Fiscal Intermediary PDF File Access


The Fiscal Intermediary Program makes frequently used forms available from this location.

The forms are provided as PDF (portable document format). This will allow viewing and printing of forms from your computer. You can learn more and download the free Acrobat Reader* distributed by Adobe Systems. If you do not have Reader installed on your computer, click on the button below to open a link to the Adobe website. Follow the instructions for downloading the free Acrobat Reader*.

 

 

 

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BLANK PDF FORMS PDF SAMPLE FILES
   
FORM M-2848 SAMPLE FORM M-2848
 FILL-IN TIMESHEET   

 

FORM SS-4 SAMPLE FORM SS-4
FORM TA-1 SAMPLE FORM TA-1
FORM 8821 SAMPLE FORM 8821
FORM W-4 SAMPLE FORM W-4
CONSENT PAYROLL AGENT FORM 2678 SAMPLE FORM 2678
CONSENT HEALTH INFORMATION  
CHANGE FORM & SUPPLY REQUEST  
EMPLOYMENT ELIGIBILITY VERIF.I-9 SAMPLE FORM I-9
DIRECT DEPOSIT APPLICATION  
DEBIT CARD APPLICATION  
1199SEIU Membership Application  
PCA SIGNATURE FORM  
PAYROLL PROCESSING AGENT CONSENT
 
LETTERS & MEMOS
 
EMPLOYMENT PACKAGE LETTER DEBIT CARD MEMO
POLICY & PROCEDURE: GRIEVANCES DUA FORM 0590-A: FILING UNEMPLOYMENT

PRIVACY NOTICE

PCA SCHEDULE 1 (2009)

WHO MAY NOT BE A PCA

PCA SCHEDULE 2 (2009)

TIMESHEET INSTRUCTIONS PCA SCHEDULE 1 (2010)
TIMESHEET INSTRUCTIONS LETTER PCA SCHEDULE 2 (2010)
PCA HOME CARE QUALITY WORKFORCE COUNCIL NOTICE PCA SCHEDULE 1 (2011)
WORKERS COMP MEMO & NOTICE PCA SCHEDULE 2 (2011)
AGENCY ADDRESSES PCA SCHEDULE 1 (2012)
CONSUMER AGREEMENT PCA SCHEDULE 2 (2012)
NEWSLETTER V1I1 I-9 MEMO
NEWSLETTER V1I2 NEWSLETTER V2I2
NEWSLETTER V2I1 NEWSLETTER V3I1
WORKFORCE COUNCIL FRAUD ARTICLE  
Non Payment of Wages Complaint Form OAG Guide to Workplace Rights and Responsibilities OAG