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Self Determination Program

PARTICIPANT DATA FORM

Rev. 06/05/2018

05211

Participant Information

Name on Social Security Card First Middle Last

Name in Payer Program First Middle Last

Street Address (Physical address where services will be provided, No PO Box)

City State Zip County

Phone ( ) ( ) ( ) Email Home Cell Fax

Gender Male Female Date of Birth Social Security # ______‐____‐_______

Authorized Representative Information (if applicable)

Name First Middle Last

Street Address

City State Zip


Relationship to Participant

Employer of Record Information (Person who will file for and hold the Federal Employer Identification Number(FEIN))

Relationship to Participant Participant (self) Other

Name First Middle Last

Street Address

City State Zip County


Date of Birth ____________ Social Security # _____‐___‐______ Driver License or MI ID #

Prior Relationships/Business Accounts

1. Yes No – Has Participant ever received services through another Fiscal Provider? If yes, Provider name:

2. Yes No – Is Participant switching FEIN holders? If yes, previous FEIN holder name:

3. Yes No – Are Prior Business Accounts established? If yes, enter account information below:

____‐______________ FEIN MI Business Tax Withholding Acct # MI Unemployment Tax Acct # MI Unemployment Rate

Yes No – If previous FEIN, does FEIN holder have employees other than caregivers?

4. Yes No – Will a Guardian sign enclosed Federal and state tax forms on the FEIN holder’s (Employer of Record’s) behalf? If yes, enter Guardian name below and attach court‐appointed guardianship paperwork.

Guardian Name _________________________ ___ ________________________ First (MI) Last

5. Budget/Auth Start Date or Reactivation Start Date ____________________


PARTICIPANT DATA FORM

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Enrollment Questions

The Consumer Direct Care Network (CDCN) representative responsible for assisting the Participant with enrollment must complete the questions below by interviewing the Participant and/or FEIN holder. If Participant/FEIN holder does not know the answer to a question, please write “participant doesn’t know” on the line next to the question. Questions for the FEIN holder named on page 1 of this form.

1. What name is shown on your most recently received Social Security Card?

2. What number is shown on your most recently received Social Security Card?

3. Have you gone by any other name(s) in the past which aren’t shown on your most recently received Social Security Card?

Yes No

a. If yes, please list your other name(s):

b. Please list when your other name(s) were used:

4. Were you ever previously assigned an FEIN by the IRS for any business previously operated/owned?

Yes No

a. If yes and known:

i. Please list the previously assigned FEIN:

ii. What was the business for?

iii. Is the business still active? Yes No Question for the Participant named on page 1 of this form.

1. Were you ever previously enrolled with another Fiscal Agent/Provider?

Yes No

a. If yes and known:

i. Please list the name of the Fiscal Agent/Provider:

ii. Please list when you were with the Fiscal Agent/Provider:

CDCN Representative Name: CDCN Representative Signature: Date:


PARTICIPANT ENROLLMENT CHECKLIST

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Participant Name Authorized Representative Name (if applicable)

Welcome to Consumer Direct Care Network (CDCN)!

Please complete the forms in the lists below, including this one. All forms need to be completed, except

in some situations when labeled “if applicable”. Check off each item below as it is completed. If you

would like a paper copy of these forms, please let us know and we will return copies to you.

CDCN and tax forms required to enroll in the Self Determination Program:

1. Participant Data Form

2. Participant Enrollment Checklist (this form)

3. Authorized Representative Designation (if applicable)

4. Fiscal Employer Agent Services Agreement

5. Backup Plan

6. SS‐4 Application for Employer Identification Number (EIN)

7. 2678 Employer/Payer Appointment of Agent

8. 518 Registration for Michigan Taxes

9. UIA Schedule A – Liability Questionnaire

10. UIA Schedule B – Successorship Questionnaire

11. 151 Authorized Representative Declaration (Power of Attorney)

12. UIA 1488 Power of Attorney

13. 8821 Tax Information Authorization (if applicable) *form not included in packet

Supplemental Forms (Discuss each and keep for future use)

Notice of Privacy Practices

Employer Handbook

Payroll Calendar and Timesheet

Status Change Form

I have reviewed and verified the above forms for completeness and all forms are readable. Participant/Authorized Representative Signature Date CDCN Representative Signature Date


AUTHORIZED REPRESENTATIVE DESIGNATION FORM

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In the Self Determination Program, program participants can appoint a responsible adult to assist

them with managing their services. This person can be a guardian, family member or other

supporter who willingly accepts the role as the Participant’s advocate and will assist them with

program compliance and employer responsibilities.

Authorized Representative Designation

I, , (Participant enrolling in the Self Determination Program),

authorize , (Representative) to act as my Authorized

Representative to direct and manage my Self Determination Program services on my behalf.

