

_______________________ _______________________Employer name (print) Employer Medicaid number

______________Date

Fiscal Solutions

470-4428 (12/06) 1

Iowa Department of Human Services

Financial Management Service Agreement

_________________Veridian Credit Union_________________________ agrees to be an (Name of banking institution or credit union)

Organized Health Care Delivery System Medicaid provider and a provider of Financial Management Services (FMS) for the Iowa Medicaid Enterprise.

___________________Veridian Credit Union_______________________ agrees to be the (Name of banking institution or credit union)

Vendor Fiscal/Employer Agent for Consumer Choices Option consumers and legal guardians, as applicable, who are the common law employers of the support service workers they hire directly. As a Vendor Fiscal/Employer Agent operating under section 3504 of the IRS code and Revenue Procedures 70-6 and 2003-70,

_________________Veridian Credit Union__________________________ agrees to perform (Name of banking institution or credit union)

the following tasks:

♦ Establish and manage consumers’ directly hired service workers’ and FMS documents and files.

♦ Provide monthly and quarterly status reports for the Department and for consumers, legal guardians, and their individual supports broker that include a summary of expenditures paid and amounts of budgets unused.

♦ Assist consumers and legal guardians in understanding their fiscal and payroll related responsibilities.

♦ Assist consumers and legal guardians in completing required federal and state tax and insurance forms.

♦ Assist consumers and legal guardians in collecting and submitting criminal background, adult and child abuse waivers on potential employees to the Medicaid Department and maintain copies of relevant documentation.

♦ Assist consumers in verifying directly hired service workers’ citizenship or alien status and maintain copies of relevant documentation.

♦ Prepare and disburses payroll for consumers or their legal guardians who hire support service workers directly. Key employer-related tasks include:

• Verifying that directly hired support service workers’ hourly wages are in compliance with federal and state Department of Labor rules;

• Collecting, verifying, processing, maintaining copies, and monitoring directly hired support services workers’ time sheets to assure it matches the consumer’s written individual budget;

470-4428 (12/06) 2

• Withholding, filing and paying federal Medicare and Social Security (FICA), federal (FUTA) and federal income tax withholding, and state income tax withholding and state (SUTA) unemployment insurance taxes;

• Computing and processing other benefits, as applicable;

• Preparing and issuing service workers’ payroll checks;

• Refunding over collected FICA, when appropriate, to directly hired support service workers and the State (employer portion of over collected FICA);

• Processing all judgments, garnishments, tax levies, or any related holds on directly hired support service workers’ pay as may be required by federal, state or local laws, as applicable; and

• Prepare and disburse IRS Forms W-2 and W-3 annually.

♦ Assist consumers and legal guardians in obtaining and renewing worker’s compensation insurance policies and paying premiums, as required.

♦ Process and pay invoices for approved goods and services included in the consumers’ written individual budgets, maintain documentation and monitor that payments are reflected in the consumer’s written individual budget.

♦ Make sure all payments made to directly hired support service workers and vendors that are returned to the FMS provider for any reason are processed in accordance with Iowa State’s Abandoned Property Law.

♦ Assist in implementing the State’s quality management strategy related to FMS.

♦ Establish an accessible customer service system and communication path for the consumer and the individual support broker.

♦ Provide real time individual budget account balances, at a minimum during normal business hours (9 am – 5 pm, Monday – Friday).

♦ Have the ability to interface with the tracking system chosen by the Iowa Department of Human Services.

As a condition of providing services under this agreement the directly hired support service worker agrees to the following:

♦ The directly hired support service worker of the consumer understands and acknowledges that the consumer or the consumer’s guardian (indicate by inserting the person’s name and title here ________________________________________) is the common law employer.

♦ The directly hired support service worker of the consumer understands and acknowledges that neither the Iowa Medicaid Enterprise nor the Financial Management Service organization is the common law employer and are not responsible for the actions of the common law employer, the consumer, or the legal guardian.

♦ The directly hired support service worker of the consumer or legal guardian understands and acknowledges that funds available for payment are authorized on the consumer’s individual budget by the Iowa Department of Human Services, Iowa Medicaid Enterprise, in advance for work performed.

470-4428 (12/06) 3

♦ The directly hired support service worker of the consumer or legal guardian understands and acknowledges that work performed in excess of the authorized amount on the consumer’s individual budget will be paid for by the personal funds of the common law employer and not by the Iowa Department of Human Services, Iowa Medicaid Enterprise or the Financial Management Service organization.

♦ The directly hired support service worker of the consumer or legal guardian meets the necessary skills and requirements to be able to perform the services hired to perform.

♦ The directly hired support service worker of the consumer or legal guardian is able to successfully communicate with the common law employer (the consumer or legal guardian).

♦ The directly hired support service worker of the consumer or legal guardian, if providing self-directed personal care services, is sixteen years of age or older. (Employee under the age of eighteen must have a parent co-sign this agreement.)

♦ The directly hired support service worker of the consumer or legal guardian, if providing the independent support broker service or providing self-directed community supports and employment services, is eighteen years of age or older.

♦ The directly hired support service worker understands and acknowledges that employees without a valid driver’s license may not transport individuals in connection with their employment responsibilities.

♦ The directly hired support service worker understands and acknowledges that all documents required by the Employment Packet, including the request to obtain a criminal record check and adult and child abuse registry information, must be completed, submitted to and processed by the FMS prior to the employee performing work.

♦ The directly hired support service worker understands and acknowledges that the results of the criminal record and adult and child abuse registry must be obtained prior to the employee performing work. The FMS will notify the common law employer when this has been obtained.

♦ The directly hired support service worker agrees to sign and submit to the common law employer (the consumer or legal guardian, as appropriate) a bi-weekly accurate time sheet of all services rendered including the type of service rendered, the date, and the number of services hours delivered (to the nearest quarter hour). Both the common law employer and the employee must sign time sheets. Time sheets need to be submitted to the FMS within five business days from the end of the payroll cycle. Time sheets received after five business days will be paid with the next payroll cycle. Time sheets received after 30 days of the last day of service provided will not be paid. Incorrect time sheets will be returned and will need to be corrected before a paycheck is issued.

