WQHCC Fiscal Agent Forms
Fiscal Assistance of Dane County has assembled the following catalog of downloadable documents and fiscal agent forms in conjunction with the Wisconsin Quality Home Care Commission. Please click on any title to download the corresponding form.

Employer Agent Data Form

• Employer Agent Data Form (Microsoft Excel)

Employer Forms

• U.S. Federal Form 56 (Acrobat PDF)
• U.S. Federal Form 2678 (Acrobat PDF)
• U.S. Federal Form 8821 (Acrobat PDF)
• U.S. Federal Form SS-4 (Acrobat PDF)
• Wisconsin Home Care Consumer Notice (Microsoft Word)

Employee Forms

• U.S. Federal Form W-4 (Acrobat PDF)
• Wisconsin Form W-5 (Acrobat PDF)
• Wisconsin From WT-4 (Acrobat PDF)
• Wisconsin DHFS Background Check Form (Acrobat PDF)
• Wisconsin Home Care Worker Notice (Microsoft Word)
• U.S. Federal Form I-9 Employment Eligibility Verification (Acrobat PDF)
• Employee Questionnaire (Microsoft Word)
• Employment Application Form (Microsoft Word)
• Authorization Agreement for Automatic Deposits (Microsoft Word)

Payroll Schedules

• Employer Agent Bi-Weekly Payroll Schedule (Microsoft Excel)
• Employer Agent Monthly Payroll Schedule (Microsoft Excel)