Inclusa Forms
Know the exact form you are looking for? Type in the form name in the search bar or click on buttons on the left to see forms sorted by role and type.
| Document Name | Summary | Tags |
|---|---|---|
| 2022 Fiscal Agent Payroll Payment Schedule | 2022 Fiscal Agent Payroll Payment Schedule. This schedule details the dates of each pay period. | Employer |
| Fiscal Agent 2023 Payroll Payment Schedule | 2023 Fiscal Agent Payroll Payment Schedule. This schedule details the dates of each pay period. | Employer |
| 2023 Employer Start-up Packet (blank) (sample) | 2022 Employer Start-up Packet. This packet includes all the forms that the Employer will need and/or have to complete for employment. | Employer |
| Employer Checklist | Employer Checklist. This form is to list all the forms that the Employer must have completed. | Employer |
| Fiscal Agent Authorization Form | Fiscal Agent Authorization Form. This form is required by the Employer/Client and Gurdian/POA. | Employer |
| IRS Form 2678 | IRS Form 2678. Allows us to file returns and 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 | Form 8821. This form authorizes information exchanges between FEA and IRS. | Employer |
| Information for the Fiscal Intermediary | Information for 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 the Release of Confidential Information. This form is to consent to iLIFE releasing confidential information to the employer (pay rates, hours, budget details, etc.) | Employer |
| Employer Information Form | Employer Information Form. This form is to list the contact information and other details of the Employer and Client. | 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 - Inclusa & My Choice Wisconsin. Both the Employer and the Client must fill out the information for employment. | Employee | |
| Inclusa (blank) (sample) | Inclusa Packet. This packet includes all the forms that must be completed for employment. | Employee |
| Fiscal In/Out Timesheet (blank) (fillable) (sample) | iLIFE Fiscal Agent Employee Timesheet. This form is used to detail the dates and times worked, and other details. | Employee |
| Fiscal Agent Mileage Log | Fiscal Agent Mileage Log. This form is used to detail transportation services. | 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 | Employer and Employee Agreement. | Employee |
| Employee Status Change Form | Employee Status Change Form. This is for the Employee only. Use this form to indicate a changed status. | 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. This form is to list direct deposit information for payment. | 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-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 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 list has all of the occupations or fields that must send a copy for their license and/or certificate 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 Applicaiton will look like once it is completed. | Vendor |
| Vendor Application Sample - Individual | Vendor Application Sample for the Individual. This is a sample of what the Vendor Application will look like once it is completed. | Vendor |
| Vendor Invoice (sample) | Sample of Vendor Invoice. 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 |