Instructions: Please fill out the sheet completely and use only ONE time sheet per week/per caregiver. 

Data Entry Instructions

1. On your desktop/mobile device/tablet, click on the applicable selection for Family Caregiver or Independent Caregiver). You MUST select either FAMILY or INDEPENDENT Caregiver.

2. Enter the first initial and last name of the Admitted Claimant.

3. Enter the first/last name of the Caregiver. 4.  Enter the Caregiver's Email Address.

5. Enter the SSN (last 4 digits only) for the claimant.

6. Enter the For Week Ending (monthly/day/year). Either enter the numerical values or hoover over the clickable calendar to select the relevant date. Scroll through the Timesheet Monthly Date Ranges to enter the week ending date.

7. Enter the Hourly Rate ($).

8. Enter the numerical value for the shifts and select either AM (morning) or PM (afternoon/evening).

9. Based on the shifts/time entered, the Total Hours field will calculate for you.

10. Based on the Total Hours and the Hourly Rate fields, the Total Reimbursement field will calculate for you.

11. Sign in the Caregiver signature slot (Note: use your mouse or mobile device/tablet pointer).

12. Sign in the Family Signature slot (Note: use your mouse or mobile device/tablet pointer).

Time Sheet Submission Instructions (once your timesheet is completed)

1. Select the Preview PDF button below to review final options. Click the back arrow button in the top left to return to your file screen. Click Submit.

2. Click Print Form to save a copy of the form for your files in PDF format.

3. Click Submit to submit final version.

*Note: You will receive an automatic (instant) email confirmation page acknowledging your submission. 

 

Caregiver Signature. I certify that all the information given is accurate and that none of the hours for which reimbursement is requested have been reimbursed by any other source for any of the amounts claimed.

Family Signature (Cannot be the caregiver except in a single-parent household). I certify that the hours were worked, are accurate, and that I have paid the caregiver the total reimbursement for the pay period noted above. 

Note: For single-parent caregivers, the caregiver signs here; too; but only to certify that the hours were actually worked and are accurately reported.