Prototype- MSFS Live & Work with the Person you serve 2014-7 Tax Exemption Form

Select action*

EnrollCancel

Select a state*

HIDE- Select a state

HIDE- Select an action

Enroll (select this if you are a new Employee)Cancel

Employee Legal Name*

Legal First NameLegal Middle NameLegal Last Name

Employee Email*

example@example.com

Participant Legal Name*

Legal First NameLegal Last Name

If you answered yes to questions 1 & 2, you are eligible for a special tax exemption. Employees who live and work with the person they are serving can claim a "Difficulty of Care" tax exemption. This means income earned will not be reported as wages or have federal taxes withheld. Alabama state wages do not qualify for this exemption and are reported as income.

Will you have the same address as the person you are serving?

YesNo

HIDE- Will you have the same address as the person you are serving?

YesNo

If you are living with the person you are serving, is this your permanent address?*

YesNo

HIDE- If you are living with the person you are serving, is this your permanent address?

YesNo

A- Select carefully below. Taxes withheld from your paycheck will be impacted by your selection. Do not make a selection that does not reflect your living situation.*

This tax exemption DOES NOT apply to me and I understand that federal and state taxes will be taken out of my paycheck based on my W-4 selections.

B- Select carefully below. Taxes withheld from your paycheck will be impacted by your selection. Do not make a selection that does not reflect your living situation.*

This tax exemption DOES apply to me and I understand that I will have no federal wages to claim or taxes withheld.This tax exemption DOES apply to me, however, I am choosing to take this exemption on my own personal tax return. I understand the IRS regulations require that if I qualify for this exemption, I must take the exemption.

HIDE- Select carefully below. Taxes withheld from your paycheck will be impacted by your selection. Do not make a selection that does not reflect your living situation.

This tax exemption DOES NOT apply to me and I understand that federal and state taxes will be taken out of my paycheck based on my W-4 selections.This tax exemption DOES apply to me and I understand that I will have no federal wages to claim or taxes withheld.This tax exemption DOES apply to me, however, I am choosing to take this exemption on my own personal tax return. I understand the IRS regulations require that if I qualify for this exemption, I must take the exemption.

*Note - it is your responsibility to inform Morning Sun if your living conditions change and you no longer qualify for this tax exemption. Morning Sun is not responsible for tax liability you owe in connection with this exemption. Please seek the advice of a tax advisor if you are unsure of the impact to your personal situation. Morning Sun is not responsible for impacts to your personal tax situation. For more information, please visit www.irs.gov and search "2014-7 Exemption."

I will provide only the services that have been approved by my Client/Employer and authorized in the Employers Service plan.

I am requesting to cancel my IRS Notice 2014-7 Certification Statement stating that I am an individual care provider receiving payments under a state Medicaid Home and Community-Based Services waiver program for care I provide to the consumer listed on this form who is under the recipient's plan of care.

Please choose one option as your reason for cancellation:*

My living situation has changed and I no longer reside with the consumer listed above.I continue to reside with the consumer listed above, but am requesting to revoke my certification statement status through Morning Sun. I understand that I must claim the exemption on my own individual tax returns.

HIDE- Please choose one option as your reason for cancellation:

My living situation has changed and I no longer reside with the consumer listed above.I continue to reside with the consumer listed above, but am requesting to revoke my certification statement status through Morning Sun. I understand that I must claim the exemption on my own individual tax returns.

This cancellation indicates that my living situation has changed and I no longer reside with the consumer listed above.

Employee Legal Name*

Legal First NameLegal Last Name

Employee Signature*

Date of signature*

Date

Please verify that you are human

Morning Sun Financial Services Live & Work with the Person you serve 2014-7 Tax Exemption Form

Morning Sun Financial Services Live & Work with the Person you serve 2014-7 Tax Exemption Form

Employee Information

Enroll

Cancellation of IRS Notice 2014-7 Certification Statement

Signatures