iris participant paperwork checklist · *guardian and/or power of attorney legal documentation is...

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GT Independence 5150 N Port Washington Rd, Suite 102, Milwaukee, WI 53217 Toll Free 1.877.659.4500 Fax 1.877.600.4129 www.gtindependence.com/iris IRIS Participant Paperwork Checklist Return completed paperwork to: [email protected] or Fax: 1-877-600-4129 Accurately complete ALL required forms to ensure timely enrollment. IRIS Participant Information Form Required Form SS-4 Application for Employer Identification Number Form 2678 Employer/Payer Appointment of Agent (leave second page blank) Form 8821 Tax Information Authorization Guardian and/or Power of Attorney Legal Documents* Sample Timesheet Leave with Participant Instructions: - Use this checklist as a tool to ensure all required documents are completed at the time of the enrollment visit. - Forms marked Required’ must be accurately completed for timely enrollment processing. *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These documents must be received prior to said Guardian or Power of Attorney acting on behalf of the Participant.

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Page 1: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

GT Independence 5150 N Port Washington Rd, Suite 102, Milwaukee, WI 53217Toll Free 1.877.659.4500 Fax 1.877.600.4129 www.gtindependence.com/iris

IRIS Participant Paperwork ChecklistReturn completed paperwork to: [email protected] or

Fax: 1-877-600-4129

Accurately complete ALL required forms to ensure timely enrollment.IRIS Participant Information Form RequiredForm SS-4 Application for Employer Identification NumberForm 2678 Employer/Payer Appointment of Agent – (leave second page blank)Form 8821 Tax Information AuthorizationGuardian and/or Power of Attorney Legal Documents*Sample Timesheet Leave with

Participant

Instructions:- Use this checklist as a tool to ensure all required documents are completed at the time of the enrollment visit.- Forms marked ‘Required’ must be accurately completed for timely enrollment processing.

*Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardianor Power of Attorney. These documents must be received prior to said Guardian or Power of Attorney acting onbehalf of the Participant.

Page 2: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

GT Independence 5150 N Port Washington Rd, Suite 102, Milwaukee, WI 53217Toll Free 1.877.659.4500 Fax 1.877.600.4129 www.gtindependence.com/iris

IRIS Participant Information FormReturn completed paperwork to: [email protected] or

Fax: 1-877-600-4129

Name:

Address:

CITY STATE ZIP

Social Security Number: Date of Birth:

MCI ID:

Phone Number: Alternate Phone:

Email:

Appointed Representative Name/Phone:(Select One) Guardian Power of Attorney

IRIS Consultant Agency (ICA):

IRIS Consultant Name:

County or Geographic Service Region (GSR):

Employer Identification Number (EIN):I know I have an EIN, but do not know the number.

Population Target Type (Select One): DD FE PD

GT Field Representative:

FIRST MIDDLE LAST

Page 3: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

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HHCSR
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HHCSR
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GT Independence, LLC.
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215 Broadus St.
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Sturgis, MI 49091
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December
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1-5
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John Carmichael
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215 Broadus St., Sturgis, MI 49091
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269-651-4500
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269-651-4501
Page 4: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

Form 2678(Rev. August 2014)

Employer/Payer Appointment of AgentDepartment of the Treasury — Internal Revenue Service

OMB No. 1545-0748

Use this form if you want to request approval to have an agent file returns and make deposits or payments of employment or other withholding taxes or if you want to revoke an existing appointment.

• If you are an employer or payer who wants to request approval, complete Parts 1 and 2 and sign Part 2. Then give it to the agent. Have the agent complete Part 3 and sign it.

Note. This appointment is not effective until we approve your request. See the instructionsfor filing Form 2678 on page 3.

• If you are an employer, payer, or agent who wants to revoke an existing appointment, complete all three parts. In this case, only one signature is required.

For IRS use:

Part 1: Why you are filing this form... (Check one)

You want to appoint an agent for tax reporting, depositing, and paying. You want to revoke an existing appointment.

Part 2: Employer or Payer Information: Complete this part if you want to appoint an agent or revoke an appointment.

1 Employer identification number (EIN) —

2 Employer’s or payer’s name (not your trade name)

3 Trade name (if any)

4 Address

Number Street Suite or room number

City State ZIP code

Foreign country name Foreign province/county Foreign postal code

5 Forms for which you want to appoint an agent or revoke the agent’s appointment to file. (Check all that apply.)

For ALL employees/

payees/payments

For SOME employees/

payees/payments Form 940, 940-PR (Employer's Annual Federal Unemployment (FUTA) Tax Return)*Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return) Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural Employees) Form 944, 944(SP) (Employer’s ANNUAL Federal Tax Return) Form 945 (Annual Return of Withheld Federal Income Tax) Form CT-1 (Employer’s Annual Railroad Retirement Tax Return) Form CT-2 (Employee Representative's Quarterly Railroad Tax Return)

*Generally you cannot appoint an agent to report, deposit, and pay tax reported on Form 940, Employer's Annual Federal Unemployment (FUTA) Tax Return, unless you are a home care service recipient.