♦ The funds used to pay the directly hired support service worker are Medicaid funds and submission of false information on time sheets may subject the directly hired support service worker to criminal action, in addition to repayment of any funds.

470-4428 (12/06) 4

♦ The directly hired support service worker agrees that Federal income tax withholding,Medicare, Social Security and Iowa State income tax withholding (as applicable) shall bewithdrawn from the directly hired support service worker’s wages per state and federal lawsby the FMS.

♦ The directly hired support service worker agrees to provide the service as specified by thecommon law employer (the consumer or legal guardian, as appropriate) on a schedulemutually agreed upon between the common law employer and the employee. Occasionalvariations in tasks and in the schedule may occur, based on mutual agreement of theparties.

♦ In the event of illness, emergency or incident preventing the directly hired support serviceworker from providing scheduled services to the common law employer (the participant orthe legal guardian, as appropriate), the directly hired support service worker agrees tonotify the common law employer as soon as possible so that the common law employercan obtain their services from someone else.

♦ The directly hired support service worker agrees to participate in training if required by thecommon law employer.

♦ The directly hired support service worker agrees to maintain all information regarding thecommon law employer in a confidential manner and to respect the common law employer’sprivacy at all times.

By signing below, the directly hired support service worker certifies that the directly hired support service worker has read and understand the information presented in this agreement and agrees to be bound by the terms of this agreement.

__________ ___________________________________________

Banking institution or credit union authorized representative Date

_________________________________________________ __________________ Employee of the consumer Date

This form is part of the Employment Packet and must be completed by each hired employee and sent to the FMS with all required paperwork before work can begin.

470-4427 (12/06) 1

Iowa Department of Human Services

Employment Agreement

This employment agreement is between ___________________________________________ (Consumer)

AND

___________________________________________________________________________ (Name of employee)

___________________________________________________________________________ (Address)

___________________________________ ___________________________________ (Phone) (Social security number)

This document must be signed, with a copy to be kept by the employer and the employee. A copy must also be submitted with the Employment Packet to the selected credit union or bank approved to provide the Financial Management Service (hereinafter called FMS). The purpose of this agreement is to establish responsibilities of the parties to each other.

The employee has been hired to provide services to the employer. The boxes checked below identifies the services that the employee is authorized to provide at the direction of the employer. Also, below are the current rates of payment for authorized services provided by the employee.

* Please note next to rate of pay if a payment arrangement different than an hourly payment is made and what that arrangement is.

Independent support broker $_______________ per hr

Self-Directed Personal Care Services

Cleaning services $_______________ per hr

Homemaking tasks $_______________ per hr

Laundry assistance $_______________ per hr

Supervision $_______________ per hr

Lawn care $_______________ per hr

Snow removal $_______________ per hr

Showering assistance $_______________ per hr

470-4427 (12/06) 2

Medication management $_______________ per hr

Personal grooming assistance $_______________ per hr

Assistance with mobility transfers $_______________ per hr

Meal preparation $_______________ per hr

Respite $_______________ per hr

Shopping $_______________ per hr

Transportation $_______________ per hr

Self-Directed Community and Employment Supports

Self-direction and self-advocacy skills development $_______________ per hr

Training on medical equipment $_______________ per hr

Personal and home skills development $_______________ per hr

Time and money management skills development $_______________ per hr

Social skills development training $_______________ per hr

Career preparation skills $_______________ per hr

Career counseling $_______________ per hr

Job hunting/career placement $_______________ per hr

Work place personal assistance $_______________ per hr

Supports to maintain a job $_______________ per hr

Grooming skills development $_______________ per hr

Cooking skills development $_______________ per hr

Cleaning skills development $_______________ per hr

Utilization of public transportation skills development $_______________ per hr

Companionship $_______________ per hr

Supports to attend social activities $_______________ per hr

Safety and emergency preparedness skills development $_______________ per hr

Other duties/please describe*: $_______________ per hr

* Please note that you may need prior approval from Medicaid to hire an employee to perform duties not included in this list.

470-4427 (12/06) 3

Employee Acknowledgments

1. The employee understands and acknowledges that ______________________________ is the employer. (Name of consumer)

2. The employee understands and acknowledges that neither the Iowa Medicaid Enterprise, the State of Iowa nor the Financial Management Service organization is the employer and that they are not responsible for the actions of the employer.

3. The employee understands and acknowledges that funds available for payment are authorized in the employer’s individual budget set by the Iowa Department of Human Services, Iowa Medicaid Enterprise in advance for work performed.

4. The employee understands and acknowledges that work performed in excess of the authorized amount in the employer’s individual budget will be paid for by the personal funds of the employer and not by the Iowa Department of Human Services, Iowa Medicaid Enterprise or the Financial Management Service organization.

5. The employee understands that they are not authorized to work in excess of 40 hours per week. Per the Iowa Division of Labor, Iowa law only requires overtime if overtime is included in the employment agreement or contract between employer and employee.

6. The employee acknowledges that the employee meets the necessary skills and requirements to be able to perform the services hired to perform.

7. The employee acknowledges that the employee is able to successfully communicate with the employer.

8. The employee acknowledges that if the employee is providing self-directed personal care services, that the employee is sixteen years of age or older. Employees under the age of eighteen must have a parent co-sign this agreement.

9. The employee acknowledges that if the employee is providing the independent support broker service or providing self-directed community supports and employment services, that the employee is eighteen years of age or older.

10. The employee understands and acknowledges that employees without a valid driver’s license may not transport individuals in connection with their employment responsibilities.

11. The employee understands and acknowledges that all documents required by the Employment Packet, including the request to obtain a criminal record check and adult and child abuse registry information, must be completed, submitted to and processed by the FMS prior to the employee performing work.

12. The employee understands and acknowledges that the results of the criminal record and adult and child abuse registry must be obtained prior to the employee performing work. The FMS will notify the employer when this has been obtained.

470-4427 (12/06) 4

13. The employee will sign and submit to the employer, or the guardian or designated personal representative, a bi-weekly accurate time sheet of all services rendered including the type of service rendered, the date, and the number of service hours delivered (to the nearest quarter hour). Time sheets must be signed by both the employer and employee (or the guardian or designated personal representative). The employee acknowledges that the employee is responsible for submitting time sheets to the FMS within five business days from the end of the payroll cycle. Time sheets received after five business days will be paid with the next payroll cycle. Time sheets received after 30 days of the last day of service provided will not be paid.