Participant Signature Date

Authorized Representative Responsibilities and Attestation

I, , (Representative), understand and agree with my role as

an Authorized Representative, which includes actively planning and managing the Participant’s in‐

home services.

I understand that my appointment as an Authorized Representative may be revoked at any time

by the Participant or myself.

I understand my responsibilities as a Representative will include, but are not limited to:

Completing paperwork to enroll the Participant in the Self Determination Program,

Hiring, training, scheduling and supervising employees,

Verifying and signing employee timesheets,

Monitoring the Participant’s budget, and

Developing an emergency backup plan for instances when regularly scheduled workers

are unable to provide service.

I affirm that I know the Participant well, that I understand their healthcare needs, and that I will

help them with all aspects of participating in the Self Determination Program.

Representative Signature Date


FISCAL EMPLOYER AGENT SERVICE AGREEMENT

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This Fiscal Employer Agent Services Agreement (Agreement) is made and entered into as of

(Start Date) between Consumer Direct Michigan, LLC doing business as Consumer Direct

Care Network Michigan (CDCN) and Participant, and/or

their Guardian and/or Authorized

Representative, if appointed by the Participant or Guardian.

1. The “Participant” is the individual receiving Medicaid services under the Self Determination Program or the MI Choice Medicaid Waiver Program, Self Determination Long Term Care option. The Participant’s services are authorized through a Prepaid Inpatient Health Plan, Community Mental Health Service Program or Michigan Choice Waiver Agent. An Authorized Representative (AR) may be authorized by the Participant/Guardian to manage day‐to‐day employee activities on the Participant’s behalf. The “Employer” is the Federal Employer Identification Number (FEIN) Holder, who is the Employer of Record and of Fact, and can employ persons to provide services to the Participant. In the case of a minor child the “Employer” is the parent/guardian of the Participant receiving services.

2. CDCN is the “Fiscal Employer Agent” (F/EA), and as authorized under IRS Revenue Procedure 70‐6 for the purpose of payroll and payroll reporting services, will file on behalf of the Employer/FEIN Holder.

3. __________________________________ is the “Authorizing Agency” associated with the Self Determination Program or MI Choice Medicaid Waiver Program that governs services and authorizes the Participant’s budget based on their Plan of Service. Authorizing Agency recognizes that CDCN, acting as the F/EA, will provide Fiscal Management Service (FMS) to the Employer/AR.

Responsibilities of Employer/AR

1. Choose CDCN to serve as its payroll agent (Fiscal Employer Agency ‐ FEA).

2. Complete all of the forms required by CDCN for its FMS services. This includes accurately filling out all required IRS and State Tax and unemployment forms. Failure on part of the Employer/AR to provide required FEIN information or to submit a complete packet may result in a delay in Employee payment, the Employer/AR paying out of pocket, or the Employer/AR paying for penalty charges.

3. Obtain a Federal Employer Identification Number (FEIN) with the assistance of CDCN.

4. Follow all federal and state employee laws, regulations, and rules.

a. Recruiting, interviewing, checking references, hiring, training, scheduling, managing, and dismissing each Employee who provides services. This includes directing the day‐to‐day care of the Participant and working out conflicts between the Employer/AR and Employees.

b. Before an Employee can begin to work and be paid in this program, the Employer/AR will receive a notice of authorization from CDCN stating employment start date.

c. Provide equal employment opportunities to all employees and interested employees without breaking discrimination law as to race, creed, color, national origin, sex, age, disability, marital status, sexual orientation, or any other status protected by law in all



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employment decisions, including recruitment, hiring, changing schedules and number of hours worked, lay off, and dismissal, and all other terms and conditions of employment. The Employer/AR accepts full and specific responsibility for following equal opportunity laws and requirements regarding Employees. Each Employee is to be treated fairly and consistently.

d. Direct Employees so that services are not provided while a Participant is hospitalized or receiving any other Medicaid‐reimbursed service.

e. Review and approve employee work‐time records through online time entries or paper time sheets which authorize the Authorizing Agency to be billed. Records must be submitted in a timely manner according to the CDCN payroll schedule. The Employer/AR can be held accountable for approving records that contain fraudulent information and result in over‐billing Medicaid.

f. Monitor the monthly tracking reports provided by CDCN and keep all expenditures within Participant’s authorized budget. Maintain compliance with the Authorizing Agency’s approved utilization amounts for the Participant.

g. Inform CDCN on a timely basis of any Participant changes in name, address, telephone number or hospitalization.

h. Inform CDCN of the standard rate of pay for the Employee, including timely notification in any changes in the rate.

5. Make payment of any wages and expenses that exceed the amount authorized in Participant’s authorized budget, and are the result of overtime worked by an Employee.

