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CA GGRC Worker Application Instructional Packet

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Dear Worker,

Thank you for applying.

GGRC has contracted with PCG Public Partnerships, LLC (PPL) to act as a Financial Management Service (FMS) provider for participants who choose to participant-direct their services. PPL will send out payment once all correct forms have been received and processed. You are not permitted to work prior to your participant receiving their good to go call from PPL.

Please use this instructional packet to fill out your employment forms. When finished, please fax the forms back to PPL at (855)867-1676. You may also email them to us at CAGGRCenrollment@pcgus.com. Your Participant will receive a phone call once the paperwork has been processed to inform them of next steps.

Should you need new forms or additional instructions, these items can be printed from our website: www.publicpartnerships.com. Click on “Select a Program” in the upper-right hand corner of the page. Then select “California” from the drop-down menu. Next, click on the California Golden Gate Regional Center Program. Lastly, click on “Program Documents” link on the right hand side of the page. You may also contact our customer service department at (877)522-1053, Monday through Friday from 8:00am to 6:00pm PST.

We look forward to working with you!

Sincerely,

Public Partnerships, LLC

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Criminal Background Check & Training Instructions

Criminal Background Check Information/Instructions: The Golden Gate Regional Center Participant Directed Services Program allows participants and employers to request criminal background checks for potential workers.

Note: As a standard practice, PPL runs all potential workers through an OIG (Officeof Inspector General) check. Regardless of the Employer’s preference for a criminal check. The OIGresults do not include a comprehensive criminal history.

If Employer conducts criminal background check, they must submit the check within 5 business days of their worker’s enrollment. B ackground check will be performed through LiveScan technologies. Once the criminal history results are received, PPL must be notified of results within 24 hours. Worker will not be able to perform services until results are received.

Employer and Worker are required to complete the “Request for LiveScan Service” form foundonline. Worker must take the form with them to the nearest LiveScan location for processing.

Understand the cost of processing a criminal background check is at the expense of the employer andwill not be reimbursed by GGRC or PPL. Costs vary from location to location; please see theLiveScan website for more information.

LiveScan locations: http://ag.ca.gov/fingerprints/publications/contact.php

Criminal Background Check & Training Preference Form: Indicate if Criminal Background Check is required or not. (Select one)

OR

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Criminal Background Check & Training Instructions

Training Instructions: Some participants require the workers to be CPR and/or First Aid Certified or have additional training(s).

If so, employer will indicate and require appropriate documentation of CPR, First Aid training, or other participant specific trainings be submitted. These will need to be received by PPL prior to services being performed.

Form will need to be signed and dated by both the Worker and Participant/Employer, then returned to Public Partnerships LLC either by mail or fax.

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Public Partnerships, LLC Fiscal Intermediary Services 7776 S Pointe PKWY W STE 150 Phoenix, AZ 85044

Employee I-9 Form

The I9 form is a U.S. Citizenship and Immigration Services form. We use this form to verify your identify and establish that you are eligible for employment in the United

States. Please fill out the attached form based on the instructions below:

1. The employee would fill out section 1 to the best of their abilities. Thisincludes the employee’s Full Legal name and Physical Street address, date ofbirth, and social security number. Remember to check the appropriate boxregarding the employee’s residency status. The employee signature anddate signed are required in Section 1. This is very important. If theemployee signature and date are missing in section 1, Public Partnerships willnot be able to process the I-9 form.

2. The employer is responsible for filling out section 2 to the best of their abilities.The employer’s signature and date are required in Section 2. This is veryimportant. If the employer’s signature and date are missing from section 2,Public Partnerships will not be able to process the I-9 form.

We will not be able to pay you until we receive this form, so this is very important!

Instructions for IRS Form W-4

The W-4 form is a form used by the Internal Revenue Service. This form is required to ensure that Public Partnerships is withholding the correct amount of federal taxes from your paycheck.

When do I send this form?

You must fill out this form at the start of employment. If you are filing as exempt, you must complete and submit a new form each year starting on January 1st (depending upon availability of the current year’s form) but no later than February 15th to maintain your exempt status. If your new form is not received by that time, Public Partnerships will default your status to Single with 0 allowances (highest taxable amount) until a new W4 form has been received.

Where can I find this form?

For more information, you can go online to www.irs.gov/pub/irs-pdf/fw4.pdf.