14. The employee acknowledges that the funds used to pay the employee are Medicaid funds and that the submission of false information on time sheets may subject the employee to criminal action, in addition to repayment of any funds.

15. The employee acknowledges that federal income tax withholding, Medicare, social security and Iowa state income tax withholding (as applicable) shall be withdrawn from the employee’s wages per state and federal laws.

16. The employee agrees to provide the service as specified by the employer on a schedule mutually agreed upon between the employer and employee. Occasional variations in tasks and in the schedule may occur, based on mutual agreement of the parties.

17. In the event of illness, emergency or incident preventing the employee from providing scheduled services to the employer, the employee agrees to notify the employer as soon as possible so that the common law employer can obtain their services from someone else.

18. The employee agrees to participate in training if required by the common law employer.

19. The employee agrees to maintain all information regarding the program participant and the common law employer, if they are not one in the same, in a confidential manner and to respect the employer’s privacy at all times.

20. The employee acknowledges and understands if the employee is injured in the course of employment, neither the Iowa Medicaid Enterprise, state of Iowa, nor the Financial Management Service is responsible for paying for the injury. I also understand that it is the employer’s responsibility to notify the employee if they do not have worker’s compensation insurance.

Employer Acknowledgments

1. The employer understands and acknowledges that they are the employer of the support service worker.

2. The employer understands that they may not schedule their employee for more than 40 hours per week. The employer may not authorize overtime payment.

3. The employer agrees to orient and train the employee (directly hired support worker) in providing the services they are hired to perform.

470-4427 (12/06) 5

4. The employer agrees to establish a list of tasks to be performed by the employee.

5. The employer agrees to establish a mutually agreeable work schedule for the employee.

6. The employer agrees to provide adequate notice of changes in the employee’s work schedule in the event of unforeseen circumstances or emergencies.

7. The employer agrees to timely authorize and sign the employee’s accurate time sheets.

8. The employer agrees that the employer is personally responsible for any employee wages or supports that exceed the individual budget.

9. The employer agrees that the employer is responsible for providing worker’s compensation insurance, if required, and that if such insurance is not purchased, the employee will be notified. The employer understands that the cost of worker’s compensation insurance can be paid from their individual budget.

Both parties acknowledge that this is an employment at will situation and that the employer has not been promised employment for a specific time period. By signing below, the employer and employee certify that they have read and understand the information presented in this agreement and agree to be bound by the terms of this agreement. The employer and employee further acknowledge that either party, with our without cause, may terminate this agreement at any time. If the agreement is terminated by either party, the FMS shall immediately be notified.

_____________________________________________ _________________________ Consumer’s signature Date

If the employer has a legal guardian or has designated a representative, the guardian or representative must also sign. If the employer is a minor, the parent or guardian of the minor must also sign.

_____________________________________________ _________________________ Employer’s signature Date

_____________________________________________ Parent/guardian/representative signature

_____________________________________________ _________________________ Capacity signing in Date

_____________________________________________ _________________________ Employee’s signature Date

470-4427 (12/06) 6

This form is part of the Employment Packet and must be sent to the FMS with all required paperwork before work can begin.

The following is a list of possible supports that the employee (directly hired support worker) may complete. Indicate the days the supports are to be completed and approximate number of hours to the nearest quarter hour required to complete. If necessary, there is space for you to write in additional instructions for each support. Please list any other approved tasks in the blank spaces provided.

Supports Sun Mon Tues Wed Thurs Fri Sat

Cleaning services

Homemaking

Laundry

Supervision

Showering assistance

Medication management

Personal grooming

Assistance with mobility transfers

Meal preparation

Respite

Shopping

Transportation

Self directed training and self advocacy skills

Training on medical equipment

Personal and home skills training

470-4427 (12/06) 7

Supports Sun Mon Tues Wed Thurs Fri Sat

Time and money management training

Social skills development training

Career preparation skills

Activities to obtain a job

Work place personal assistance

Supports to maintain a job

Grooming skills development

Cooking skills development

Cleaning skills development

Utilization of public transportation

Companionship

Supports to attend social activities

Safety and emergency preparedness training

All parties may amend this agreement in writing at anytime.

_____________________________________________ _________________________ Consumer’s signature Date

_____________________________________________ __________________________ Parent/guardian/representative signature Date

_____________________________________________ _________________________ Employee’s signature Date

Form W-4 (2018) Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4. Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply. • For 2017 you had a right to a refund of allfederal income tax withheld because youhad no tax liability, and• For 2018 you expect a refund of allfederal income tax withheld because youexpect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions If you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty. Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040- ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/ W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens,before completing this form.

Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim. Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status. Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year. Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate ▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2018 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married filing separately, check “Married, but withhold at higher Single rate.”

City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5 6 $

7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption. • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

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

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

Page 2 Form W-4 (2018)

your wages and other income, including income earned by a spouse, during the year. Line G. Other credits. You might be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as the earned income tax credit and tax credits for education and child care expenses. If you do so, your paycheck will be larger but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account.

Deductions, Adjustments, and Additional Income Worksheet Complete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income, such as interest or dividends.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Two-Earners/Multiple Jobs Worksheet Complete this worksheet if you have more

than one job at a time or are married filing jointly and have a working spouse. If you don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate. Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

Instructions for Employer Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary. New hire reporting. Employers are

required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9, and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/programs/css/ employers.

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date. Box 10. Enter the employer’s employer identification number (EIN).

Page 3 Form W-4 (2018)

Personal Allowances Worksheet (Keep for your records.) A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A B Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . B C Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C

{ • You’re single, or married filing separately, and have only one job; or } D Enter “1” if: • You’re married filing jointly, have only one job, and your spouse doesn’t work; or D

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less. E Child tax credit. See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “4” for each eligible child. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “2” for each eligible child. • If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter “1” for each eligible child. • If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . E

F Credit for other dependents. • If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “1” for each eligible dependent. • If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents). • If your total income will be higher than $175,550 ($339,000 if married filing jointly), enter “-0-” . . . . . . . F

G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here . . G H Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . ▶ H

{ • If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income and want to increase your withholding, see the Deductions,

For accuracy, Adjustments, and Additional Income Worksheet below. complete all • If you have more than one job at a time or are married filing jointly and you and your spouse both worksheets work, and the combined earnings from all jobs exceed $52,000 ($24,000 if married filing jointly), see the that apply. Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 above.