6. Read CDCN’s Notice of Privacy Practices, which I received a copy of. It describes my rights and privileges under CDCN’s privacy rules. The rules follow federal privacy regulations (HIPAA). CDCN’s Privacy Officer can be reached toll‐free at 1‐877‐532‐8530.

7. Immediately Report:

a. Any possible Medicaid fraud to the CDCN Fraud Hotline 1‐877‐532‐8530.

b. Abuse, neglect and exploitation or impairment or health risk to the appropriate authorities, i.e., Adult Protective Services, Authorizing Agency, and CDCN.

c. Employee changes, including name, address or employment status within five (5) working days.

8. Appoint a temporary Authorized Representative if the Participant or current Authorized Representative is not capable or available to direct the Participant’s care.

9. Maintain required Employee training for all employees. Responsibilities of CDCN

1. Provide the Employer/AR with all forms and documents necessary to enroll in the Participant in the Self Determination Program and provide a face‐to‐face enrollment meeting to successfully complete all enrollment materials.



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2. Perform background checks on prospective employees the Employer/AR wishes to hire and issue an Employee Enrollment Packet to Employer/AR after employee successfully completes the background check.

3. Pay wages to Employee on a bi‐weekly schedule, in accordance with the time records approved in writing by the Employer/AR.

4. Provide Workers’ Compensation coverage as directed by state law for Employees.

5. Deposit employer‐related taxes in the aggregate using Employer of Record’s individual FEIN.

6. Follow all IRS and State reporting guidelines.

7. Reimburse Employees for expenses incurred while providing services to the Participant, when such expenses are authorized on the Participant’s budget. CDCN must receive reimbursement forms and receipts in a timely manner (within 30 days after the end of the month in which the expense was incurred) to release payment.

8. Track the total number of budgeted service hours used and provide monthly reports (by mail or online) to the Employer/AR detailing hours used and hours remaining. The Employer/AR is responsible for monitoring monthly tracking reports and not using more service hours than approved for by the case manager.

9. Submit all claims for services to the Authorizing Agency on behalf of the Employer.

10. CDCN will not pay for tasks that are not authorized on the Participant’s Authorized Individual Budget until approved by the case manager and reimbursement is received from the Authorizing Agency.

11. Obtain Fiscal Employer Agency authorization pursuant to IRS procedure code 70‐6 and follow all IRS guidelines including obtaining all proper Federal and State authorizations.

12. Follow all tax exemptions and withholdings as stated on Employee’s W‐4, and process all tax withholdings & filings including Federal and State income taxes, FICA, Medicare tax, FUTA, and SUTA, and any other mandated withholding, as appropriate, on behalf of the Employer of Record.

13. Inform Employer/AR of Customer Complaint Process and work to resolve any problem.

Limitations on CDCN Payment Obligation

If Employer/AR authorizes use of all hours before the end of the authorization period, Employer/AR will need to make other service arrangements. Additional Agreement Terms and Conditions

1. Term and Termination: This Agreement will be effective as of the signature date noted on the last page of the Agreement and will continue until terminated. Both CDCN and Employer/AR have the right to terminate this Agreement at any time. CDCN reserves the right to terminate services with 30‐days’ notice when circumstances are deemed unsafe for CDCN staff, participant(s), worker(s), or for any other reason as determined by CDCN in its sole discretion. If CDCN terminates this agreement, CDCN will notify Participant by email or by regular US mail.



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2. Term of Prohibition on Staff Solicitation: During the term of service with CDCN, and for a period of 180 days after termination of services with CDCN, Employer/AR will not hire or otherwise utilize services of any person previously provided by CDCN, except through a contract with CDCN. If Employer/AR does so, Employer/AR will pay CDCN upon demand, as liquidated damages, the sum of $2,500.00 or 20% of the annualized salary (whichever is greater) for each CDCN employee so hired or utilized.

3. Partial Invalidity: If any portion of this Agreement does not apply to Employer/AR, changes over time, or is determined to be illegal or invalid, that part of the Agreement shall be modified to the extent possible to give it its intended effect and/or meaning, and all remaining provisions of the Agreement shall continue in full force and effect.

4. Arbitration: If Employer/AR or CDCN decide that they are unable to resolve a disagreement within thirty (30) days of notification to the other party regarding the dispute, Employer and CDCN will choose someone from the American Arbitration Association together (known as an independent arbitrator) to work out the disagreement. The cost of the person chosen will be paid equally by both Employer and CDCN. The decision of the arbitrator may be given to a judge in the event the decision is not accepted by either party.

5. Governing Law: This Agreement shall in all respects be construed in accordance with and governed by the laws of the State on which your local office is situated, without regard to its conflict of laws rules. Employer and CDCN agree that the courts in the Judicial District in which your primary State office sits shall have exclusive jurisdiction with respect to any controversy or dispute arising out of or relating to this Agreement and not resolved pursuant to the terms of this Agreement.

