Respite Tax Forms for Families What the forms mean… Form 2848 Power of Attorney and Declaration of Representative: (This form is permission for the CLC Administrative Services, Inc. (CLC) to file required payroll reports and make payroll tax payments to the IRS on the family’s behalf. This limited Power of Attorney restricts interaction only to matters specified on form.) Family is responsible for completing the following information in each section; without this form we are unable to provide you with any payroll services: 1. Taxpayer name(s) and address Daytime telephone number 7. Signature and Date of tax payer and print name Form SS-4 Application for Employer Identification Number: (This form is submitted to the IRS to obtain an EIN for the family. The IRS stipulates each family using respite caregivers is a household employer that requires they have their own EIN.) 1. Legal Name 4a, 4b, and 6. Address, County 7a. Name of Responsible Party 9a. SSN 11. Estimated start date for respite 13. Under household how many respite workers are you expected to have in the next 12 months (if you currently only have one respite worker, put 1, two respite workers, put 2…etc) no more than 3. 15. Same as start date for respite 18. Check yes or no Print, Sign and date bottom of form including phone number Form 2678 Employer/Payer Appointment of Agent: (This form appoints the CLC to process payroll on the family’s behalf) Complete #2, #4 Sign, print, telephone number, and date Part 3 Robert Decker signs this form. Form 8821 Tax Information Authorization: (This form is required by the IRS to allow CLC to interact with IRS regarding employer payroll taxes) 1. Name, address, and telephone number, Sign, print, and date bottom of form *Families will not be held accountable for filing any additional information for their taxes or paying any money for this service.

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