Employee Payroll Change Form printable pdf download

Employee Payroll Change Form

Company Name: _____________________________________________ Page ____ of ______

Employee Name: ____________________________________________ Employee ID ______

Please submit this change list to our office with all pertinent fields filled in and legible.

Send copy of court order for all garnishment and child support deductions.

Address Change to: _________________________________________

_________________________________________

Wage Change Information:

Position(s): _____________________________ Department /Location (if applicable) __________________

AND/OR

Hourly rate _______

Salary (specify both): per pay _________ & Annual amount __________

Other pay (specify): _________________________ amount: _____________

Tips: Credit Card ___ Cash ___ Both ____

Withholding Changes:

W‐4 ~ IRS Withholding Certificate

______ (attach new form)

IT‐ 2104 ~ NYS Withholding Certificate ______

(attach new form)

Direct Deposit Change: _____ (attach new form)

Deduction Changes:

(

All deductions will be made per pay period unless otherwise indicated)

Per Pay Pretax Effective

Per Pay

Health Insurance Amt ______ Y / N _______

Cafeteria Flex _____

Amount _________

Dental Insurance Amt ______ Y / N _______

Cafeteria Flex (Annual Max) _____________

Life Insurance Amt ______ Y / N _______

Garnishment ____ Amount _________

HSA

Amt ______ Y / N _______

Child Support ____ Amount__________

Savings

Amt ______ Y / N _______

Loan ____ Amount__________

Union Dues

____

Amount__________

Other___ Specify deduction type ____________________________________ Amount __________

Pension Type (i.e. 401k): __________ __________

Amount _______ or ____%

Retirement Code:

______________________ (Municipals Only)

NOTES: ______________________________________________________________________________

_____________________________________________________________________________________

Benefits (Employer Provided):

Pension Type (i.e. 401k): _____________ Amount per pay _______ or ____% Start Date ___/___/___

HSA ____ Amount $_______ Annual Limit $ ________________

HVRG Fax # 518‐828‐8934

Jan/12

Employee Payroll Change Form

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