6. Indemnification and Hold Harmless: Employer and CDCN (the “Indemnifying Party”) agree to save and hold each other (the “Indemnified Party”) harmless from and against, and will indemnify each other for, any liability, loss, cost, expense or damage whatsoever caused by reason of any injury sustained by any person or to property by reason of any act, neglect, default or omission of Indemnifying Party. If Indemnified Party is sued in court or compelled to arbitrate for damages by reason of any of the acts of Indemnifying Party, Indemnifying Party will defend said action on behalf of Indemnified Party. Alternatively, and with agreement of Indemnifying Party, Indemnified Party may defend the same and any expenses, including reasonable attorney’s fees that Indemnified Party may pay or incur in defending said action and the amount of any judgment, award or settlement that Indemnified Party may be required to pay will be promptly reimbursed by Indemnifying Party upon demand.

7. Waiver of Terms and Conditions: The failure of Employer/AR or CDCN in any one or more instances to enforce one or more of the terms and conditions of this Agreement or to exercise any of its rights or privileges, or the waiver of any breach of such terms or conditions, shall not be construed as thereafter waiving any such terms, conditions, rights or privileges, and the same shall continue and remain in force and effect as if no waiver had occurred.

8. Timely Notification: The Employer/AR and CDCN agree that all contact must occur in a timely way. Any notice will be given immediately, so that neither Employer nor CDCN is hurt by a delay.



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9. Modification of Agreement: Any changes to the terms of this Agreement must be in writing, signed and dated by Employer/AR and CDCN.

10. Privacy: All activities related to this Agreement shall adhere to state and federal confidentiality laws and regulations; including, without limitation the Administrative Simplification provision of the Health Insurance Portability and Accountability Act (“HIPAA”) and regulations promulgated thereunder, 45 C.F.R. Parts 160 – 164 (the “Regulations”), as amended.

11. Workers Compensation Program: If the Employer/AR and Employee do not follow CDCN’s safety program policies, safety training requirements, and injury reporting procedures, the Participant (and their Employees) may be removed from CDCN’s Worker Compensation coverage.

12. Decision to Serve: CDCN can choose to not serve the Participant. This will happen if the Employer/AR does not follow policies and procedures or if the Participant’s health and safety needs cannot be met with the self‐directed program. CDCN will discuss their concerns with the Employer/AR and the Authorizing Agency. If necessary, the Participant’s case manager will assist the Employer/AR with transitioning services within thirty (30) days.

13. Entire Agreement: This Agreement constitutes the entire agreement between Employer/AR and CDCN and supersedes all prior oral and written statements. This Agreement may be modified, amended or changed only by a written document signed by both Employer/AR and CDCN. This Agreement shall not create any benefits, rights, privileges, remedies or claims for, in, by, or on behalf of any parties who are not signatories to this Agreement.

Conclusion

The FEIN Holder is the Employer (of Fact and of Record). The Employer/AR understands and accepts responsibility for recruiting, hiring, training, supervising and terminating their Employee(s). The Employer/AR is responsible for the actions of their Employees while they are providing services. Acceptance of this Agreement is shown by signing below. CDCN Michigan Representative, Signature Date Printed Name

Participant or Guardian, Printed Name Signature Date

Authorized Representative, Printed Name Signature Date


BACKUP PLAN

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Participant Name Authorized Representative Name (if applicable)

Each Participant is required to have an Emergency & Backup Plan. Consumer Direct Care Network (CDCN) will assist you in developing your plan. You should use this if your regularly scheduled Self Determination Program employee cannot work or if you have an emergency. It is your responsibility to use, change, and update your Emergency & Backup Plan. There are potential risks involved if your plan is not effective. The potential risks may include loss of employment, placement in a hospital or nursing facility, personal or other forms of harm or injury, up to and including death.

Plan of Action

Primary Caregiver – Start by identifying your primary caregiver:

My primary Self Determination Program employee is:

Their phone number is:

Backup Caregivers – Please list who you will call if your normally scheduled caregiver(s) cannot work. Back up caregivers may include friends, family, past caregivers, church members, or volunteers.

Name Address (City and Zip) Days/Time Not Available Phone

Other Supports – Please list other supports you will call if you think your health and safety are at risk

Relative Name Address City Zip Phone

Case Manager Name Address City Zip Phone

Physician Name Address City Zip Phone

Other Agency Name Address City Zip Phone


BACKUP PLAN

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In an emergency I could also: (check all that may apply)

Activate my Lifeline

Contact 911

Other

Remember these things when considering your Emergency & Backup Plan. Don’t get caught unprepared! Please check the boxes to show you’ve reviewed the following information.

