New Hire/ Payroll Change Form

New Hire/ Payroll Change Form
INSTRUCTIONS: complete the employee section only and return to your employer with a voided check and completed W-4
EMPLOYEE SECTION
First Name
Middle Int
Last Name
Phone Number & Email

Phone NumberEmail
Email Address
example@example.com
Social Security Number
Social Security Number
Social Security Number
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Zip Code

American Indian/Alaskan Asian Black/African American Hispanic/LatinoRace:Filing StatusStateAddressCityWhite/Caucasian Two or more race Other
Filing Status

SingleGender: MaleFemale
Filing Status

Married
Withholding Allowance
Additional Withholding: Fed.
St.
Amount
Amount
Start Date

MonthDayYear
Date
Deduction: Type

Direct Deposit Account Type:CHECKING
Amount
Amount
Start Date

MonthDayYear
Date
Bank Name & Routing Number
Bank Name & Routing Number
EMPLOYER SECTION
Job Status

Part Time Full Time
Part Time Full Time
Hire Date

MonthDayYear
Date
Job Title
Hourly Rate
/hour OR
Job Location
Date

MonthDayYear
Date
Should be Empty: