Fiscal Agent Handbook and Forms

Important note:

ALL APPROPRIATE FORMS MUST BE SIGNED.

Case Manager Start-Up Forms:

• Case Manager Checklist
• Authorization
• Termination report for Employer
• Termination report for Employee

Fiscal Agent Roles & Responsibility:

• Fiscal Agent Roles & Responsibility

Employer Start-Up Forms:

• Handbook
• Employer Checklist
• IRS Form 2678 with copy of Guardianship or POA papers
• IRS Form SS-4 & Instructions for Completing Form SS-4
• Fiscal Intermediary
• Worker’s Compensation (optional form)
• If the client/employer has a guardian or power of attorney, the following forms are required:
  • Guardianship or Power of Attorney Documents
  • IRS Form 56 & Instructions for Completion
    • IRS Form 56 is needed if the client/employer has a guardian
  • IRS Form 2848 & Instructions for Completion
    • IRS Form 2848 is required if the client/employer has a guardian or power of attorney
  • Form F-00036 & Instructions for Completion
    • Form F-00036 is required if the client/employer has a power of attorney

Employee Start-Up Forms:

• Employee Checklist
• Employee New Hire/Status Change Form
• I-9 Eligibility, signed by Employer
• W-4
• Copy of Social Security card
• Background Check Information and Release
• Background Information Disclosure
• Change of Address Form
• Direct Deposit with voided check (optional form)
• Employer & Employee Agreement, signed by Employer (optional form)

Employee Payment Forms:

• Employee Time Report, signed by Employer and Employee
• Fiscal Agent Mileage Log

Vendor Start-Up Forms:

• Vendor Checklist
• W-9  
• Authorization for Fiscal Agent Vendors
• Direct Deposit Authorization with voided check

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