What if the employee is under 18?

If your state allows employees under the age of 18, the employee would still be required to fill out a W-4 form. It would be completed the same way that an employee age 18 or over would.

Will Public Partnerships help me figure out how to file?

Since Public Partnerships is not a tax advisor, for advice on how to file, or for help regarding your specific tax situation, you should contact your local tax advisor or the IRS. Customer service can assist with questions regarding the below instructions.

Note: If you are having trouble figuring out what your withholding should be, the IRS does provide a W-4 calculator on their website: https://www.irs.gov/Individuals/IRS-Withholding-Calculator

What parts of the form are required?

In addition to your signature, several fields are required to complete your W-4. Your name, social security number, home address (no post office boxes), filing status, and number of allowances are all needed for an accurate form. You will see this on page 1 of your W-4 form toward the bottom of the page.

Take a look at the example below to see what a completed W-4 could look like:

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Instructions for IRS Form W-4

Note: If you are filing as exempt, you should write exempt in line 7 and leave lines 5 and 6 blank. Alternatively, if you are claiming allowances, you should write the number of allowances in line 5 and leave line 7 blank. If you want to claim an additional dollar amount in addition to the amount that was claimed in box 5, please write the dollar amount is box 6.

Who signs the W-4 form?

The Employee will sign and date the bottom of the first page of the W-4 form. The Employer’s name and address is needed on line 8, underneath the Employee’s signature. The Employer’s EIN is optional and can be left blank if unknown. Note: The Employer is the individual who signs and approves timesheets. PPL is NOT your employer.

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Instructions for IRS Form W-4

Are there parts that are not required?

The “Deductions and Adjustments” worksheet on the second page of your W-4 form is included toaid you in filling out yourW-4 properly for yoursituation. As this isincluded to help you,please keep this page foryour records and do notsend this back to PublicPartnerships. To processyour W-4 form, PublicPartnerships will only needthe first page of the formon which the sectionentitled “Employee’sWithholdingAllowance Certificate”is located.

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Instructions for CA Form DE-4

The DE-4 form is a form used by the State of California. This form is required to ensure that Public Partnerships is withholding the correct amount of California state taxes from your paycheck.

When do I send this form?

You must fill out this form at the start of employment. If you are filing as exempt, you must complete and submit a new form each year starting on January 1st (depending upon availability of the current year’s form) but no later than February 15th to maintain your exempt status. If your new form is not received by that time, Public Partnerships will default your status to Single with 0 allowances (highest taxable amount) until a new DE-4 form has been received.

Where can I find this form?

For more information, you can go online to http://www.edd.ca.gov/pdf_pub_ctr/de4.pdf.

What if the employee is under 18?

Services may not be provided by anyone under the age of 18 in the state of California.

Will Public Partnerships help me figure out how to file?

Since Public Partnerships is not a tax advisor, for advice on how to file, or for help regarding your specific tax situation, you should contact your local tax advisor or the State of California Franchise Tax Board at 1-800-852-5711. Customer service can assist with questions regarding the below instructions.

What parts of the form are required?

In addition to your signature, several fields are required to complete your DE-4. Your name, social security number, home address (no post office boxes), social security number, and filing status are required in the top portion of the form.

In addition, you will need to provide either a number of allowances, OR a specific dollar amount, OR check the box stating that you are exempt. Please select ONLY ONE of those three options.

Take a look at the example below to see what a completed DE-4 could look like:

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Instructions for CA Form DE-4

Note: Even if you have filled out a W-4 form for your federal taxes, you still must complete a California DE-4 form. Your filing status on your W-4 will not apply to your state taxes.

Who signs the DE-4 form?

The Employee will sign and date in the middle of the first page of the DE-4 form. The Employer does not have to fill out anything on this form. The portion entitled “Employer’s name and address” and “California employer account number” is not required and may be left blank. Note: The Employer is the individual who signs and approves timesheets. PPL is NOT your employer.

Are there parts that are not required?

Pages 2-4 of the DE-4 form are not required in order for your form to be processed. Please do not send these pages back to PPL, these are for you to keep for your records.

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Keep this form

Instructions for Direct Deposit Setup

What is the purpose of this form?

This is an optional form and should be submitted back to Public Partnerships if a worker would like their payments made via Direct Deposit, they may fill out and submit this form to Public Partnerships, LLC (PPL). Keep in mind, it will take approximately one to two pay periods for direct deposit to become active. In the interim, the employee will receive a paper check mailed to the address on file. How do I complete this form?

