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This form serves as an official verification of shared residency status, which is a regulatory requirement for FMS agencies. Caregivers are required to provide comprehensive personal and service-recipient details, including addresses and dates for temporary living arrangements. The form emphasizes the caregiver's responsibility to continue logging work shifts despite their live-in status and requires an attestation of truthfulness from both the employee and the managing party. Additionally, the document mandates the submission of supporting documentation, such as government-issued identification, residential leases, tax statements, or utility bills, to confirm the residency match, ensuring full regulatory compliance with state-level caregiver tracking mandates.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/evv-exemption-form-live-in-caregiver-declaration/304719/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/evv-exemption-form-live-in-caregiver-declaration/304719.png","ImageObject",442,249,{"name":88,"@type":89},"Terk","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-28","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete this form?","Question",{"text":108,"@type":109},"This form should only be completed by caregivers who live at the same address as the person they are providing services to.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Does completing this form exempt a caregiver from entering shift hours?",{"text":113,"@type":109},"No, completing the form does not exempt the caregiver from the requirement to enter their shift hours on the actual date they were worked.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is required to accompany this form?",{"text":117,"@type":109},"Applicants must provide one form of documentation showing the caregiver's name and address matching the person receiving services, such as a driver's license, lease, tax statement, or two months of utility bills.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},304719,1790137005,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Electronic Visit Verification (EVV) Live In Caregiver Form  \nThis form should only be completed if you live at the same address as the person you support.  \nEmployee Name:   Employee Number  Name of Person Receiving Services:   \nManaging Party Name:    \nHome address of Employee and Person Receiving Services:  \nAddress:    \nCity:   State:   Zip Code:    \nIs this a permanent or temporary living arrangement?  \nPermanent  Temporary  \nIf Temporary, what are the dates of this temporary living arrangement?  \nStart Date   End Date    \n  (Initial) I understand, as a live-in caregiver, that I must continue to enter my shift on the date it was worked. Completing this form does not exempt me from being required to enter the hours worked on the day they were worked.  \nWe attest that the above-named employee and person using services live at the same address listed above and the information provided is accurate.  \nEmployee Signature:   Date:    \nManaging Party Signature:   Date:    \nFMS Agencies are required to collect documentation of the live in caregiver status. Documentation must show the caregiver’s name and current address matching the person receiving services. This documentation will be collected yearly. As documentation, please include one of the following items  with your form:  \n• Copy of your current MN Drivers License or ID Card  \n• Residential Lease  \n• Tax Statement  \n• At least two consecutive months of utility bills with the address matching the person receiving services.  \nEVV Exemption Form Page 1 of 1","cbCaibnVxoIXhYoC","https://ap.wps.com/l/cbCaibnVxoIXhYoC","pdf",179392,"English","# Caregiver and Recipient Information\n## Living Arrangement Status\n## Attestation and Certification\n## Required Documentation","[{\"question\":\"Who should complete this form?\",\"answer\":\"This form should only be completed by caregivers who live at the same address as the person they are providing services to.\"},{\"question\":\"Does completing this form exempt a caregiver from entering shift hours?\",\"answer\":\"No, completing the form does not exempt the caregiver from the requirement to enter their shift hours on the actual date they were worked.\"},{\"question\":\"What documentation is required to accompany this form?\",\"answer\":\"Applicants must provide one form of documentation showing the caregiver's name and address matching the person receiving services, such as a driver's license, lease, tax statement, or two months of utility bills.\"}]","EVV Exemption Form - Live-In Caregiver Declaration | PDF",1789816515]