Prototype- Louisiana Employer Electronic Visit Verification (EVV) Data Information Form

Prototype- Louisiana Employer EVV Data Information Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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I am new Employer generating the form electronicallyI am an existing Employer generating the form electronicallyI need to print the form
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Louisiana Employer EVV Data Information Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Morning Sun as your Fiscal Employer Agent (FEA), is authorized to represent you for purposes of employer tax reporting responsibilities. Morning Sun will also manage the initial setup of the employer, employee's and participant's information within the Electronic Visit Verification system (EVV). Please complete all sections to provide the contact information for the Participant, Employer, and Authorized Representative (if applicable). If you have more than one employee, please enter contact information for ALL employees.
Participant

This is the person that receives services. Other terms include, Consumer, Client, or Person Served
Participant Legal Name*

Legal First NameLegal Last Name
Participant Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Participant Parish*
Participant Date of Birth*

MonthDayYear
Date
Participant Gender*

MaleFemale
HIDE- Participant Gender (Circle one)

MaleFemale
Employer

This is the person that is responsible for supervising an Employee. In some cases, the Employer can be the Participant or their Authorized Representative.
Employer Legal Name*

Legal First NameLegal Last Name
Employer Email*
example@example.com
Employer Phone Number*
Please enter a valid phone number.
Employer Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Employer Parish*
Employer Date of Birth*

MonthDayYear
Date
Authorized Representative

This is a person that can act on the Employer's behalf
Authorized Representative Legal Name

Legal First NameLegal Last Name
Authorized Representative Email
example@example.com
Authorized Representative Phone Number
Please enter a valid phone number.
Authorized Representative Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Authorized Representative Parish
Authorized Representative Date of Birth

MonthDayYear
Date
Employee

This is the person that is responsible for providing services to the Participant

Employee 1
Employee 1 Legal Name

Legal First NameLegal Middle NameLegal Last Name
Employee 1 Email
example@example.com
Employee 1 Phone Number
Please enter a valid phone number.
Employee 1 Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Employee 1 Parish
Employee 1 Date of Birth

MonthDayYear
Date

Employee 2
Employee 2 Legal Name

Legal First NameLegal Middle NameLegal Last Name
Employee 2 Email
example@example.com
Employee 2 Phone Number
Please enter a valid phone number.
Employee 2 Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Employee 2 Parish
Employee 2 Date of Birth

MonthDayYear
Date

Employee 3
Employee 3 Legal Name

Legal First NameLegal Middle NameLegal Last Name
Employee 3 Email
example@example.com
Employee 3 Phone Number
Please enter a valid phone number.
Employee 3 Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Employee 3 Parish
Employee 3 Date of Birth

MonthDayYear
Date

Employee 4
Employee 4 Legal Name

Legal First NameLegal Middle NameLegal Last Name
Employee 4 Email
example@example.com
Employee 4 Phone Number
Please enter a valid phone number.
Employee 4 Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Employee 4 Parish
Employee 4 Date of Birth

MonthDayYear
Date

Employee 5
Employee 5 Legal Name

Legal First NameLegal Middle NameLegal Last Name
Employee 5 Email
example@example.com
Employee 5 Phone Number
Please enter a valid phone number.
Employee 5 Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Employee 5 Parish
Employee 5 Date of Birth

MonthDayYear
Date

HIDE- End
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Any changes to personal information above requires a notification to Morning Sun Financial Services using the Employee Change Form, found on our website at www.morningsunfs.com.

Your signature means you have read and understand why this is needed.
Employer Legal Name*

Legal First NameLegal Last Name
Employer Signature*

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Prototype- Louisiana Employer EVV Data Information Form

Louisiana Employer EVV Data Information Form

Participant

Employer

Authorized Representative

Employee

Signatures