Accounting Rx - Employee Payroll Enrollment And Update Form

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EMPLOYEE PAYROLL ENROLLMENT AND UPDATE FORM
Employer _______________________________________________________________
Date Submitted: _________________
First Name ______________________________ M.I.________ Last Name ________________________
Hire Date: ___________________________
Address _______________________________________________________________________________
Termination Date: ____________________
Change Date: _______________________
City ________________________________ State ________ Zip ____________ County ______________
SSN ____________________________ DOB ____________________
Auth. Signature ______________________
E-Mail ________________________________________________________________________________
Marital Status:
Married
Single
Gender:
Male
Female
LOCATION
Default Location ____________________________________________________ Other _________________________________________________________
Default Department _________________________________________________ Other _________________________________________________________
PAYROLL ITEMS
PAY TYPE (select one):
Salary
Hourly
Salary:
Annual Salary $________________
Hourly:
Rate Type __________________________________________________ Rate Amount $ ______________________________________________
Rate Type __________________________________________________ Rate Amount $ _______________________________________________
Rate Type __________________________________________________ Rate Amount $ _______________________________________________
Rate Type __________________________________________________ Rate Amount $ _______________________________________________
DEDUCTION ITEMS
Pre-Tax Items:
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
After-Tax Items:
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
Item Type __________________________________________ Item Amount $________________________________________________
Retirement Plan Employer Match:
Yes
No
Match % ________________________________________________________
WITHHOLDING INFORMATION
A-4 STATE
W-4 FEDERAL
Total Exemptions (Line 6)________________________
Single
Married
Additional State w/h (Line 5) ______________________
Married withhold at Single rate
Total Allowances (Box 5)________Additional w/h___________
DIRECT DEPOSIT
NOTES
Please attach voided check for each account
(no deposit tickets)
Please attach Direct Deposit Authorization form
072915

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