Forms
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To designate a respite worker, both parties must complete and sign/initial the areas indicated on the Parent/Guardian Waiver. The person being designated must complete a W-4 and DE 4. A copy of a signed Social Security card or other documentation matching the person’s name to the Social Security number should be included. The original forms must be received by Respite, Inc. before a worker can be paid, however, services can be provided during the interim. In order to match the forms with the correct person it is best to submit the original forms with the person’s first timesheet.
Click on the following titles to open and print forms:
Title 17 Respite Worker Requirements (56792)
Parent/Guardian Waiver – Designate a Respite Worker
Fill in the blanks as indicated.
W-4 (Federal Withholdings)
A copy of documentation matching the respite worker’s name with Social Security number should be included.
DE 4 (California Withholdings)
This form is for designating California taxes.
USCIS Form I-9 Employment Eligibility Verification
Verifying a designated worker’s identity is mandatory and the parent/guardian’s responsibility.
Complete and keep this form for your records. (May be audited by ICE.)
Do not return this form to our office.
*New* EVV Forms
EVV Attestation Form
If your worker is considered live-in staff, they do not have to participate in the EVV system.
EVV Participation Form
If your worker does not meet the requirements to be live-in staff, use this form. They will be required to use the EVV system.