I (Participant/Authorized Representative) will talk with backup caregivers before an emergency comes up. We will discuss employment, pay, availability, and my personal care needs.

I will identify the personal care tasks that must be performed in a given day. These are the

tasks that are essential to my health and safety. In an emergency situation I may only get these essential needs met. I will keep my list of essential needs updated and available to any backup caregivers.

I know that in order for a caregiver to be paid, they must complete all employment

paperwork. This means they need to have a completed application packet on file with CDCN. I will receive an “Okay to Work” form letting me know they can begin working.

If I think I am at risk for abuse, neglect or exploitation I should contact the Michigan

Department of Human Services Centralized Intake for Abuse and Neglect at 1‐855‐444‐3911.

Participant/Authorized Rep. Signature Date

CDCN Representative Signature Date

You will be mailed a copy of this form by a Program Coordinator.

Please keep it for your records.

Form SS-4(Rev. December 2017)

Department of the Treasury Internal Revenue Service

Application for Employer Identification Number(For use by employers, corporations, partnerships, trusts, estates, churches, government agencies, Indian tribal entities, certain individuals, and others.)

Go to www.irs.gov/FormSS4 for instructions and the latest information.

See separate instructions for each line. Keep a copy for your records.

OMB No. 1545-0003

EINT

yp

e o

r p

rin

t c

lea

rly.

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

2 Trade name of business (if different from name on line 1) 3 Executor, administrator, trustee, “care of” name

4a Mailing address (room, apt., suite no. and street, or P.O. box) 5a Street address (if different) (Do not enter a P.O. box.)

4b City, state, and ZIP code (if foreign, see instructions) 5b City, state, and ZIP code (if foreign, see instructions)

6 County and state where principal business is located

7a Name of responsible party 7b SSN, ITIN, or EIN

8a

Is this application for a limited liability company (LLC) (or a foreign equivalent)? . . . . . . . . Yes No

8b If 8a is “Yes,” enter the number of LLC members . . . . . .

8c If 8a is “Yes,” was the LLC organized in the United States? . . . . . . . . . . . . . . . . . . Yes No

9a Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.

Sole proprietor (SSN) Estate (SSN of decedent)

Partnership Plan administrator (TIN)

Corporation (enter form number to be filed) Trust (TIN of grantor)

Personal service corporation Military/National Guard State/local government

Church or church-controlled organization Farmers’ cooperative Federal government

Other nonprofit organization (specify) REMIC Indian tribal governments/enterprises

Other (specify) Group Exemption Number (GEN) if any 9b

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

State Foreign country

10 Reason for applying (check only one box) Banking purpose (specify purpose)

Started new business (specify type) Changed type of organization (specify new type)

Purchased going business

Hired employees (Check the box and see line 13.) Created a trust (specify type)

Compliance with IRS withholding regulations Created a pension plan (specify type)

Other (specify) 11 Date business started or acquired (month, day, year). See instructions. 12 Closing month of accounting year

13

Highest number of employees expected in the next 12 months (enter -0- if none). If no employees expected, skip line 14.

Agricultural Household Other

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

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

16 Check one box that best describes the principal activity of your business. Health care & social assistance Wholesale-agent/broker

Construction Rental & leasing Transportation & warehousing Accommodation & food service Wholesale-other Retail

Real estate Manufacturing Finance & insurance Other (specify)

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

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

If “Yes,” write previous EIN here

Third

Party

Designee

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

Designee’s name Designee’s telephone number (include area code)

Address and ZIP code Designee’s fax number (include area code)

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

Name and title (type or print clearly)

Applicant’s telephone number (include area code)

Signature Date

Applicant’s fax number (include area code)

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 16055N Form SS-4 (Rev. 12-2017) 05151

Form 2678(Rev. August 2014)

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

OMB No. 1545-0748

Use this form if you want to request approval to have an agent file returns and make

deposits or payments of employment or other withholding taxes or if you want to

revoke an existing appointment.

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

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

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

For IRS use:

Part 1: Why you are filing this form...

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

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

1 Employer identification number (EIN) —

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

3 Trade name (if any)

4 Address

Number Street Suite or room number

City State ZIP code

Foreign country name Foreign province/county Foreign postal code

5 Forms for which you want to appoint an agent or revoke the agent’s

appointment to file. (Check all that apply.) For ALL

employees/ payees/payments

For SOME employees/

payees/payments

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

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

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

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

Sign your

name here

Date / /

Print your name here

Print your title here

Best daytime phone

Now give this form to the agent to complete. ■

For Privacy Act and Paperwork Reduction Act Notice, see the instructions. IRS.gov/form2678 Cat. No. 18770D Form 2678 (Rev. 8-2014)05152

Power of Attorney for UIA

05224

Concessionaire’s Sales Tax Return

Authorized Representative Declaration (Power of Attorney)

I certify that the information provided on this form is true, correct and complete to the best of my knowledge and belief.