Deductions, Adjustments, and Additional Income Worksheet Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage

income.

1 Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $

{ $24,000 if you’re married filing jointly or qualifying widow(er) } 2 Enter: $18,000 if you’re head of household . . . . . . . . . . . 2 $

$12,000 if you’re single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $ 4 Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or

blindness (see Pub. 505 for information about these items) . . . . . . . . . . . . . . . . 4 $ 5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $ 6 Enter an estimate of your 2018 nonwage income (such as dividends or interest) . . . . . . . . . 6 $ 7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7 $ 8 Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 9 Enter the number from the Personal Allowances Worksheet, line H above . . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/ Multiple Jobs Worksheet, also enter this total on line 1, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 .................................................................................................................................... 10

Page 4 Form W-4 (2018)

Two-Earners/Multiple Jobs Worksheet Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

1 Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . . 4 5 Enter the number from line 1 of this worksheet . . . . . . . . . . . 5 6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . . 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2018. For example, divide by 18 if you’re paid every

2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2018. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 $

Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST paying job are—

Enter on line 2 above

If wages from LOWEST paying job are—

Enter on line 2 above

If wages from HIGHEST paying job are—

Enter on line 7 above

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $5,000 0 $0 - $7,000 0 $0 - $24,375 $420 $0 - $7,000 $420 5,001 - 9,500 1 7,001 - 12,500 1 24,376 - 82,725 500 7,001 - 36,175 500 9,501 - 19,000 2 12,501 - 24,500 2 82,726 - 170,325 910 36,176 - 79,975 910

19,001 - 26,500 3 24,501 - 31,500 3 170,326 - 320,325 1,000 79,976 - 154,975 1,000 26,501 - 37,000 4 31,501 - 39,000 4 320,326 - 405,325 1,330 154,976 - 197,475 1,330 37,001 - 43,500 5 39,001 - 55,000 5 405,326 - 605,325 1,450 197,476 - 497,475 1,450 43,501 - 55,000 6 55,001 - 70,000 6 605,326 and over 1,540 497,476 and over 1,540 55,001 - 60,000 7 70,001 - 85,000 7

60,001 - 70,000 8 85,001 - 90,000 8

70,001 - 75,000 9 90,001 - 100,000 9

75,001 - 85,000 10 100,001 - 105,000 10

85,001 - 95,000 11 105,001 - 115,000 11

95,001 - 130,000 12 115,001 - 120,000 12

130,001 - 150,000 13 120,001 - 130,000 13

150,001 - 160,000 14 130,001 - 145,000 14

160,001 - 170,000 15 145,001 - 155,000 15

170,001 - 180,000 16 155,001 - 185,000 16

180,001 - 190,000 17 185,001 and over 17

190,001 - 200,000 18

200,001 and over 19

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 who claims no withholding allowances; 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 aren’t required to provide the information requested on a form that’s 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.

44-019a (10/04/2017)

Centralized Employee Registry Reporting Form To be completed by the employer within 15 days of hire. Please print or type.

EMPLOYER INFORMATION

FEIN Required - -FEIN plus last 3-digit suffix used when filing Iowa withholding tax.

Submit this information online at www.iowachildsupport.gov

or fax to 1-800-759-5881 or mail to Centralized Employee Registry, PO Box 10322, Des Moines IA

50306-0322. Employer Phone Number ( )

Name Address City State ZIP -

Questions: For A through D below, please see instructions on back for definitions and clarification.

A. Is dependent health care coverage available? ................................................................................ Yes No

B. Approximate date this employee qualifies for coverage (MMDDYY) .............................................. - -C. Employee start date (MMDDYY) ..................................................................................................... - -D. Address where income withholding and garnishment orders should be sent, if different from address above.AddressCity State ZIP -

EMPLOYEE INFORMATION

Employee Date of Birth - - Employee Social Security Number - - Last Name First name Middle Initial Address City State ZIP -

DETACH HERE

2018 IA W-4 Employee Withholding Allowance Certificate

https://tax.iowa.gov To be completed by the employee

Marital Status: Single (or married but legally separated) Married

Print your full name Social Security Number

Home Address City State ZIP EXEMPTION FROM WITHHOLDING If you do not expect to owe any Iowa income tax and have a right to a full refund of ALL income tax withheld, enter “EXEMPT” hereand the year effective here . Nonresidents may not claim this exemption. Check this box if you are claiming an exemption from Iowa tax based on the Military Spouses Residency Relief Act of 2009 ........................... If claiming the military spouse exemption, enter your state of domicile here ........................................................

IF YOU ARE NOT EXEMPT, COMPLETE THE FOLLOWING: 1. Personal allowances ............................................................................................................................................. 1. 2. Allowances for dependents ................................................................................................................................... 2. 3. Allowances for itemized deductions ...................................................................................................................... 3. 4. Allowances for adjustments to income .................................................................................................................. 4. 5. Allowances for child and dependent care credit .................................................................................................... 5. 6. Total allowances. Add lines 1 through 5 ........................................................................................................... 6. 7. Additional amount, if any, you want deducted each pay period ............................................................................ 7.

Employee: I certify that I am entitled to the number of withholding allowances claimed on this certificate, or if claiming an exemption from withholding, that I am entitled to claim the exempt status.

Employee Signature

Date

Employers: Detach this part and keep in your records. However, if the employee is claiming more than 22 withholding allowances or an exemption from withholding when wages are expected to exceed $200 per week, complete the section below and send it to the Iowa Department of Revenue. See Employer Withholding Requirements on the back of this form.

Employer Name

Employer Address

FEIN

This form will be used for all CCO Employers unless you notify VFS otherwise.

