Employee Data Sheet - Leclerc Group Accounting & Payroll

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Leclerc Group Accounting & Payroll
phone: 207.798.6800
Fort Andross, 14 Maine Street
fax: 207.798.3929
Suite 216 C, Box 6
mobile: 207.319.4120
Brunswick, Maine 04011
Employee Data Sheet
Employer: _______________________________________________________________________________
Last Name: ________________________________ First Name: ___________________________MI:______
Address: ________________________________________________________________________________
City: ______________________________________ State: _____________________ Zip: _______________
Home Phone: _______________________________Mobile Phone: _________________________________
Fax: ______________________________________ Email: ________________________________________
SSN: _____________________________________ DOB: _________________________________________
Job Title: __________________________________ Date of Hire: ___________________________________
Pay Rate: _________________________________ Check One: Hourly_______ Salary_______ Other______
Are you a United States citizen? ________________If not, please explain: ____________________________
FOR OFFICE USE ONLY:
Withholding Information
Federal
State
FILING STATUS
_________
_________
NUMBER OF ALLOWANCES
_________
_________
EXEMPT FROM WITHHOLDING
_________
_________
ADDITIONAL WITHHOLDING
_________
_________
EXEMPT FROM UNEMPLOYMENT
_________
_________
LAST PAY CHANGE
_______________________________________________
NEXT REVIEW
_______________________________________________
TERMINATION DATE
_______________________________________________
VACATION
_______________________________________________
SICK
_______________________________________________
HOLIDAY
_______________________________________________
OTHER
_______________________________________________

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