05225

UIA Schedule A - Liability QuestionnaireIssued under authority of the Michigan Employment Security Act of 1936, as amended, MCL 421.1 et seq. Filing is mandatory for all employers. You must complete all items on this form accurately and completely. Failure to do so may subject you to the penalties provided under the MES Act.

UIA Account Number, if already assigned Federal Employer Identification No. (required)

An employing unit becomes liable to pay Michigan unemployment taxes when the employing unit meets any of the following criteria:

Pays $1,000 or more in gross wages for covered employment in a calendar year. Employs one or more employees in 20 different weeks within a calendar year. Acquires all or part of an existing Michigan business. Pays at least $1,000 in cash, not including room and board, for domestic service within a calendar quarter. Pays at least $20,000 in cash, not including room and board, for agricultural service within a calendar quarter, OREmploys at least 10 agricultural workers in each of 20 different weeks in the current or preceding calendar year. Elects coverage under the terms of the Michigan Employment Security (MES) Act. Is subject to federal unemployment tax.

When any one of the above criteria is met, you must submit Form 518, Registration for Michigan Taxes, and UIA Schedule A - Liability Questionnaire and UIA Schedule B - Successorship Questionnaire. You must also begin quarterly filing of Form UIA 1028, Employer's Quarterly W a g e / Tax Report. Unemployment taxes are due and payable beginning with the first calendar quarter in which you had payroll. Due dates for tax and wage reports are April 25, July 25, October 25 and January 25. Providing inaccurate or incomplete information in this Registration, or UIA Schedules A or B, will be evidence of intentional misrepresentation and may subject you to the civil and/or criminal penalties provided in Sections 54 and54b of the Michigan Employment Security (MES) Act.

Month Day Year

On what date did/will you first employ anyone in Michigan?

Complete the appropriate sections below according to the type of employer being registered. SECTION 1EMPLOYERS OTHER THAN AGRICULTURAL OR DOMESTIC/HOUSEHOLD(See instructions to determine if applicable)

If Agricultural, skip to Section 2. If Domestic/Household,skip to Section 3.

If you have had a gross payroll of $1,000 or more within a calendar year, enter the date it was reached or will be reached.

If you have had 20 or more calendar weeks in which one or more persons performed services for you within a calendar year, enter the date the 20th week was reached or will be reached. The weeks do not have to be consecutive nor the persons the same.

Month Day Year

Month Day Year

If Employer is a NonProfit, a Governmental Agency / Indian Tribe/ Tribal Unit, a Federal Unemployment Tax Act (FUTA) Subjectivity, or is selecting Elective Coverage, then complete only one of the following four employer types below that best describes the business.

1. NONPROFIT EMPLOYERSNonprofit organizations finance their unemployment liability by either (1) paying unemployment taxes on the taxable wages of their employees (contributing) or (2) making a specific prior election to reimburse the UIA for any unemployment benefits paid totheir former employees (reimbursing). A nonprofit organization that does not elect to be reimbursing will be, by default, contributing.

To elect contributing status, check this box: and skip paragraphs A – D below.

To elect reimbursing status, see paragraphs A – D. A. Nonprofit employers electing reimbursing status must provide the UIA with a copy of the documentation from the Internal

Revenue Service (IRS) granting 501(c)(3) status.

Check this box if you elect to be a reimbursing employer. Attach a copy of your IRS 501(c)(3) documentation. Failure to check this box will result in the establishment of your liability as a contributing employer.

B. If you are a nonprofit employer electing reimbursing status, enter $the amount (or estimate) of your gross annual payroll

C. Bonding Requirements. Section 13a of the Michigan Employment Security (MES) Act requires that nonprofit employers electing reimbursing status on or after December 21, 1989, and that have, or expect to have, a gross payroll of more than $100,000 during any calendar year must notify the UIA of that fact immediately and must provide a surety bond, irrevocable letter of credit, or other banking device approved by the UIA, in an amount to be determined by the UIA to secure the employer's obligations under the MES Act. If you exceed $100,000 in gross payroll in a later year, you are obligated to notify the UIA, and provide the bond at that time.

D. If your organization is funded more than 50 percent by a grant, list the source and duration of the grant.

Source Start Date End Date

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Michigan Unemployment Insurance Agency

2. GOVERNMENTAL AGENCIES, INDIAN TRIBES AND TRIBAL UNITSGovernmental entities generally reimburse unemployment insurance benefits paid to former employees on a dollar-for-dollar basis unless they elect to make quarterly "contribution" payments.

