New Employee/change Form - Accupay

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new employee/change form
Company/Employer
Department
Title
Name of Employee
Email Address
Address
City
State
Zip
Yes
No
SSN
-
-
U.S. Citizen?
Work visa?
Yes
No
What Type?
Date of Birth
Hire Date
Full-Time
Part-Time
Hourly Rate $
per hour
Salary $
per pay period
Additional Recurring Earnings: Type ____________________ $______________________ per ____________________
Tax Information (please attach W-4 and applicable state/local tax withholding forms)
Indiana County of Residence as of January 1 of this year
Outside Indiana - Current Locality/County/School District (list all localities for which you have withholding tax liability)
Filing Status (check one)
Married
Single
Married, withhold at higher Single rate
Federal
State
Exemptions (number)
Fixed Amount or Percentage (instead of tables)
Extra Amount to withhold in addition to tables
Type
Amount
*Pre-Tax Deductions
*Please call
AccuPay at
317.885.7600 if
unsure whether a
deduction should
*After Tax Deductions
be taken before
or after tax.
Please fax completed form to 317.885.7591

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