• Fill in your Name, Participant/Employer Name, PPL ID (if known), and Social Security Number in the blanks at the top of the page.

• Check off the appropriate box indicating if the request is a new request, Change request, or a Cancellation request.

• Check off the appropriate box indicating if the Direct Deposit is going to a Checking Account,

Savings Account, or a Pay Card.

• Check off the “Do NOT Send the Paper Remittance Advice…” box if you prefer to view your paystubs online.

• Attach a Voided Check to the form OR submit documentation from your current financial entity confirming the account number and routing number. Cancellation request DO NOT require supporting documentation, but DO require the Participant/Employer name to be listed.

• Sign and Date the bottom of the form.

Where to send the form? Fax E-mail Mail

1-855-867-1676 caggrc@pcgus.com

Public Partnerships, LLC Attn: CA GGRC 7776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044

Public Partnerships, LLC CA GGRC 7776 S Pointe Pkwy W Suite150 Phoenix, AZ 85044

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PPL E-Timesheet/E-Invoice Notification

Dear Participant and Worker,

The purpose of this letter is to inform you of the benefits of submitting your timesheets and invoices online. Online timesheets/invoices are a fast and easy option to submit timesheets and mileage invoices. This will allow you to avoid faxing or mailing them to us. The online system will catch most errors. That means it most likely will not allow you to submit incorrect timesheets or invoices. You will also be able to monitor your timesheet and invoice status in the online timesheet system. You may also view and print check stubs from this area as well.

Please note: in order to send in timesheets and invoices online, both the Worker and Employer will have to register for an online account. The worker will need to create and submit their timesheet or invoice online. Once they have completed this, the Worker must notify the Employer. The Employer must then sign in and approve the submission. The Employer will also have the option to reject the timesheet or invoice if it has errors.

For more information regarding how to submit online for payment or how to create an account, please visit http://www.publicpartnerships.com/programs/california/GGRC/program.asp. Then, select “Registering For Portal – Employers and Workers”. For any additional questions, please contact customer service at (877) 522‐1053 or email us at CAGGRC@pcgus.com Our customer service team is available Monday- Friday 8am-5pm. We look forward to speaking with you!

Sincerely,

Public Partnerships, LLC

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Paper Timesheet Instructions

PPL accepts paper timesheets by fax or mail. Timesheets are read by a machine (like the ones that reads standardized tests), so it is important that you fill out these timesheets clearly and completely.

Required Fields All of these fields MUST be completed for the timesheet to be paid. This list corresponds to the timesheet image found on the previous page. A. Member’s Name: This is the name of the Member receiving services. Please print theMember’s name clearly on the line.

B. Member ID: This ID is your Consumer ID number which starts with the letter “C”.12

C. Employee’s Name: This is the name of the employee who is providing services to theMember for days worked on this timesheet.

D. Employee ID: This ID is generated by PPL and will start with the letter “E.”

E. Service Type: Fill in the circle for the service being provided.

F. Year: Fill in the current calendar year.

G. Specify Pay Period: Fill in the circle that corresponds to the dates of work being submitted;either the 1st – 15th or the 16th – End of Month. Do not use a √ or an X.

H. Date Worked: Fill in the 2 digit month and 2 digit day for the date of work being reported.For example, July 9th would be reported as 07/09.

I. Time IN: Enter the time the employee started working. Please remember that you MUST fillin the corresponding circle for AM or PM.

J. Time OUT: Enter the time the employee finished working. Please remember that you MUST fill in the corresponding circle for AM or PM.

K. Date of Employee Signature: This should be the date that the employee reviewed and signedthe timesheet.

L. Employee Signature: Signature of the Employee who provided service on the dates worked.

M. Date of Member/Employer Signature: This should be the date that the Member reviewedand signed the timesheet.

N. Signature of Member/Employer: Signature of the Member/Employer who reviewed andapproved the timesheet.

Special Situations 1. Working overnight: When you work overnight (past midnight), you must complete one

line for work you did before midnight and another line for work you did after midnight.For example, if you worked overnight Friday September 5th, 2014 from 9:00 PM to 6:00 AM. Enter the Time IN as 9:00 PM. Enter the Time OUT for that day as 11:59PM. Now, you did not finish working at 11:59 PM, you just finished working on Friday at that time. Enter the rest of your time for Saturday September 6th, 2014, from 12:00 AM to 6:00 AM.

