Employee Name:

Address:

Phone Number:

Email Address:

Date of Birth:

Social Security #:

Marital Status:

(Single/Married/Married but withhold at a Single rate)

Total Federal Allowances:

(Line #5 on a W-4, ex. number of dependants)

Additional Federal Withholdings (if any):

(Line #6 on a W-4, ex. $25.00)

Rate of Pay: $

per hour - OR - $

annually

Date of Hire:

Additional Deductions (401k, dental, etc. this is optional):

Bank Name:

Bank Account Number:

Bank Routing Number:

Entire Amount to be deposited in this account?

If not, Amount to be deposited here:

Bank Name:

Bank Account Number:

Bank Routing Number:

Amount to be deposited here: