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COMPLETES SECTION IV. IN EITHER CASE, EMPLOYER SHOULD COMPLETE AND SIGN EMPLOYER CERTIFICATION. I. EMPLOYER BACKGROUND Business / Organization Name Total Number of Employees Contact Name Phone Business Address Employer is a charitable organization in the State of Kansas and exempt from income tax under Internal Revenue Code 501 (c)(3). Circle One: Yes No II. EMPLOYEE BACKGROUND Name Hire Date Job Title Job Location Last Four Digits SSN III. HOME AND COMMUNITY-BASED WAIVER SERVICES Th.

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