Children’s Long-Term Support Forms

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Document NameSummaryTags
2023 Fiscal Agent Payroll Payment Schedule2023 Fiscal Agent Payroll Payment Schedule. This schedule details the dates of each pay period. Employer
2024 Fiscal Agent Payroll Payment Schedule2023 Fiscal Agent Payroll Payment Schedule. This schedule details the dates of each pay period. Employer
2024 Employer Start-up Packet (blank) (sample)2023 Employer Start-up Packet. This packet has all the forms that the Employer must complete for employee employment. Employer
Employer ChecklistEmployer Checklist. This checklist shows all the forms that an Employer must complete. Employer
Fiscal Agent Authorization FormFiscal Agent Authorization Form. This form is required by the Employer/Client and Guardian/POA. Employer
IRS Form 2678IRS Form 2678. This form allows the FEA to file returns, make deposits, and/or payments of employment on behalf of the participant employer. Employer
IRS Form SS-4IRS Form SS-4. This form is used to apply for an EIN on behalf of the participant employer. Employer
IRS Form 8821IRS Form 8821. This form authorizes information exchanges between the FEA and IRS. Employer
Information for the Fiscal IntermediaryInformation for the Fiscal Intermediary. This form is used for determining if Employers/Clients have participated in the program, and if so, if they had a fiscal agent. Employer
Employer Status Change FormEmployer Status Change Form. This form is used to make changes to contact information, termination date, or having check stubs sent to themselves. Employer
Consent for Release of Confidential InformationConsent for Release of Confidential Information. This form is to consent to iLIFE relasing confidential information to the employer (pay rates, hours, budget details, etc.)Employer
Employer Information FormFiscal Agent Employer/Client Information Form. This form is used for contact and other information. Employer
Information for Guardians and Power of AttorneyInformation for Guardians and Power of Attorney. This form has information for parents/guardians and Power of Attorneys to know before you sign on behalf of the Employer. Employer
Form F-00036Form F-00036. This form is only required if the client/employer has a power of attorney. This form allows POAs to plan for future financial decisions. Employer
New Employee Set-Up FormNew Employee Set-Up Form.Employee
Relationship Disclosure FormRelationship Disclosure Form. This form is to identify if the Employer and Client have a legal relationship with each other. Employee
Employer and Employee Agreement. This form is used for the Employer and Employee to agree to certain terms.Employee
Employee Status Change FormFiscal Agent Employee Status Change Form. This form is used to make changes to contact information, termination date, or having check stubs sent to themselves. Employee
Form I-9Form I-9. This form is used to verify the identity and employment authorization of individuals hired in the United States. Employee
W-4Form W-4. This form determines how much is withheld from an employee's paycheck for federal income tax. Employee
Direct Deposit Authorization FormDirect Deposit Authorization Form. This form is to list direct deposit information for payment. Employee
Employee Start-Up Packet for Children's Waiver Programs (blank) (sample)Children's Waiver Programs. This packet has all the forms that must be completed to participate in Children's Waiver Programs. Employee
Kenosha County Training Verification FormTraining Verification form for Children's Long-Term Support. Employee
Portage County Certification: Participant Specific Training Participant specific training required for new employeesEmployee
Fiscal Agent Mileage LogFiscal Agent Mileage Log. This form is used to detail transportation services. Employee
Children's Waiver Programs In/Out Timesheet (blank) (fillable) (sample)Children's Waiver Programs In/Out Timesheet. This Timesheet is used to detail services provided in the Children's Waiver Program. Employee
Vendor Start-up PacketVendor Start-up Packet. This packet includes all the forms the vendor may need to complete to be an approved service provider.Vendor
Vendor ChecklistVendor Checklist. This form details what forms a vendor must complete for the application process. Vendor
W-9 (sample)Sample Form W-9. This IRS tax form is a sample to show how it is used. This is used to confirm a vendor's information for tax-filling purposes. Vendor
Authorization for Fiscal Agent VendorsAuthorization for Fiscal Agent Vendors. This form is to authorize Client/Employer and Provider/Employee information. Vendor
Provider AgreementProvider Agreement. This form is used for the Provider to agree to provide/arrange for training.Vendor
Direct Deposit Authorization with voided checkDirect Deposit Authorization with voided check. This form is used to void a check. Voided Check or letter from the bank must be attached with this form. Vendor
Credentialing Requirements ListCredentialing Requirements List. This lists the occupations or fields that must send a copy for their license and/or certifiicate in order to receive payment. Vendor
Adult Family Home InformationAdult Family Home Information. This form is required for Adult Family Home providers. Vendor
Vendor Application Sample - AgencyVendor Application Sample for Agency. This is a sample of what the Vendor Application will look like once it is completed. Vendor
Vendor Application Sample - IndividualVendor Application Sample for Individual. This is a sample of what the Vendor Application will look like once it is completed. Vendor
Vendor Invoice (sample)Vendor Invoice Sample. This is a sample of what the Vendor Invoice will look like once completed. Vendor
Case Manager ChecklistCase Manager Checklist. This checklist shows the forms that must be completed by the Case Manager. Case Manager
Case Manager Start-up PacketCase Manager Start-up Packet. This packet must be completed by the Case Manager.Case Manager