Milestone Academy Employee Payroll Packet

Payroll Packet
Employer Company Code
Employer Name
New Hire Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Location
Date of Birth

MonthDayYear
Date
Date of Hire

MonthDayYear
Date
Employment Type

Full TimePart Time
Starting Pay
Payment Yearly or Hourly?

YearlyHourly
Employee Notes and Deductions
Employee Signature
Date

MonthDayYear
Date
Supervisor Signature
Date

MonthDayYear
Date
Form W-4
First Name and Middle Initial
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead of household (check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)
If your total income will be $200,000 or less ($400,000 or less if married filing jointly) Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500
Add the amounts above for qualifying children and other dependents. You may add to this the amount if any other credits. Enter the total here
Other income (not from jobs)
Deductions
Extra withholding
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Signature
Date

MonthDayYear
Date
Employer's name and address
First date of employment

MonthDayYear
Date
EIN
Employment Eligibility Verification
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Other Last Names Used (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
U.S.. Social Security Number
Employee's Email Address
Employee's Telephone Number
Check one of the following boxes to attest to your citizenship or immigration status

A citizen of the United StatesA noncitizen national of the United StatesA lawful permanent resident (Enter USCIS or A-Number)A noncitizen (other than Item Numbers 2, and 3 above)
Authorized to work until (exp date if any)

MonthDayYear
Date
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.
Signature of Employee
Today's Date

MonthDayYear
Date
Employer Review and Verification
List A
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
Document Title 2
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
Document Title 3
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
List B
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
List C
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
Additional Information
Option

Check here if you used an alternative procedure authorized by DHS to examine documents.
First Date of Employment

MonthDayYear
Date
Last Name, First name and Title of Employer or Authorizes Representative
Signature of Employer or Authorized Representative
Today's Date

MonthDayYear
Date
Employer’s Business or Organization Name
Employer’s Business or Organization Address, City or Town, State, ZIP Code
Supplement A, Preparer and/or Translator Certification for Section 1
Last Name (Family Name) from Section 1
First Name (Given Name) from Section 1
Middle Initial (if any) from Section 1
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator
Date

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator
Date

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator
Date

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator
Date

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supplement B, Reverification and Rehire
Last Name (Family Name) from Section 1
First Name (Given Name) from Section 1
Middle Initial (if any) from Section 1
Date of Rehire (if applicable)

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.
Document Title
Document Number (if any)
Expiration Date (if any)

MonthDayYear
Date
Name of Employer or Authorized Representative
Signature
Today's Date

MonthDayYear
Date
Additional Information (initial and date each notation)
Additional Information

Check here if you used an alternate procedure authorized by DHS to examine documents
Date of Rehire (if applicable)

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.
Document Title
Document Number (if any)
Expiration Date (if any)

MonthDayYear
Date
Name of Employer or Authorized Representative
Signature
Today's Date

MonthDayYear
Date
Additional Information (initial and date each notation)
Additional Information

Check here if you used an alternate procedure authorized by DHS to examine documents
Date of Rehire (if applicable)

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.
Document Title
Document Number (if any)
Expiration Date (if any)

MonthDayYear
Date
Name of Employer or Authorized Representative
Signature of Employer or Authorized Representative
Today's Date

MonthDayYear
Date
Additional Information (initial and date each notation)
Additional Information

Check here if you used an alternate procedure authorized by DHS to examine documents
Date of Rehire (if applicable)

MonthDayYear
Date
Last Name (Family Name)
First Name (Given Name)
Middle Initial
AmCheck Employee Direct Deposit Agreement
Employee Name
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Signature
Date

MonthDayYear
Date
Bank Name
Bank Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Bank Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Transit/ABA Number (9 digits)
Account Number
I hereby authorize AmCheck to initiate direct deposit credit, debit and/or correction entries to my:

Checking AccountSavings AccountHealth Savings Account
I elect to have the following amount direct deposited

Entire Net PayFlat Dollar AmountPercentage of Net Pay
If selected 'Flat Dollar Amount' enter the amount
If selected 'Percentage of Net Pay' enter the amount
Return this form with one of the following

Voided CheckBank Account Specification SheetBank Letter Stating Account Information
Please upload your document

Cancelof
Should be Empty:

Payroll Packet

Form W-4

Employment Eligibility Verification

Employer Review and Verification

Supplement A, Preparer and/or Translator Certification for Section 1

Supplement B, Reverification and Rehire

AmCheck Employee Direct Deposit Agreement