2. Multiple shifts:. If you work for a member more than once in a day. you can entertwo different Time IN and Time OUT times on one timesheet; however, you must 13

enter each as a separate line item. If you need to enter more than two shifts (two Time IN and Time OUT times for the same day), you will need to move onto a second timesheet for the same pay period.

For example, say you started working for Chrissy at 9:00 AM. You helped her until 10:05 AM. You left to run an errand, came back at 11:15 AM, and stayed until 12:30 PM. You would create a separate entry for each shift; one from 9:00 AM to 10:05 AM and another from 11:15 AM to 12:30 PM.

General Suggestions • Fill in the timesheet clearly. Your Member will need to be able to read the timesheet clearly inorder to approve it on time.

• Use a new timesheet for each pay period, DO NOT make copies of timesheets. Ensure yourtimesheet is centered on the paper.

• Fill in all the required fields. You will not be paid unless all of the fields are filled in.

• Use black ink.

• Use separate timesheets for different Members.

• Do not round time. Write the exact time. Our systems will round your time for you.

• If you make a mistake, use a new timesheet; do not use Whiteout.

Obtaining Timesheets You can download copies of the timesheets online at www.publicpartnerships.com. Click on “Who We Serve,” select (California) from the map of the United States, and click on the (CA GGRC) Service Option; click program documents (located in the green banner on the right-hand side of the screen). A list of documents will then appear. Timesheets will be located under TIMESHEETS & INVOICES and will be titled GGRC Timesheet.

Where to Send Timesheets Fax to: 1-855-597-3876 Mail to: Public Partnerships, LLC

Attn: CA GGRC 7776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044

Questions? We’re here to help. Call our Customer Service Team at 1(877)522-1053.

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Worker ID:

Participant ID:

Worker's Name:

Participant's Name:

NOTE:1. For the Service Code box, please enter the code that correspond to the service delivered.These can be found on the Timesheet Service Code list in the enrollment packets. If you deliveredmore than one type of service during this pay period, you will need to complete a separatetimesheet per service code.2. If you work through midnight, enter your Time Out on the first day as 11:59 PM.On the next line enter your Time In on day two as 12:00 AM.3. Use Black Ink; Fill in Circles Completely; DO NOT PhotoCopy

CA GGRC - Participant Directed Services TimesheetTimesheetTimesheet

DateWorked

Month DayM M D D

Specify Pay Period: 1st - 15th 16th to End of MonthYear

Time OUT

HH MM

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AM PM

AM PM

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MAIL: PUBLIC PARTNERSHIPS LLC, ATTN: CA GGRC,7776 S Pointe Pkwy W, Phoenix, AZ 85044 FAX: PPL @ 1-855-597-3876

By signing below, I certify that I have provided theservices to the consumer during the times describedon this timesheet.

Date:

/ /Worker Signature: Consumer/Employer or Representative:

Date:

/ /

I certify that the consumer has received hoursof service as reported above.

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:

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Service Code:

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26833

2683315

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Transportation (Passes, Other) Invoice Instructions

If you submit invoices on paper, it is important that you fill out the invoices clearly and completely, otherwise payment may be delayed. This document will cover how to submit a paper invoice for Transportation (Passes, Other) Invoices Only.

Please Note: If you are requesting reimbursement for bus mileage or trip, please see the document labeled “Transportation Invoices for Mileage & Trip.” Do NOT follow the process listed on these instructions.

For 470 PASS Authorizations ONLY: There are 10 required fields on our Transportation Invoice. All of these fields MUST be completed for the invoice to be paid. This list corresponds to the invoice image that follows.

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Transportation (Passes, Other) Invoice Instructions

Required Fields for Transportation (Mileage, per trip) Invoice

A. Worker’s Name: Enter the name of the person providing services.B. Participant’s Name: Enter the name of the person receiving services.C. Worker ID: This is the PPL ID given to the worker. It begins with the letter “E” and is

followed by 4-6 digits.D. Participant ID: This is the Participant’s ID number. It can be found on the participant’s

Individual Service Plan and should begin with the letter “C”.E. Service Code and Type of Pass: Check the appropriate box for the Service Code

associated with your Participant’s Service Authorization and the type of pass you areinvoicing for.

