Provider Wage Supplement Staff Upload

50%

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.

Basic Information