Company/ Employer Name
*
Employee Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Employee's E-mail address
(To give employee access to paystubs online)
Social Security #
*
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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5
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11
12
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29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
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2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1996
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1993
1992
1991
1990
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1988
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1986
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1984
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1980
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1974
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1972
1971
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1967
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1961
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1941
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Hire Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
Year
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Withholding as documented on Form W4
(after 01/01/2020)
Step 1 (c) Marital Status
*
Single or Married Filing Separate
Married Filing Joint
Head of Household
Step 2 (c) Multiple Jobs- Is this box checked
*
Yes
No
Step 3 Dependents Credit Adjustment, if any
(leave blank if blank of Form W4)
Step 4 (a) Other income (not from Job), if any
Step 4 (b) Deductions (deductions wksht), if any
Step 4 (c) Extra Withholding (per check), if any
Withholding for State taxes, if applicable
Marital Status
*
Single
Married
# of allowance
*
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Exempt (line 7)
Pay Information
Amount
*
Pay Type
*
Hourly
Salary per Month
Salary per Year
Commissions
Other
Deductions
Is this employee subject to wage or child support garnishments?
*
Yes
No
If yes, send us copies of all garnishment orders
Please describe any other deductions
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Direct deposits
Complete this section if employer offers direct deposit
Name of employees bank
Bank Routing # (9 digits)
Bank account number
Signature
Clear
Make sure all information is entered in correct before submitting. Once you hit the submit button you no longer will be able to make change. If changes needs to be made then call our office (801)576-9998. Thanks
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