Company Change Form - Vermont Employers

Company Change Form - Vermont Employers - Employer Health
Client Number
Client Name
Company Number *
Company Name *
Date Requested

Month Day Year
Date
Change Effective Date *

Month Day Year
Please note: For proper audit, PayData requires advance notice for company changes.
Indicate type of change

New Change
Code
Code Type
Description
Default W2 Box

12DD
General Ledger Number
General Ledger Offset Number
Please check this box if the employer pays the full amount of the premium for health insurance.
Note: The aggregate reportable cost of the employer-sponsored group health plan coverage must be reported in Box 12DD of the W2. Please reference the VT information below.

Vermont Employers Beginning in 2015:
I agree to and authorize PayData to make the above changes to our company set up.
Authorized Client Representative *
Title *
Signature *
Date *

Month Day Year
Date
Should be Empty:

Company Change Form - Vermont Employers - Employer Health