F. Month of Use: The month that the Pass will be used forG. Amount to be reimbursed: This is the amount of your pass. You must submit a copy of a

receipt to be reimbursed. H. Additional Comments: Any additional comments on the type of pass or reimbursement (if

applicable). I. Date and Worker’s Signature. This is the Worker’s signature and the date that the worker

signed the timesheet. J. Date of Employer’s Signature. This is the Employer’s signature and the date that the

Employer signed the timesheet.

General Suggestions

• Fill out all required fields for invoice clearly. If the machine cannot be read and needs to becorrected it may delay your payment.

• Do not use markers or pencil. Markers tend to bleed and can cause invoice errors.

• If you work with more than one participant, make sure you submit separate invoices.

• For any invoice requiring backup documentation (Passes) make sure you submit a copy of yourpass or receipt along with your invoice.

• Do not use white-out on any of the document they will be rejected.

• Submit your invoices within 30 days of delivering the service.

• If you need additional space, please add any extra lines to a separate invoice sheet. Double sidedinvoices may not be processed in their entirety.

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Transportation (Passes, Other) Invoice Instructions

Obtaining New Invoices

We have included copies of both invoices with this packet. You can make copies of the invoices we give you but make sure they are full-size.

You can print copies of blank invoices from the Web Portal. (See Web Portal Instruction packet). You can also call customer service and ask them to send you invoices.

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CA GGRC Participant Directed Program Transportation (Passes, Other) Invoice

Worker Name: Worker ID Number:

Participant Name: Participant ID Number:

FOR MONTHLY PASS AUTHORIZATIONS: Please select the authorized service code from the list, if not listed pleasesupply the service code per the Participant’s Service Authorization under “OTHER”. Workers are also required to fill out theDate of Purchase, and Amount to be Reimbursed sections. Additional Comments are optional

Service Code (Please Check One)

Type of Pass

470

1PI BART Pass - per item1MM Senior/Disabled 31-Day Transit Pass for Marin LocalMSF1 Monthly Pass - SF MUNI Disabled PassMSM1 Monthly Pass - Samtrans "Eligible Discount"MSM2 Monthly Pass - Samtrans "Adult - Into SF" TAFT Monthly TAFT Pass OTHER: Detail:

ALL PASSES AND TRIP INVOICES MUST BE ACCOMPANIED WITH APPROVED BACKUP DOCUMENTATION (A COPY OF THE PASS, OR A RECEIPT FROM PURCHASE OF PASS)

PLEASE KNOW THAT FAILURE TO FILL OUT THIS FORM COMPLETELY AND ACCURATELY CAN RESULT IN DELAY OF PAYMENT.

Worker Signature Date Employer Signature Date

FAX OR MAIL INVOICE REQUEST TO: FAX: (855)-867-1676 MAIL: PPL, CA GGRC, 7776 S Pointe Pkwy W, Suite 150, Phoenix, AZ 85044

Month of Use Amount to be Reimbursed Additional Comments (If Applicable)

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Transportation (Mileage, Per Trip) Invoice Instructions

If you submit invoices on paper, it is important that you fill out the invoices clearly and completely, otherwise payment may be delayed. This document will cover how to submit a paper invoice for Mileage, per trip ONLY.

Please Note: If you are requesting reimbursement for bus passes, please see the document labeled “Transportation Passes, Other.” Do NOT follow the process listed on these instructions.

For Mileage, Per Trip: There are 14 required fields on our Transportation Invoice. All of these fields MUST be completed for the invoice to be paid. This list corresponds to the invoice image that follows.

Transportation (Mileage, Per Trip) Invoice Instructions

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Required Fields for Transportation (Mileage, per trip) Invoice

A. Worker’s Name: Enter the name of the person providing services.B. Participant’s Name: Enter the name of the person receiving services.C. Worker ID: This is the PPL ID given to the worker. It begins with the letter “E” and is

followed by 4-6 digits.D. Participant ID: This is the Participant’s ID number. It can be found on the participant’s

Individual Service Plan and should begin with the letter “C”.E. Service Code: Check the appropriate box for the Service Code associated with your

Participant’s Service AuthorizationF. Date of Service: This is the date the trip took place. It should be in dd/mm/yy format.G. Authorized Rate: Enter the rate authorized by the Participant’s Service AuthorizationH. Starting and Ending Address: You must include Street Address, City, State, and Zip on

the two lines provided.I. Roundtrip (Y/N): If the trip is a roundtrip, place a “Y” in this box. Otherwise put an “N”.J. Total Trip Mileage: Enter the total miles of the trip. Note: The trip must take the most

direct route.K. Trip Amount: Enter the total amount (in dollars) to be reimbursed for the trip.L. Total Amount to be Invoiced For: The total of all the items in the “Trip Amount”

column.M. Worker’s/Person Being Reimbursed Signature and Date: This is the Worker’s

signature and the date that the worker signed the timesheet.

