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
WH-4 STATE
W-4 FEDERAL
Personal Exemption (Line 5) ________________________
Single
Married
Dependent Exemption (Line 6) ______________________
Married withhold at Single rate
Additional State w/h ______________________________
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