Paychex Employee Information Form
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1PAYCHEX EMPLOYEE INFORMATION FORM
CLIENT NUMBER: #5886
DATE ___________
CHECK ONLY ONE:
[ ]
NEW EMPLOYEE
[ ]
CHANGE OF INFORMATION ON CURRENT EMPLOYEE
[ ]
REHIRE OF OLD EMPLOYEE PREVIOUSLY ON PAYCHEX SYSTEM
EMPLOYEE NUMBER (FOR CHANGE OR REHIRE ONLY) ________________
EMPLOYEE NAME (LAST / FIRST / MIDDLE) ____________________________________________________
ADDRESS ________________________________________________________________________________
CITY AND STATE ____________________________________
ZIP CODE ______________________
SOCIAL SECURITY NUMBER __________________________________
DEPARTMENT NUMBER
__________________________________
SALARY (PER PAY PERIOD)
__________________________________
HOURLY RATE #1
__________________________________
HOURLY RATE #2
__________________________________
HOURLY RATE #3
__________________________________
MARITAL STATUS (circle):
SINGLE
MARRIED
MARRIED WITHHOLD AT HIGHER SINGLE RATE
FEDERAL EXEMPTIONS
_____________
ADDTL $$ ______
FLAT $$ ______
HIRE DATE
__________________________________
BIRTH DATE
__________________________________
SHOULD STATE TAX BE WITHHELD?
[ ] YES
[ ] NO
IF YES, WHICH STATE?
VA
MD
DC
OTHER ________
STATE EXEMPTIONS
_____________
ADDTL $$ _______
FLAT $$ _______
IF MARYLAND, WHICH COUNTY? ________________________________
STATE IN WHICH EMPLOYEE “WORKS”
VA
MD
DC
OTHER ________
WILL EMPLOYEE BE DIRECT DEPOSIT?
[ X ] YES
IF YES, SEND CHECK & AUTHORIZATION.
ADDITIONAL INFORMATION
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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