Wraparound Forms

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Document NameSummaryTags
2022 Fiscal Agent Payroll Payment Schedule2022 Fiscal Agent Payroll Schedule. This schedule shows the dates of each pay period. Employer
2022 Employer Start-up Packet (blank) (sample)Fiscal Agent Employer/Client Start-up Packet. This packet contains all of the forms that will need to be completed for employment. Employer
Employer ChecklistEmployer Checklist. This checklist lists all the forms that appear in the packet. Employer
IRS Form 2678IRS 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-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 FEA and IRS. Employer
Information for the Fiscal IntermediaryInformation for Fiscal Intermediary. This form is used for determining if Emplooyers/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 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 FormEmployer Information Form. This form is to list the contact information and other details of the Employer and Client. 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. Both the Employer and the Client must fill out the information for employment. Employee
Relationship Disclosure FormRelationship Disclosure Form. This form is to identify if the Employer and Client have a legal relationship with each other. Employee
Fiscal Agent Employer/Client and Employee Agreement for Children's Waiver Programs only. This form must be signed by the Employer/Client and the Employee to agree on the tasks and duties to be performed by the Employee. 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
Background Check Information and ReleaseBackground Check Information and Release. This form has individuals list all the previous places they have lived, any names they used to go by, and other background information. Employee
Background Information Disclosure - EnglishBackground Check Disclosure Form. This form is used to verify the identity of the employee for employment. Employee
Background Information Disclosure - HmongBackground Check Disclosure Form. This form is used to verify the identity of the employee for employment. Employee
Background Information Disclosure - SpanishBackground Check Disclosure Form. This form is used to verify the identity of the employee for employment. Employee
Direct Deposit Authorization FormDirect Deposit Authorization. This form is to list direct deposit information for payment. Employee
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
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-filing 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 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 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 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 the Individual. This is a sample of what the Vendor Application will look like once it is completed. Vendor
Vendor Payroll ScheduleVendor Payroll Schedule. This is the schedule of when Vendors will receive payments. Vendor
Vendor Invoice (sample)Sample of Vendor Invoice. This is a sample of what the Vendor Invoice will look like once it is completed.Vendor