Inclusa Forms
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| 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-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 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 |