NEW HIRE FORM HEALTH WITH HEART

NEW HIRE FORM HEALTH WITH HEART

MUST BE LEGIBLE IN ORDER TO GET PAID DO NOT SKIP ANY INFORMATION THIS WILL DELAY YOUR PAY
DATE OF HIRE

MonthDayYear
Date
PAYRATE
Name

First NameMiddle NameLast Name
SOCIAL SECURITY #
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE #
Please enter a valid phone number.
BIRTHDAY

MonthDayYear
Date
EMAIL
example@example.com
2ND EMAIL
example@example.com
Your paystub will be emailed to you each pay period. You will need to keep these in the event that you need them for proof of employment, loan etc.
Please make sure you receive your paystub each period. We are happy to resend 1 paystub within 1 week after the payroll date if you didn't receive
FEDRAL EXEMPTIONS W-4 2019 and before

SINGLEMARRIED# OF EXEMPTIONS/DEPENDENTSADDITIONAL AMOUNT IF ANY
W-4 2021 (FOR MORE DETAIL SEE FORM W-4)

SINGLE OR MARRIED FILING SEPARATE CHECK BOXMARRIED CHECK BOXHEAD OF HOUSEHOLD CHECK BOX
DO YOU WANT THE 2000 CREDIT FOR CHILDREN UNDER 17 THAT YOU CLAIM If Yes write the amount of the credit you wish to take (2000 x # children)
OTHER INCOME (IF YOU HAVE OTHER INCOME YOU WOULD LIKE TO HAVE FEDERAL WITHHOLDING WITHHOLD ON WRITE OTHER INCOME IN BOX
IF YOU EXPECT TO CLAIM DEDUCTIONS OTHER THAN THE STANDARD DEDUCTION AND WANT TO REDUCE YOUR WITHHOLDING WRITE THE REDUCTION IN BOX
EXTRA WITHHOLDING IF YOU WOULD LIKE TO HAVE ADDITIONAL EXTRA FEDERAL WITHHOLDING PER PAY PERIOD WRITE AMOUNT IN THE BOX
OHIO EXEMPTIONS (BLANK WILL BE ZERO
DO YOU NEED SCHOOL DISTRICT TAX WITHHELD (THIS IS ONLY IF YOU LIVE IN A TAXING SCHOOL DISTRICT)

YESNO
THIS IS A SCHOOL DISTRICT TAX NOT A CITY TAX
SCHOOL DISTRICT 4 DIGIT CODE
NAME OF SCHOOL DISTIRCT
PERCENT % TO BE WITHHELD
DIRECT DEPOSIT INFORMATION
NAME OF BANK
CHECKING OR SAVINGS
ROUTING #
ACCOUNT #
DIRECT DEPOSIT AUTHORIZATION
I hereby authorize my employer and their agents to initiate electronic deposits to the bank account shown below. I understand that adjustment and/or reversing entries may be made to this account to insure an accurate and balanced accounting of all transactions.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

NEW HIRE FORM HEALTH WITH HEART

DIRECT DEPOSIT INFORMATION