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EMPLOYEE DATA SHEET COMPANY NAME: EMPLOYEE (if applicable) EMPLOYEE NAME: LASTFIRSTMI ADDRESS CITY STATE ZIP □ Male □ Female SSN: DOB HIRE DATE EMAIL Job Code (SOC)LOCATION DEPARTMENT PAY FREQUENCY: (circle one) WEEKLY BI-WEEKLY SEMI-MONTHLY MONTHLY QUARTERLY SALARY PER PAY PERIOD HOURLY RATE(S) (IF APPLICABLE) rate 1: rate 2: rate 3: per hour CONTRACT EMPLOYEE (1099) CHECK HERE Amount per pay period TAX WITHOLDIING STATUS – Employees Only (transfer from W-4 / L-4): Federal Tax Status: □ Married □ Single of Allowances Withhold Extra State Tax Status: □ Married □ Single of Exemptions of Dependents Withhold Extra DEDUCTIONS / REIMBURSMENTS: (attach court orders for child support) Ded./ Reimb.Name Amount per check Pre-tax □ Yes □ No Ded./ Reimb.Name Amount per check Pre-tax □ Yes □ No DIRECT DEPOSIT: (attach voided check or bank authorization) □ checking □ savings Account Routing or □ checking □ savings Account Routing or I authorize Payroll Rx to initiate credit entries for payroll to the above account(s)..
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