EMPLOYEE PAYROLL INFORMATION FORM
1. Employee Information
Employee Legal Name:
*
First Name
Last Name
Social Security Number:
*
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Hire Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2. Employment & Pay Information
Company / Employer Legal Name:
*
Employment Type:
*
Full-Time
Part-Time
Temporary
Seasonal
Pay Frequency:
*
Weekly
Biweekly
Semi-Monthly
Monthly
3. Federal Form W-4 Information
Filing Status:
*
Single or Married Filing Separately
Married Filing Jointly / Qualifying Surviving Spouse
Head of Household
Step 2 – Multiple Jobs / Spouse Works:
*
IRS Estimator
Multiple Jobs Worksheet
Checkbox
N/A
Step 3 – Dependents / Credits:
Qualifying Children:
*
Other Dependents:
Total Credit Amount: $
Step 4(a) – Other Income: $
Back
Next
Step 4(b) – Deductions: $
Step 4(c) – Extra Withholding: $
W-4 Employee Signature:
*
W-4 Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
4. State Withholding Information
State of Employment:
*
State of Residence:
*
State Withholding Form:
State Additional Withholding: $
State Exempt from Withholding:
*
Yes
No
5. Direct Deposit Information
Payment Method:
*
Direct Deposit
Paper Check
Bank Name:
Account Type:
Checking
Savings
Routing Number:
Account Number:
Verify Account Number:
6. Employee Certification
I certify that the information provided on this Employee Payroll Information Sheet is complete and accurate. I understand that official federal, state, and local tax forms may be required and that I am responsible for notifying my employer of any changes to my personal, tax, banking, or employment information.
Employee Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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