44-019b (10/04/2017)

TOP PORTION OF FORM – CENTRALIZED EMPLOYEE REGISTRY REPORTING FORM – EMPLOYER REPORTING REQUIREMENTS An employer doing business in Iowa who hires or rehires an employee must complete this section. Submit online at www.iowachildsupport.gov. You may also mail this portion of the page to Centralized Employee Registry, PO Box 10322, Des Moines IA 50306-0322; or fax it to 800-759-5881. Please include your FEIN. If you have questions about employer reporting requirements, call the Employers Partnering in Child Support (EPICS) Unit at 877-274-2580.

Questions A through DA. Is a family health insurance plan offered through employment? This question does not relate to insurability of employee’s dependents. B. Example: Is dependent insurance coverage offered upon hire or after six months of employment? This question does not relate to insurability of employee’s dependents.

C. Indicate the first day for which the employee is owed compensation. (Required by 42 U.S. Code § 653a) D. This information is needed for income withholding and garnishment purposes.

BOTTOM PORTION OF FORM – IA W-4 INSTRUCTIONS – EMPLOYEE WITHHOLDING ALLOWANCE CERTIFICATE Exemption from Withholding

You should claim exemption from withholding if you are an Iowa resident and both of the following situations apply: (1) for 2017 you had a right to a refund of all Iowa income tax withheld because you had no tax liability and, (2) for 2018 you expect a refund of all Iowa income tax withheld because you expect to have no tax liability. Nonresidents may not claim this exemption. You must complete a new W-4 within 10 days from the day you anticipate you will incur an Iowa income tax liability for the calendar year (or your fiscal year). If you anticipate you will incur an Iowa income tax liability for the following year, then you must complete a new W-4 on or before December 31 of the current year. If you want to claim an exemption from withholding next year, you must file a new W-4 with your employer on or before February 15. Taxpayers 64 years of age or younger: (1) You are exempt if your filing status is single, your net income is less than $5,000, and are claimed as a dependent on another person’s Iowa return; (2) your filing status is single, your net income is less than $9,000, and you are not claimed as a dependent on another person’s Iowa return; (3) your filing status is other than single and your combined net income is $13,500 or less. See your payroll officer to determine how much you expect to earn in a calendar year. Military personnel in active duty status, as defined in Title 10 of the U.S. Code, are exempt from withholding. Under the Military Spouses Residency Relief Act of 2009, you may be exempt from Iowa income tax on your wages if: (1) your spouse is a member of the armed forces present in Iowa in compliance with military orders; (2) you are present in Iowa solely to be with your spouse; and (3) you maintain your domicile in another state. If you claim this exemption, check the appropriate box, enter the state other than Iowa you are claiming as your state of domicile, and attach a copy of your spousal military identification card to the IA W-4 provided to your employer. Taxpayers 65 years of age or older: (1) You are exempt if you are single and your net income is $24,000 or less; (2) filing status is other than single and your combined net income is $32,000 or less. Only one spouse must be 65 or older to qualify for the exemption. Note: Pension exclusion and any reportable Social Security amount must be added to net income for purposes of determining the low-income exemption.

Filing Requirements/Number of Allowances Each employee must file this Iowa W-4 with his/her employer. Do not claim more allowances than necessary or you will not have enough tax withheld. 1. Personal Allowances: You can claim the following personal allowances: (a) 1 allowance for yourself or 2 allowances if you are unmarried and eligible to claim head of household status. Add 1 additional allowance if you are 65 or older,

and/or 1 additional allowance if you are blind. (b) If you are married and your spouse either does not work or is not claiming his/her allowances on a separate W-4, you may claim the following allowances for

them: 1 for your spouse, 1 additional allowance if your spouse is 65 or older, and/or 1 additional allowance if your spouse is blind. (c) If you are single and hold more than one job, you may not claim the same allowances with more than one employer at the same time. If you are married and

both you and your spouse are employed, you may not both claim the same allowances with both of your employers at the same time. (d) To have the highest amount of tax withheld, claim "0" allowances on line 1. 2. Allowances for Dependents: You may claim 1 allowance for each dependent you claim on your Iowa income tax return. 3. Allowances for Itemized Deductions: (a) Enter total amount of estimated itemized deductions .............................................................................................. (a) $ (b) Enter amount of your standard deduction using the following information ............................................................... (b) $ If single, married filing separately on a combined return, or married filing separate returns, enter $2,030. If married filing a joint return, unmarried head of household, or qualifying widow(er), enter $5,000. (c) Subtract line (b) from line (a) and enter the difference or zero, whichever is greater ............................................... (c) $ (d) Additional allowance: Divide the amount on line (c) by $600, round to the nearest whole number and enter on line 3 of the IA W-4 on other side. 4. Allowances for Adjustments to Income: Estimate allowable adjustments to income for payments to an IRA, Keogh, or SEP; penalty on early withdrawal of savings; alimony paid; moving expense deduction from federal form 3903; and student loan interest, which are reflected on the Iowa 1040 form. Divide this amount by $600, round to the nearest whole number, and enter on line 4 of the IA W-4. 5. Allowances for Child and Dependent Care Credit: Persons having child/dependent care expenses qualifying for the federal and Iowa Child and Dependent Care Credit may claim additional Iowa withholding allowances based on their net incomes. If you have qualifying child and dependent care expenses and wish to reduce your Iowa withholding on the basis of this credit, you may claim additional withholding allowances for Iowa based on the information below. Married persons, regardless of their expected Iowa filing status, must calculate their withholding allowances based on their combined net incomes. Note that taxpayers with net income of $45,000 or more cannot claim withholding allowances for the Child and Dependent Care Credit.

