Wisconsin’s Self-Directed Supports Program
Example Form 2678: Employer / Payer Appointment of Agent
Instructions
On Form 2678, enter the
following information:
x Check box to appoint
an agent for tax
reporting, depositing,
and paying;
x Do not fill in the
Employer
Identification
Number (EIN); it will
be entered when it is
assigned;
x Enter the Employer’s
or Payer’s (IRIS
Participant) name;
x Enter the Employer’s
or Payer’s (IRIS
Participant) address;
x In the For ALL
Employees Column,
check box for Form
940, 940-PR row and
the Form 941, 941PR, 941-SS row.
x Check box to state the
Employer (IRIS
Participant) is a home
care services
recipient;
x Sign the Employer’s
(IRIS Participant)
name;
x Enter date;
x Print the Employer’s
(IRIS Participant)
name;
x Enter the Employer’s
(IRIS Participant)
daytime phone
number.
Continued on Page 2
9
Form 2678 Page 2
Instructions
x Leave blank (will be
completed by the
Fiscal Employer Agent
(FEA)).