Form 2354, Learning Your Responsibilities as an Employer

Effective Date: 08/2011


PDF: 2354.pdf


Updated: 8/2012


To inform an individual receiving In-Home and Family Support Program benefits of his potential legal responsibilities as an employer if he hires an individual to perform a service.


When to Prepare

  • At the time the applicant's or individual's service plan is being discussed and developed, give him Form 2354 if he requests, or is considering requesting, a service for which he potentially may hire an individual (including, but not limited to, attendant, home health aide, homemaker, chore, respite and transportation).
  • If a service is subsequently approved for which an individual who potentially may hire an attendant, Form 2354 also must be sent to the individual, along with Form 2065-E, Notification of In-Home and Family Support Program Benefits.

Number of Copies

Original only.

Detailed Instructions

The form should be given for both situations listed above. Documentation in the case record must indicate when Form 2354 is given or sent to the individual, along with the date given or sent. If the form is sent with Form 2065-E, the comments section of this form must reference Form 2354.

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