Withholding Allowances AllowedIowa Net Income: $0 - $20,000 Allowances: 5; Iowa Net Income: $20,000 - $30,000 Allowances: 4; Iowa Net Income: $30,000 - $44,999 Allowances: 3 Enter the number of allowances on line 5 of the IA W-4 on the reverse side. If you are married and both you and your spouse are employed, the total allowances for child and dependent care that you and your spouse may claim cannot exceed the total allowances shown above. 6. Total: Enter total of lines 1 through 5. 7. Additional Amount of Withholding Deducted: You may need to have additional tax withheld if you have two or more jobs are married and you both work, or have income other than wages. Income other than wages would include: interest and dividends, capital gains, rent, alimony received, gambling winnings, etc. If you are not having enough tax withheld, you may request your employer to withhold more by filling in an additional amount on line 7. Estimate the amount you will be under-withheld, and divide that amount by the number of pay periods per year. If you reside in a school district that imposes school district surtax, consider reducing the amount of allowances shown on lines 1-5, or have additional tax withheld on line 7. Changes in Allowances: You may file a new W-4 at any time if the number of your allowances increases. You must file a new W-4 within 10 days if the number of allowances previously claimed by you decreases. Penalties: Penalties apply for willfully supplying false information or for willful failure to supply information, which would reduce the withholding allowances. If you file as exempt from withholding and you incur an income tax liability, you may be subject to a penalty for underpayment of estimated tax. Employer Withholding Requirements: The employer must maintain records of the W-4s. If the employee is claiming more than 22 withholding allowances or is claiming exemption from withholding when wages are expected to exceed $200 per week, the employer must send a copy of the W-4 under separate cover within 90 days to the Compliance Services, Iowa Department of Revenue, PO Box 10456, Des Moines, Iowa 50306-0456. Questions about Iowa taxes: Call Taxpayer Services at 515-281-3114 or 800-367-3388 or e-mail idr@iowa.gov.

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Please refer to these instructions to complete Form I-9.

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USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

START 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) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

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):

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.

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

Last Name First Name Middle Initial

Address Apt. Number City or Town State ZIP Code

Date of Birth U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

I attest, under penalty of perjury, that I am (check one of the following boxes):

Signature of Employee Today's Date (mm/dd/yyyy)

Form I-9 07/17/17 N Page 2 of 3

USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

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 AIdentity 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. In the fields below, "Employer" refers to the CCO Member.The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of or Authorized Representative First Name of 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

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You (Emp

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

(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 l

of Acceptable Documents.")

List A

Last Name First Name M.I. Citizenship/Immigration Status

OR List B AND List C

Document Title

Issuing Authority

Document Number

Expiration Date

Document Title

Issuing Authority

Document Number

Expiration Date

Document Title

Issuing Authority

Document Number

Expiration Date

Signature of or Authorized Representative Today's Date

Last Name of or Authorized Representative First Name of or Authorized Representative

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

The employee's first day of employment

Employer's Business or Organization Name

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 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Iowa Department of Revenue

https://tax.iowa.gov Employee’s Statement of Nonresidence in Iowa

44-016 (07/06/15)

Employee’s Name: SSN:

Address:

City, State, ZIP:

Employer’s Name:

Address:

City, State, ZIP:

Employer

You are required to have a copy of this form on file for each employee who is a resident of Illinois receiving wages or salary paid in Iowa and who claims exemption from withholding of Iowa income tax under the reciprocal agreement between Iowa and Illinois.

Employee

Iowa and Illinois have a reciprocal agreement for individual income tax purposes. A resident of Illinois working for wages or salary in Iowa should complete and file this form with their employer so that the employer will be aware it is appropriate to withhold Illinois income tax. Any wages or salary made by an Illinois resident working in Iowa is taxable only to Illinois and not to Iowa.

Note: If you change your state of residence, you must notify your employer within 10 days.

Declaration: I hereby declare, under penalty of perjury, that I am a resident of the state of Illinois and that, pursuant to an agreement existing between that state and the state of Iowa, I claim exemption from withholding of Iowa income tax on compensation paid to me in the state of Iowa.

Employee Signature: _______________________________________ Date: _________________

PLEASE COMPLETE ONLY IF YOU ARE A RESIDENT OF ILLINOIS WORKING IN IOWA

cco_6/18

Direct Deposit Authorization Employee information Employee name: ________________________________________________________ Address: ______________________________________________________________ City: ___________________________ State: _______ Zip code: ____________ Phone number: ____________________ Email: __________________________

CCO member information CCO member name: _____________________________________________ Medicaid number: _______________________________________________

Financial institution information Financial institution name: ________________________________________ Account type: _______Checking _________Savings Account number: ________________________________________________ Routing number: ________________________________________________

I hereby authorize Veridian Fiscal Solutions to initiate direct deposit credit entries and, if necessary, to direct the financial institution above to initiate debit entries or adjustments to correct any deposit errors to my checking or savings account at the financial institution. I understand this authorization will override any previous authorization and will remain in effect until the date Veridian Fiscal Solutions has received written or electronic notification from me of its termination in such time and in such manner as to afford Veridian Fiscal Solutions and the financial institution named above a reasonable opportunity to act on it. I understand that I must immediately notify Veridian Fiscal Solutions before I close the account listed above while this authorization is in effect.

Signature: _____________________________________________________________

Please attach a voided check or deposit slip. With this, we have all the information we need to make a direct deposit into your account.

A direct deposit stub for each payment will be available online. Simply log into your account and click on “Pay Stubs” under the “My Account” tab. If you need a paper copy of a direct deposit stub, please contact us.

Please return this completed form and attachment to Veridian Fiscal Solutions by: 1) Email: ccoiowa@veridiancu.org2) Fax: 319-236-67853) Mail: P.O. Box 4502 Waterloo, IA 50704

cco_10/17

2018 Payment schedule

All time sheets and vendor invoices must be submitted no later than the 5th and the 20th of each

month. This will ensure that payment will be received by the 15th and the last day of the month. Time

sheets and vendor invoices can be submitted as soon as each pay period ends.

To make sure time sheets and vendor invoices can be paid, submit all documentation within 30 days from the last

day of service. After 30 days, Veridian Fiscal Solutions may no longer have access to the funding for

payment.

Processing:

We mail paper checks on the pay date. Employees, ISBs and Vendors who use direct deposit will have

the payment post to their account on the pay date. These pay dates will change if the pay date falls on

a weekend or holiday. When this occurs, we will mail checks and post direct deposits on the Friday

before the pay date. Veridian is not responsible for U.S. Postal Service delays.

