To verify and document that the applicant qualifies and is eligible to be employed by the Consumer Directed Services (CDS) employer.
This form also serves as the Financial Management Services Agency (FMSA) applicant verification form. The FMSA must verify all applicants before the CDS employer can hire the applicant.
To certify by employer and applicant signature that the applicant:
- does meet the qualifications and criteria for employment, or
- does not meet one or more of the qualifications and criteria for employment.
When to Prepare
The employer must complete this form with each applicant before the employer can hire the applicant or rehire a former employee.
Number of Copies
Original and two copies.
The employer keeps the original or a copy in the employee's personnel file and sends the original or a copy to the FMSA when the form is completed.
The employer must keep this form while in effect, plus five years after termination of employment or until resolution of all outstanding litigation, claims and audits.
Individual's Name — Enter the name of the individual.
Employer Name — Enter the name of the employer.
Applicant Name — Enter the name of the applicant.
Applicant Social Security Number — Enter the applicant's Social Security number.
The employer must verify the applicant meets each criterion. The employer enters a check mark to indicate the criterion is met. The employer must ensure the forms and/or copies of documentation used to verify the criteria are valid and kept in the employee's personnel file.
The employer sends copies of the forms to the FMSA.
FMSA Certification and Acknowledgment
The FMSA enters a check mark to indicate the applicant either does or does not meet all of the qualifications for employment.
Employer Signature/Date — The employer signs and dates the form.
FMSA Signature/Date — The FMSA must sign and date this form to certify the applicant either qualifies for employment or does not qualify. Once the FMSA signs this form and sends it back to the employer, the employer may hire the applicant if the applicant qualifies for employment.