Children’s Long-Term Support Forms
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| Document Name | Summary | Tags |
|---|---|---|
| 2023 Fiscal Agent Payroll Payment Schedule | 2023 Fiscal Agent Payroll Payment Schedule. This schedule details the dates of each pay period. | Employer |
| 2024 Fiscal Agent Payroll Payment Schedule | 2023 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 Checklist | Employer Checklist. This checklist shows all the forms that an Employer must complete. | Employer |
| Fiscal Agent Authorization Form | Fiscal Agent Authorization Form. This form is required by the Employer/Client and Guardian/POA. | Employer |
| IRS Form 2678 | IRS 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-4 | IRS Form SS-4. This form is used to apply for an EIN on behalf of the participant employer. | Employer |
| IRS Form 8821 | IRS Form 8821. This form authorizes information exchanges between the FEA and IRS. | Employer |
| Information for the Fiscal Intermediary | Information 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 Form | Employer 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 Information | Consent 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 Form | Fiscal Agent Employer/Client Information Form. This form is used for contact and other information. | Employer |
| Information for Guardians and Power of Attorney | Information 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-00036 | Form 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 Form | New Employee Set-Up Form. | Employee |
| Relationship Disclosure Form | Relationship 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 Form | Fiscal 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-9 | Form I-9. This form is used to verify the identity and employment authorization of individuals hired in the United States. | Employee |
| W-4 | Form W-4. This form determines how much is withheld from an employee's paycheck for federal income tax. | Employee |
| Direct Deposit Authorization Form | Direct 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 Form | Training Verification form for Children's Long-Term Support. | Employee |
| Portage County Certification: Participant Specific Training | Participant specific training required for new employees | Employee |
| Fiscal Agent Mileage Log | Fiscal 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 Packet | Vendor Start-up Packet. This packet includes all the forms the vendor may need to complete to be an approved service provider. | Vendor |
| Vendor Checklist | Vendor Checklist. This form details what forms a vendor must complete for the application process. | Vendor |
| W-9Â (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 Vendors | Authorization for Fiscal Agent Vendors. This form is to authorize Client/Employer and Provider/Employee information. | Vendor |
| Provider Agreement | Provider Agreement. This form is used for the Provider to agree to provide/arrange for training. | Vendor |
| Direct Deposit Authorization with voided check | Direct 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 List | Credentialing 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 Information | Adult Family Home Information. This form is required for Adult Family Home providers. | Vendor |
| Vendor Application Sample - Agency | Vendor Application Sample for Agency. This is a sample of what the Vendor Application will look like once it is completed. | Vendor |
| Vendor Application Sample - Individual | Vendor 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 Checklist | Case Manager Checklist. This checklist shows the forms that must be completed by the Case Manager. | Case Manager |
| Case Manager Start-up Packet | Case Manager Start-up Packet. This packet must be completed by the Case Manager. | Case Manager |