Provider Wage Supplement Staff Upload

33%

PRIM ID
Basic Information
To be Filled out by Center Director
Provider Name*
License Number*
Director Name*
First Last
Director Title
Director Email*
Enter Email Confirm Email
Director Phone Number*
Are you uploading a Federal Tax form?*
- No
- Upload a W-2 for Specific Employee
- Upload a W-4 for Specific Employee
- Upload a W-9 for Home Providers Only
Employee Name*
First Last
Employee Date of Birth*
Employee Last 4 digits of SSN*
Most Recent W-2 Tax Form*
Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Most Recent W-4 Tax Form*
Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Most Recent W-9 Tax Form*
Accepted file types: pdf, jpg, png, gif, jpeg, bmp.

Upload Documents
Reporting Month*
Reporting Year*
Please Select the type of documents you are uploading
- Staff List Document
- Supplement Signature Document
- Proof of Hours Worked
- Other
Staff List Document
Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Supplement Signature Document
Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Documentation for Staff Hours Worked*
Drop files here or

Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Additional Documents
Drop files here or

Accepted file types: pdf, jpg, png, gif, jpeg, bmp.
Additional Comments or Notes

Summary

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05/09/2025
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By signing this document, you agree to the following statement:*
I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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Basic Information