Common use of ACKNOWLEDGEMENTS AND SIGNATURE Clause in Contracts

ACKNOWLEDGEMENTS AND SIGNATURE. Applicant must check all boxes, sign, and date. ☐ I affirm that the information I have provided on this form is complete and accurate to the best of my knowledge. ☐ I authorize DHS IRIS partner agencies to conduct a background check now and to automatically conduct future background checks – without notice – every 4 years and ad hoc for as long as I provide paid IRIS services. ☐ I understand that an out-of-state or out-of-country background check may increase processing time. SIGNATURE – Applicant Date Signed Division of Medicaid Services F-01201C (02/2017) Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the participant’s Fiscal Employer Agent. Name – Participant-Hired Worker (Last, First) Name – Participant Employer (Last, First) Date of Birth – Participant-Hired Worker The participant employer requires the following tasks and duties to be performed by the participant-hired worker: The participant employer agrees to provide/arrange for worker training as described below: Supportive Home Care (SHC) Self-Directed Personal Care (SDPC) Respite Care (R) Other Mileage If “Other”, please explain: Supportive Home Care (SHC) Self-Directed Personal Care (SDPC) Respite Care (R) Other Mileage Indicate the rate and the number of miles per month the participant-hired worker is authorized to provide. If “Other”, please explain: I (We) understand that the services are provided under Medicaid regulations and that I (we) may not charge in excess of the amount authorized on the participant employer’s plan. After the participant-hired worker has performed the service(s) per this agreement, time reports are due to the participant’s Fiscal Employer Agent. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. SIGNATURE – Participant-Hired Worker Date Signed SIGNATURE – Participant Employer Date Signed

ACKNOWLEDGEMENTS AND SIGNATURE. Applicant must check all boxes, sign, and date. ☐ I affirm that the information I have provided on this form is complete and accurate to the best of my knowledge. ☐ I authorize DHS IRIS partner agencies to conduct a background check now and to automatically conduct future background checks – without notice – every 4 years and ad hoc for as long as I provide paid IRIS services. ☐ I understand that an out-of-state or out-of-country background check may increase processing time. SIGNATURE – Applicant Date Signed Division of Medicaid Services F-01201C (02/2017) Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the participant’s Fiscal Employer Agent. Name – Participant-Hired Worker (Last, First) Name – Participant Employer (Last, First) Date of Birth – Participant-Hired Worker The participant employer requires the following tasks and duties to be performed by the participant-hired worker: The participant employer agrees to provide/arrange for worker training as described below: Supportive Home Care (SHC) Self-Directed Personal Care (SDPC) Respite Care (R) Other Mileage If “Other”, please explain: Supportive Home Care (SHC) Self-Directed Personal Care (SDPC) Respite Care (R) Other Mileage Indicate the rate and the number of miles per month the participant-hired worker is authorized to provide. If “Other”, please explain: I (We) understand that the services are provided under Medicaid regulations and that I (we) may not charge in excess of the amount authorized on the participant employer’s plan. After the participant-hired worker has performed the service(s) per this agreement, time reports are due to the participant’s Fiscal Employer Agent. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. SIGNATURE – Participant-Hired Worker Date Signed SIGNATURE – Participant Employer Date Signed