- To serve as the primary document to record the employee's hourly pay, hourly overtime rate, benefits, payroll deductions and the payroll process/distribution policy.
- To itemize for the Financial Management Services Agency (FMSA) the optional benefits the employee will have for payroll.
- To itemize the documents that must be provided to the FMSA before the end of the employee's first pay period.
- To document that the employee is aware of the Wage and Benefits Plan.
- To notify the FMSA of changes to the Wage and Benefits Plan for each employee.
When to Prepare
The employer completes this form and submits it to the FMSA for each new employee before the end of the employee's first pay period. The employer must also use this form to notify the employee and the FMSA at the time of any change(s) to the employee's Wage and Benefits Plan.
The employer completes this form based on the budget approved for the program service. The employer reviews the form with the employee when completed and any time there is a change in the employee's Wage and Benefits Plan.
Number of Copies
Original and two copies.
The employer keeps the original form in the employee's personnel file and gives a copy to the employee. The employer must provide a copy to the FMSA before the end of the employee's first pay period to ensure that the employee's first paycheck is calculated in accordance with the employee's Wage and Benefits Plan. Changes must be provided to the FMSA before the end of the payroll period in which the change(s) is effective.
The employer must keep this form for five years after termination of the employee's employment or until all outstanding litigation, claims and audits are resolved.
Employee Name — Enter the last name, first name and middle initial of the employee.
Social Security No. — Enter the employee's Social Security number.
Date of Hire — Enter the date the employee was hired.
First Date of Work — Enter the date of the employee's first work day.
Initial Wage and Benefit Plan — Enter a check mark if this is the first Wage and Benefits Plan for this employee.
Plan Change – Effective Date — Enter a check mark if this is a change to the employee's Wage and Benefit Plan. Enter the effective date of the change(s).
Document only the items that are being changed on the remainder of the form. The employee and the employer must sign and date the form. A copy of this form is provided to the FMSA before the end of the pay period in which the change(s) is effective.
Name of Program Service Being Provided — Enter the name of the program service being provided by the employee (see Attendant Services below).
Regular Hourly Wage — Enter the hourly rate for the applicable service(s) to be provided by the employee based on the approved budget.
Attendant Services are:
- personal attendant services in the following programs: Community Care for Aged and Disabled (CCAD); Consumer Managed Personal Attendant Services (CMPAS);
- habilitation in Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD);
- intervener in DBMD;
- supported home living in Home and Community-based Services (HCS); and
- community support in Texas Home Living (TxHmL).
Respite services are in CLASS, Medically Dependent Children Program (MDCP), HCS, TxHmL and DBMD.
Calculation of Overtime Hourly Wage — Enter the regular hourly rate and one-half (50%) of the regular hourly rate. Add the two amounts together to determine the hourly overtime rate for each service to be provided by the employee.
The employer must verify with the FMSA that each benefit is allowable, reasonable and budgeted before completing this section of this form.
The employer documents each benefit that will be provided to the employee.
Enter a check mark to indicate which item(s) is applicable to the employee. Enter information as indicated for each item that is checked. Attach detail related to each item checked and send with this form to the FMSA for processing.
W-4 Employee's Withholding Allowance Certificate — Each employee must complete an Internal Revenue Service (IRS) Form W-4 at the time of hire. This item must be checked for each new employee and any time the employee revises the Form W-4. Attach the Form W-4 to this form and submit to the FMSA.
Mark the following items that are applicable to the employee. Enter information as required for each applicable item. Refer to Appendix V, Definitions and Categories for Employer-Related Expenses, for more information.
Required Garnishments — If applicable, enter information and attach detail (court order, etc.) for the FMSA to process. Common examples are court-ordered child support, alimony ("spousal maintenance" payments) and guaranteed student loan payments. This type of deduction does not need to be authorized by the employee to be valid under the Texas Payday Law. Deductions for court-ordered garnishments and other wage attachments required by law may take an employee below minimum wage. The employer and the FMSA are required to have a copy of any court order that requires a garnishment.
Voluntary Withholdings — If applicable, enter information and attach detail (employee's request, support documentation, etc.) for the FMSA to process. Optional benefits the employee may request and approve to be withheld and deposited (paid from the employee's payroll) by the FMSA may include, but are not limited to: life or health insurance premiums, retirement account (401K, IRA, etc.) or a savings account. The employee must request in writing that a withholding and payment be made from wages for an optional benefit. The FMSA is required to make the deduction in accordance with directions from the employee.
Other (specify) — If applicable, explain employee-requested deductions/withholdings from payroll that do not fall into any category above.
Note: The employer and the FMSA must have documentation to support the amount of wages withheld.
- Federal Withholding – FICA (Social Security tax, Medicare)
Documentation: W-4, tax rate tables (IRS)
- Garnishments – child support, alimony, guaranteed student loan
Documentation: court order, agency mandate/order
- Optional Benefits – insurance, retirement, etc.
Documentation: employee/employer signed request; invoice from vendor (insurance company, etc.)
Time Sheets/Service Delivery Logs — Enter the date(s) the employee must complete the time sheet for each pay period.
Paychecks — Enter the payroll distribution method (mailed to employee, mailed to employer, direct deposit) and frequency used by the FMSA.
Employee Signature and Date — The employee must sign and date this completed form.
Employer Signature and Date — The employer must sign and date this form.