Check here if you are a home care service recipient, and you want to appoint the agent to report, deposit, and pay FUTA tax for you. See the instructions.

I am authorizing the IRS to disclose otherwise confidential tax information to the agent relating to the authority granted under this appointment, including disclosures required to process Form 2678. The agent may contract with a third party, such as a reporting agent or certified public accountant, to prepare or file the returns covered by this appointment, or to make any required deposits and payments. Such contract may authorize the IRS to disclose confidential tax information of the employer/payer and

payer remain liable.

✗ Sign your name here

Print your name here

Print your title here

Best daytime phone

Now give this form to the agent to complete. ■▶

For Privacy Act and Paperwork Reduction Act Notice, see the instructions. IRS.gov/form2678 Cat. No. 18770D Form 2678 (Rev. 8-2014)

Date

agent to such third party. If a third party fails to file the returns or make the deposits and payments, the agent and employer/

OShultz
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Owner
Page 5: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

Page 2 Part 3: Agent Information: If you will be an agent for an employer or payer, or want to revoke an appointment, complete this part.

6 Agent’s employer identification number (EIN) —

7 Agent’s name (not trade name)

8 Trade name (if any)

9 Address

Number Street Suite or room number

City State ZIP code

Foreign country name Foreign province/county Foreign postal code

Check here if the employer is a home care service recipient receiving home care services through a program administered by a federal, state, or local government agency.

Under penalties of perjury, I declare that I have examined this form and any attachments, and to the best of my knowledge and belief, it is true, correct, and complete.

✗ Sign your name here

Date / /

Print your name here

Print your title here

Best daytime phone

Form 2678 (Rev. 8-2014)

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John Carmichael
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GT Independence, LLC.
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215 Broadus St
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Sturgis
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MI
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49093
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John Carmichael
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CEO
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269-651-4500
Page 6: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

GT Independence 215 Broadus Sturgis, MI 49091

877.659.4500 www.gtindependence.com

Your life. Your choice.

To Whom It May Concern:

GT Independence is an agent operating under Section 3504 of the Internal Revenue Code serving Home Care Service Recipients (HCSRs), as defined in Internal Revenue Manual 21.7.2.4.11.3(2) and (3). HCSRs rely upon their employees to provide critical home care services to help them live safely and independently in their homes. As a Section 3504 agent that is authorized via an executed Form 2678, GT Independence manages federal tax responsibilities on behalf of these employers.

HCSRs are Americans who are over 65 and/or have disabilities or chronic health conditions. According to the Centers for Disease Control (CDC), individuals with these characteristics are at highest risk for experiencing severe complications from COVID-19. As a result, the CDC has urged that these individuals stay home and avoid non-essential interactions during this outbreak. According to the Centers for Medicare and Medicaid Services (CMS), more Americans are expected to become HCSRs during the COVID-19 outbreak for many reasons, including:

• Concerns regarding COVID-19 outbreaks at nursing homes, prompting families to move loved ones back home and receive services at home instead

• Inability to receive home care services through home care agencies, due to illness outbreaks among professional home care providers

Because HCSRs are particularly vulnerable to COVID-19 complications, GT Independence cannot safely conduct face-to-face meetings with HCSRs to collect “wet” physical signatures on Form 2678. Collecting physical signatures through the mail is time-intensive and will lead to dangerous service delays for vulnerable Americans who need home care services immediately—in many cases, for tasks as fundamental as being able to receive medication and use the bathroom. Failing to receive these services will lead to hospitalization in many cases, exacerbating nationwide hospital bed shortages.

In light of these facts, we respectfully request that the Internal Revenue Service waive its requirement for physical signatures on Form 2678 for the duration of the COVID-19 outbreak. The attached Forms 2678 are included with electronic signatures to protect the health and safety of vulnerable Americans and expedite their ability to receive essential home care services.

Thank you for your time and consideration. If you have any questions, please contact me at 269-651-4500

Best Regards,

John Carmichael Chief Executive Officer (CEO)

Page 7: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These

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OShultz
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John Carmichael & attached list of appointees 215 Broadus St Sturgis, MI 49091
OShultz
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0302-59793R
OShultz
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269-651-4500
OShultz
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269-651-4501
OShultz
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Research and verify FEIN and request re-activation
OShultz
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Owner
Page 8: IRIS Participant Paperwork Checklist · *Guardian and/or Power of Attorney legal documentation is required if the IRIS Participant has a legal Guardian or Power of Attorney. These