Fiscal Agency Forms

Welcome! All necessary forms which include; Federal, State and agency are provided by Peaceful Living with instructions for completion. Below are the forms that are required, please click the appropriate form and print. The forms will need to be mailed and/or brought to the office located at 1200 Hosford St. 107 Hudson, WI 54016. Please contact Sam Cain at 715-386-7071 if you have any questions.

(to access click on the name of the form to open it)

Participant Start-up Forms

Participant Checklist
Form 2678
– Sample Form 2678
Form SS-4
– Instructions for Completing Form SS-4
– Sample Form SS-4
Fiscal Agent Information (if applicable)
Worker’s Compensation (optional)
– Sample Worker’s Compensation Form
Participant Direct Deposit Authorization Form with voided check or bank verification (optional)
If the participant has a guardian or power of attorney, the following forms are required:

Guardianship or Power of Attorney Documents
Form 56
– Instructions for Completing Form 56
– Form 56 is required if the participant has a guardian.
Form 2848
Instructions for Completing Form 2848
Form 2848 is required if the participant has a guardian or power of attorney.
Form F-00036
– Form F-00036 is required if the participant needs to assign a power of attorney.


Employee Start-up Forms

Employee Checklist
New Employee Set-up Form, approved by participant or participant’s guardian
– Sample New Employee Set-up Form
Form W-4
– Sample Form W-4
– Form WT-4, required only if claiming exempt on Form W-4
Form I-9, approved by participant or participant’s guardian
– Sample Form I-9, for help completing the Form I-9
Copy of signed Social Security Card
Wisconsin Medicaid Program Provider Agreement (F-00180B), approved by participant or participant’s guardian
– Sample Wisconsin Medicaid Program Provider Agreement
Background Information Disclosure Addendum
Background Information Disclosure – English
– Background Information Disclosure – Hmong
– Background Information Disclosure – Spanish
Direct Deposit Authorization Form with voided check or bank verification (optional)
-Direct Deposit Brochure, for information about direct deposit
Employer and Employee Agreement, approved by participant or participant’s guardian (optional)
Training Documentation Form, approved by participant or participant’s guardian (optional)


Employee Payment Forms

2013 IRIS Time Report Payment Schedule
Employee Time Report, fillable version
-Note: you can type all information in this Time Report, but you must print it for the participant or guardian and employee signatures.
Employee Time Report, blank version
– Sample Employee Time Report, for help filling out the Employee Time Report
Employee Mileage Log, fillable version
– Note: you can type all information in this Mileage Log, but you must print it for the participant or guardian and employee signatures.
Employee Mileage Log, blank version
– Sample Employee Mileage Log
Employee Expense Report, fillable version
– Note: you can type all information in this Expense Report, but you must print it for the participant or guardian and employee signatures.
Employee Expense Report, blank version
Sample Employee Expense Report


Other Employee Forms

Employee Status Change Form, to change employee information