A. If you are a governmental agency, or Indian tribe or tribal unit, identify the type (i.e., city, township, commission, authority, tribe, etc.)

B. Enter your fiscal year beginning date

Month Day

C. Check this box if you elect to be a contributing employer. Leaving this box unchecked will result in the establishment of your liability as a reimbursing employer.

D . Indian tribes and tribal units are subject to the same bonding requirements as nonprofit employers (see Line 1C, above).and must provide the amount (or estimate of their gross annual payroll here:

3. FEDERAL UNEMPLOYMENT TAX ACT (FUTA) SUBJECTIVITY. Select this option ONLY if you are NOT liable for UIA taxes State

under any of the other employer types.

If you are already subject to FUTA, enter the state, other than Michigan, where you became liable Note: "Subject to FUTA" refers to filing Form 940 with the IRS. If you are required to file Form 940 (FUTA) with the IRS in other states, you are required to file and pay state unemployment taxes in Michigan.

4. ELECTIVE COVERAGE. For employers who would not otherwise be liable for unemployment taxes, such as churches.

Check this box if you wish to elect coverage under the MES Act. Approval is subject to UIA review; some qualifiers apply. Your election, if granted, will apply to all your employees. Give your reason for electing coverage in the space provided below. If you are an individual owner or partnership electing to cover family members, specify their relationship to the owner or partners. You may not elect coverage for your parents or spouse, nor for your child under theage of 18. Individual owners and partners cannot elect coverage for themselves. You may not elect coverage for domestic employment below the statutory requirements stated above. Election of coverage remains in effect for a minimum of two calendar years.

SECTION 22. AGRICULTURAL EMPLOYERS ONLY

A. If you have had a total cash payroll of $20,000 or more for agricultural services performed within a calendar quarter in either the current or preceding calendar year, not including room and board, enter the date the $20,000 was reached or will be reached.

B. If you have had at least 10 agricultural workers in each of 20 different weeks in the current or preceding calendar year, enter the date the 20th week was reached or will be reached. The weeks do not have to be consecutive nor the persons the same.

SECTION 33. DOMESTIC/HOUSEHOLD EMPLOYERS ONLY

A. If you have had a cash payroll of $1,000 or more for domestic services within a calendar quarter in either the current or preceding calendar year, not including room and board, enter the date the $1,000 was reached or will be reached.

SECTION 4ALL EMPLOYERS

Month Day Year

Month Day Year

Month Day Year

Print Name of Owner/Officer Signature of Owner/Officer

Title Telephone Number Date

Print Name of Owner/Officer Signature of Owner/Officer


Attach this schedule to Form 518, Registration for Michigan Taxes and mail it to the Michigan Department of Treasury.05227

518 Schedule B (Rev. 11-07)

UIA Schedule B - Successorship QuestionnaireIssued under authority of the Michigan Employment Security Act of 1936, as amended, MCL 421.1 et seq. Filing is mandatory for employers.

You must complete all items on this form accurately and completely. Failure to do so may subject you to the penalties provided under the Michigan Employment Security (MES) Act. Attach additional sheets if necessary.

Successorship Reporting Requirement. If you acquired any part of the Michigan assets, trade or business of another employer, as defined in Part 3 of this form, by purchase, rental, lease, inheritance, merger, foreclosure, bankruptcy, gift or any other form of transfer, you must provide the following information. If you made multiple acquisitions, you must file a separate UIA Schedule B for each acquisition (photocopies of this form are acceptable). If you made no acquisitions, you are still required to complete this schedule. If subsequent to completing this registration form, you transfer the assets (by sale or transfer), organization (payroll/employees), trade (customers/accounts), or business (products/services), in whole or in part, to a new or previously existing business in Michigan, it is mandatory that you notify this Agency immediately by completing an additional Schedule B.

UIA Account Number (if already assigned)

Federal Employer Identification No. (required)

PART I: QUESTIONS ABOUT PRIOR OR CURRENT BUSINESS FORMATIONS, ACQUISITIONS OR MERGERS

For each of the following five business formation, acquisition or merger types, the employer must indicate the pertinent businessname, address and UIA Account Number in the space provided.

1. In the past 6 years, have you formed, acquired or merged with a business by any means? If no, check box and continue. If yes, provide the following:

Business Name and Address UIA Account Number

a. If you formed a new business, what did you acquire from the previously existing business? (check all that apply)Land Buildings Employees Trade

Furniture/Fixtures Customer Accounts

Equipment Inventory Accounts Receivable Goodwill None

b. If you purchased, acquired or merged with an existing business by any means (including lease), what assets did you acquire? (check all that apply)

Land Buildings Employees Trade



c. What was the business activity of the previous business?