Time Period Time sheet/invoice/ Pay date receipt due date

January 1-15 1/20/2018 1/31/2018

January 16-31 2/5/2018 2/15/2018

February 1-15 2/20/2018 2/28/2018

February 16-28 3/5/2018 3/15/2018

March 1-15 3/20/2018 3/30/2018

March 16-31 4/5/2018 4/13/2018

April 1-15 4/20/2018 4/30/2018

April 16-30 5/5/2018 5/15/2018

May 1-15 5/20/2018 5/31/2018

May 16-31 6/5/2018 6/15/2018

June 1-15 6/20/2018 6/29/2018

June 16-30 7/5/2018 7/13/2018

July 1-15 7/20/2018 7/31/2018

July 16-31 8/5/2018 8/15/2018

August 1-15 8/20/2018 8/31/2018

August 16-31 9/5/2018 9/14/2018

September 1-15 9/20/2018 9/28/2018

September 16-30 10/5/2018 10/15/2018

October 1-15 10/20/2018 10/31/2018

October 16-31 11/5/2018 11/15/2018

November 1-15 11/20/2018 11/30/2018

November 16-30 12/5/2018 12/14/2018

December 1-15 12/20/2018 12/31/2018

December 16-31 1/5/2019 1/15/2019

Electronic time sheet option This free option will make completing and submitting your time sheet faster and easier. WebTime entry is a convenient online tool that will help you and your employers.

Benefits include: • No more faxing • Review your hours anytime and anywhere an internet connection is available • You can verify if your employer has approved your hours

Before you are eligible to use this service, your employer needs to enroll in WebTime entry. Once your employer is registered, you can register at https://ccoweb.veridiancu.org. You will be asked to enter your employee number, which becomes your account number. Then, you will need to create a password that has at least six characters. Your employee number can be found on your check stub.

Questions? You can review and download a manual online at https://ccoweb.veridiancu.org (click on the “Help” section) or you contact our Consumer Choices Option Department.

Email: ccoiowa@veridiancu.orgPhone number: (319) 226-4692 (319-CCO-IOWA)Toll-free: (866) 226-4692 (866-CCO-IOWA)

Fiscal Solutions

cco_12/15

Information about time sheets & vendor invoices

• Veridian Fiscal Solutions must have all time sheets and vendor invoices no later than the 5th and the 20th of the month. This will make sure that employees and vendors are paid by the 15th and the last day of the month. Please see our payment schedule for the actual pay dates. You do not need to wait until the payroll deadline to submit a time sheet or reimbursement request. You can turn these in as soon as each pay period ends.

• Submit all time sheets and vendor invoices within 30 days from the last day worked. Veridian may not have access to the funding after 30 days have passed.

• All time sheets must be filled out in black ink or typed.

• It is important to fill in your time sheet after every shift.

• Each time sheet must be complete. Make sure it is signed and dated by the employee and employer before it is turned in.

• Veridian cannot accept documents with photocopied or typed signatures.

Email time sheets to ccoiowa@veridiancu.org at the end of each pay period. If you email your time sheet, you will get a confirmation that we received it.

You can also send your documents by fax or mail:

Fax: 1-319 236-6785, Attn: Consumer Choices Option

Mail: Veridian Fiscal Solutions Consumer Choices Option P.O. Box 4502 Waterloo, IA 50704

• Please send each employee time sheet as its own email or fax. Questions? Please call Veridian Fiscal Solutions at 1-319- 226-4692 or 1-866- 226-4692.

FaxDate: ___________

From: _______________________Phone number: _______________________Fax number: _______________________Pages: _______________________

To: Veridian Fiscal Solutions - Consumer Choices Option DepartmentPhone number: 319-CCO-IOWA (319-226-4692)Toll-free: 866-CCO-IOWA (866-226-4692)Fax number: 319-236-6785Address: P.O. Box 4502, Waterloo, IA 50704-9924

Re: ______________________________________________________CCO member name: _______________________Medicaid number: _______________________

Notes:Please fax each document separately. For example, if you have three employee time sheets to submit, please submit each employee’s time sheet to Veridian Fiscal Solutions in a separate fax.

To avoid having your additional questions or requests missed, please email our Consumer Choices Option Department at ccoiowa@veridiancu.org or call (319) 226-4692 or (866) 226-4692.

Fiscal Solutions

Employer/Medicaid Number: ________________________ *All fields must be filled out completely or timesheet will be returned

Social Security Number*:

Hourly wage*:

Pay Period From:

Date* Start

Time*

End

Time*

Start

Time*

End

Time*

Total

Hours

Worked*

Rate of

Pay*

SERVICE PROVIDED AND NARRATIVE* Services provided

must match service on the individual budget. Please identify in

the narrative if hours worked are from the emergency back up

plan or from savings.(Use more than one line if needed.)

Note any

progress/changes for

consumer

Employee*:

Consumer Choices Option

Semi-Monthly Time Sheet

Employer's first and last name*:

Position*:

470-4429 (Rev. 3/08) 1 Iowa Department of Human Services

Employer/Medicaid Number: ________________________ *All fields must be filled out completely or timesheet will be returned

Date* Start

Time*

End

Time*

Start

Time*

End

Time*

Total

Hours

Worked*

Rate of

Pay*

SERVICE PROVIDED AND NARRATIVE*Services provided

must match service on the individual budget.Please identify in

the narrative if hours worked are from the emergency back up

plan or from savings. (Use more than one line if needed.)

Note any

progress/changes for

consumer

Total Hours worked per this pay period:

470-4429 (Rev. 3/08) 2 Iowa Department of Human Services

Employer/Medicaid Number: ________________________ *All fields must be filled out completely or timesheet will be returned

Employer's Signature

Date:

I certify that the person whose name appears on this time sheet has worked the time indicated. I understand that by signing an employee time card which

contains false information about hours worked, may make me a party to Medicaid fraud and legal action could occur.

In event that my total expenses for this bi-monthly period exceeds my approved allocation, I authorize Veridian Credit Union to use any available funds from

my savings, in order to assure payment of this time sheet. The employer agrees that the employer is responsible for any employee wages or supports that

exceed the individual budget and savings or that are not identified on the individual budget and savings.

Comments:

All time recorded on the time sheets needs to be documented to the nearest quarter hour. Time sheets must be received by the Financial Management Service within 30

days of the last day of service provided. Time sheets must be submitted by the 7th/22nd days of the month to be paid by the 15th/last day of the month.

Employee's Signature

Date:

Did the employee perform the job in a respectful and courteous manner?