General Suggestions

• Fill out all required fields for the invoice clearly. If the machine cannot read your invoice and itneeds to be corrected, it may delay your payment.

• Do not use markers or pencil. Please use only black or blue ink.• If you work with more than one Participant, make sure you submit separate invoices for each.• For any invoice requiring supporting documentation, make sure you submit a copy of your

receipt along with your invoice.• Do not use white-out on any invoice, it will not be paid.• Submit your invoices within 30 days of delivering the service. • If you need additional space, please add any extra lines to a separate invoice sheet. Double sided

invoices may not be processed in their entirety.

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Transportation (Mileage, Per Trip) Invoice Instructions

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Obtaining New Invoices

You may print copies of blank invoices from the Web Portal. (See Web Portal Instruction packet). You may also print blank invoices from our website in the forms section at www.publicpartnerships.com. Lastly, you may call customer service to request blank invoices be mailed to you.

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CA GGRC Participant Directed Program Transportation (Mileage, Per Trip) Invoice

Worker Name: Worker ID Number:

Participant Name: Participant ID Number:

FOR BOTH PER TRIP AND MILEAGE AUTHORIZATIONS: THE WORKER MUST SELECT THE AUTHORIZED SERVICE CODE BEING INVOICED FOR AND LIST THE DATE OF SERVICE, RATE FORTHE SERVICE, AND THE TOTAL AMOUNT BEING INVOICED. THE WORKER MUST ALSO ENTER THE START AND END ADDRESSES OF EACH LOCATION. IF THE TRIP IS A ROUNDTRIP, PLACEA “Y” IN THE ROUNDTRIP COLUMN. THESE LOCATIONS MUST BE APPROVED BY GGRC AND INCLUDED IN THE CONSUMER’S IPP. TRAVEL FROM THE CONSUMER’S HOME TOINTERDISCIPLINARY TEAM APPROVED DESTINATION(S) AND RETURN TO THE CONSUMER’S HOME, AS INDICATED HERE-IN MUST USE THE MOST DIRECT ROUTE.

FOR MILEAGE (MR/2MR) AUTHORIZATIONS ONLY: You must enter the Total Trip Miles FOR PER TRIP AUTHORIZATIONS ONLY: You must attach a copy of the receipt if available.

Please Select your

Service Code

MR Mileage

2TOSM TRIP - REDI-WHEELS Lifeline fare 3TOM TRIP - GOLDEN GATE TRANSIT ZONE 2-5 2MR Mileage 3TOSF TRIP - SF Paratransit – ADA Fare 4TOM TRIP - GOLDEN GATE TRANSIT MARIN Local Fare 1TOB TRIP - BART per one-way trip 1TOM TRIP - WHISTLESTOP WHEELS 5TOM TRIP – WHISTLESTOP WHEELS SPEC. ROUTE

1TOSM TRIP - REDI-WHEELS/REDI-COAST 2TOM TRIP – WHI. WHEELS EXTENDED TRIP 6TOM TRIP – WHISTLESTOP WHEELS (INTERCOUNTY)

Trip # Date of Service

Authorized Rate

Address Roundtrip Total Trip Miles (MR/2MR)

Trip Amount Start End (Y/N) (in Dollars)

1

2

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TOTAL AMOUNT BEING INVOICED: $___________._______

PLEASE KNOW THAT FAILURE TO FILL OUT THIS FORM COMPLETELY AND ACCURATELY CAN RESULT IN DELAY OF PAYMENT.

Worker/Person being reimbursed Signature Date FAX INVOICE REQUEST TO: FAX: (855)-867-1676 or MAIL: PPL, CA GGRC, 7776 S Pointe Pkwy W, Suite 150, Phoenix, AZ 85044

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