2. At the current time, are you forming or acquiring a business by any means? If no, check box and continue, If yes, provide the following:


a. If you formed a new business, what did you acquire from a previously existing business? (check all that apply)Land Buildings Employees Trade



b. If you are purchasing or acquiring an existing business by any means (including by lease), what assets are you acquiring? (check all that apply)




c. Will any owner or owners of the previous business continue to operate or manage the business being registered by this form?

Yes No If yes, provide name, title and business address below.

d. What was the business activity of the previous business?

e. What will be the business activity, if any, of the previous business after the new business being registered is formed?

f. What will be the business activity of the new business being registered by this form? 05228

Michigan Unemployment Insurance Agency

518 Schedule B, Page 2

PART I: QUESTIONS ABOUT PRIOR OR CURRENT BUSINESS FORMATIONS, ACQUISITIONS OR MERGERS (continued)

3. At the current time, are you incorporating an existing business entity? If no, check box and continue. If yes provide the following:


a. What was the business activity of the business entity you are incorporating?

b. What will be the business activity of the new business being registered by this form?

4. At the current time, are you merging, by any means, with one or more business entities? If no, check box and continue. If yes, provide the following:


a. If you are purchasing or acquiring an existing business by merger, what are you acquiring? (check all that apply)




b. If you are forming a new business, what are you acquiring from a previously existing business? (check all that apply)Land Buildings Employees Trade



c. Will any owner or owners of the merging business continue to operate or manage the business being registered by this form?

Yes No If yes, provide name, title and business address below.

d. What was the business activity of the merging business?

e. What will be the business activity of the continuing business being registered by this form?

5. Are you intending to form a business at a future time, by any means?

Yes No

If yes, please explain:

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518 Schedule B, Page 3

PART II: FORMER OWNER INFORMATIONFormer Owner's Name Former Owner's UIA Account Number or FEIN, if known.

Corporate Name or DBA Area Code & Telephone Number

Current Street Address (not a P.O. Box)

City, State, ZIP

PART III: ACQUISITION INFORMATION

1. Did you acquire all, part, or none of the assets of any former business? All Part

2. Did you acquire all, part, or none of the organization(employees/payroll/personnel) of any former business?

What Percent? Date Acquired

None

a. If all or part, indicate the percent and date acquired.

b. Did you acquire all or part of the employees/payroll/personnel of any former business

What Percent? Date Acquired

All Part None

by leasing any of those employee/payroll/personnel? Yes No (If yes, provide a copy of your lease agreement)

3. Did you acquire all, part, or none of the trade(customers/accounts/clients) of any former business? All Part

4. Did you acquire all, part, or none of the former owner's

What Percent?

What Percent?

Date Acquired

Date Acquired

None

Michigan business (products/services) of any former business?

5. Was the Michigan business described in 1-4 above being operated at the time of acquisition? If no, enter the date it ceased operation.

6. Are you conducting/operating the Michigan business you acquired?

7. Is your Michigan business substantially owned or controlled in any way by the same interests that owned or controlled the organization, business or assets of a former business?

All Part

Yes No

Yes No

Yes No

Month Day Year

None

8. Did you hold any secured interest in any of theMichigan assets acquired? Yes No If yes, enter balance owed $

9. Enter the reasonable value of the Michigan organization,trade, business or assets acquired? $

Providing inaccurate or incomplete information in this Registration, or UIA Schedules A or B, will be evidence of intentional misrepresentation and may subject you to the civil and/or criminal penalties in Sections 54 and 54b of the Michigan Employment Securities (MES) Act.

Print Name of Owner/Officer Signature of Owner/Officer/Authorized Agent


Print Name of Owner/Officer Signature of Owner/Officer/Authorized Agent


Attach this schedule to Form 518, Registration for Michigan Taxes and mail it to the Michigan Department of Treasury.05230

By signing this form, I authorize Treasury to communicate with my representative consistent with the authority granted.

05232

Power of Attorney (POA) Complete this form if you wish to appoint someone to represent you with the State of Michigan Unemployment Insurance Agency, or if you wish to revoke or change your current Power of Attorney representation. Please read the instructions on page 2 before completing this form.

PART 1: EMPLOYER INFORMATION

**

PART 2: REPRESENTATIVE INFORMATION AND AUTHORIZATION DATES

*

PART 3: TYPE OF AUTHORIZATION

GENERAL AUTHORIZATION

LIMITED AUTHORIZATION

WORK OPPORTUNITY TAX CREDIT (WOTC)

Required Beginning Date Required End Date

PART 4: CHANGE IN POWER OF ATTORNEY

CHANGE IN POWER OF ATTORNEY REPRESENTATION:

REVOKE PREVIOUS AUTHORIZATION:PART 5: EMPLOYER’S SIGNATURE

***

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