Never Seldom Sometimes Usually Always

470-4429 (Rev. 3/08) 3 Iowa Department of Human Services

THIS IS A SAMPLE TIME SHEET We recommend using our online timesheet option, WebTime entry, which can be found at https://ccoweb.veridiancu.org. However, if it is necessary to complete a paper time sheet, please use this sample as a guide to avoid potential processing delays. If you need a blank time sheet sent to you, please email Veridian’s Consumer Choices Option Department at ccoiowa@veridiancu.org or call (319) 226-4692 or (866) 226-4692. You can also download and print blank time sheets from the Medicaid Web site at www.ime.state.ia.us/HCBS/HCBSConsumerOptions.html.

Employer/Medicaid number: 1234567a *All fields must be filled out completely or time sheet will be returned.

Consumer Choices Option Semi-Monthly Time Sheet

Employee*: John Doe (example) Social Security number*: 123-45-6789

Position*: Respite/SCL Hourly wage*: $12.00/$14.00

Employer’s first and last name*: Mary Jane (example)

Pay period from: January 1 - January 15

Date* Start Time*

End Time*

Start Time*

End Time*

Total Hours

Worked*

Rate of Pay*

SERVICE PROVIDED AND NARRATIVE* Services provided must match service on the

individual budget. Please identify in the narrative if hours worked are from the emergency backup plan or from savings. (Use more than one line if needed.)

Note any progress/changes

for consumer.

1/3 8:00 a.m. 1:00 p.m. 5 $12.00 Respite

1/5 2:00 p.m. 6:00 p.m. 4 $14.00 SCL – Meal planning, grocery shopping, public transportation skills, cooking

1/9 3:00 p.m. 7 $12.00 Respite

This semi-monthly sample only shows a few work shifts. The full semi-monthly time sheet has rows for shifts shown on page one and two.

Time sheet tips from Veridian: If you submit a time sheet twice a month, please list hours for the 1st through the 15th and the 16th through the last day of the month separately. If you submit a time sheet once a month, please list only hours for one month on each time sheet.

Please clearly list the service code (respite, SCL, personal care, etc.) and your hourly wage for the service.

Please list the total hours worked for each service code separately. For this sample time sheet, you would list 12 hours respite and 4 hours SCL.

PLEASE USE BLACK INK ONLY Do not use pencil, colored ink or gel pens.

8:00 a.m.

Employer/Medicaid number: 1234567a *All fields must be filled out completely or time sheet will be returned.

All time recorded on the time sheets needs to be documented to the nearest quarter hour. Time sheets must be received by the Financial Management Service within 30 days of the last day of service provided. Time sheets must be submitted by the 7th/22nd day of the month to be paid by the 15th/last day of the month.

I certify that the person whose name appears on this time sheet has worked the time indicated. I understand that by signing an employee time card which contains false information about hours worked, may make me a party to Medicaid fraud and legal action could occur.

Did the employee perform the job in a respectful and courteous manner?

Never Seldom Sometimes Usually Always

Comments:

In the event that my total expenses for this semi-monthly period exceed my approved allocation, I authorize Veridian Fiscal Solutions to use any available funds from my savings in order to assure payment of this time sheet. The employer agrees that the employer is responsible for any employee wages or supports that exceed the individual budget and savings or that are not identified on the individual budget and savings.

Employee’s Signature Employer’s Signature

1/9/2013 1/9/2013 Date Date

Each time sheet must be signed and dated by both the employee and employer.

Any time sheets with missing, photocopied or typed signatures will not be processed.

(example) (example)

Rev. 05/15

Why? Financial companies choose how they share your personal information. Federal law gives

consumers the right to limit some but not all sharing. Federal law also requires us to tell you

how we collect, share, and protect your personal information. Please read this notice carefully to

understand what we do.

What? The types of personal information we collect and share depend on the product or service you

have with us. This information can include:

- Social Security number and employment information

- Checking and savings account information and transaction history

- Account balances and income

How? All financial companies need to share members’ personal information to run their everyday

business. In the section below, we list the reasons financial companies can share their members’

personal information; the reason Veridian Fiscal Solutions chooses to share; and whether you

can limit this sharing.

Reasons we can share your personal information Does Veridian Fiscal

Solutions share? Can you limit this sharing?

For our everyday business purposes—

such as to process your transactions, maintain

your account(s), respond to court orders and legal

investigations, or report to credit bureaus

YES

NO

For our marketing purposes—

to offer our products and services to you

YES NO

For joint marketing with other financial companies NO We don’t share

For our affiliates’ everyday business purposes—

information about your transactions and experiences

YES NO

For our affiliates’ everyday business purposes—

information about your creditworthiness

NO We don’t share

For our affiliates to market to you NO We don’t share

For nonaffiliates to market to you NO We don’t share

Questions? Call 1-866-226-4692 or go to https://ccoweb.veridiancu.org

T

YOUR

Who we are

Who is providing this notice? Veridian Fiscal Solutions

What we do How does Veridian Fiscal Solutions

protect my personal information?

To protect your personal information from unauthorized access

and use, we use security measures that comply with federal law.

These measures include computer safeguards and secured files

and buildings.

How does Veridian Fiscal Solutions

collect my personal information? We collect your personal information, for example, when you

open an account or give us your contact information

show your government-issued ID or tell us where to send the money

provide account information

We also collect your personal information from other companies.

Why can’t I limit all sharing? Federal law gives you the right to limit only

sharing for affiliates’ everyday business purposes—

information about your creditworthiness

affiliates from using your information to market to you

sharing for nonaffiliates to market to you

State laws and individual companies may give you additional rights to

limit sharing.

Definitions

Affiliates Companies related by common ownership or control. They can be

financial and nonfinancial companies.

Our affiliates include financial companies with a common corporate identity, such as Veridian Credit Union and Veridian Insurance.

Nonaffiliates Companies not related by common ownership or control. They can be

financial and nonfinancial companies.

Veridian Fiscal Solutions does not share with nonaffiliates so they can market to you.

Joint marketing A formal agreement between nonaffiliated financial companies that

together market financial products or services to you.

Veridian Fiscal Solutions doesn’t jointly market.

2