Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering your employer information, including the employer's name, address, and contact details. If there have been any recent changes to these details, ensure to check the box indicating a new address and attach the necessary change form.
3. Fill in the Personal Care Attendant (PCA) information. Include the PCA number, Social Security Number (SSN), full name, address, city, state, and contact numbers, along with the email address.
4. For each day of the week, enter the time in and time out for each work shift in the designated fields. Ensure you are using the correct AM or PM indicators. Record the total hours worked for both day/evening and night shifts as applicable.
5. After filling out Week 1, proceed to Week 2 and repeat the process for each day, ensuring the accuracy of the time entries and total hours worked.
6. Carefully review all the information entered for completeness and accuracy. Make any necessary corrections before proceeding.
7. Once the form is completed, you can save changes, download, print, or share the form as needed.

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