New / Change Employee Status Form

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NEW / CHANGE EMPLOYEE STATUS FORM
❏ New Hire
❏ Employee Change
❏ Terminate
(Term date):____/____/____
Basic Information
Emp ID: _________
Last Name: ___________________________________ First Name: _________________________ Middle Name: ______
Address: __________________________________________________________ City: _____________________ State: _____ Zip: _____________
Gender (Optional): ❏ Male ❏ Female
Phone Number (Optional): __________________________________
Birth Date : ______ /______ /______
Social Security #: _________________________________________ Or Temporary Visa # (if applicable): _____________________________________
Department and Status Information
Hire Dates: _____/_____/_____
Employee Type: ❏ W2
❏ 1099
Employee Status: ❏ Active ❏ Terminated ❏ New Hire ❏ Rehire
Department_____________________________________________
Worker Comp Code : ___________________________________________
Pay Rate Information
Pay Type: ❏ Hourly ❏ Salary
❏ Weekly ❏ Semi-Monthly ❏ Monthly ❏ Annually
Pay Freq
Salary: $_______________________
Base Rate: $_______________________
: ❏ Hourly ❏ Salary
Avg. Hours: ______________
Tax Information
Federal Tax Info:
Filing Status ❏ Single ❏ Married
# Exemptions: ________________ Additional Withholding $ __________________
State Tax Info:
Filing State: ___________ Filing Status: ❏ Single ❏ Married
# Exemptions:________________ Additional Withholding $__________________
Unemployment State: _________
Work State: ___________
Local Taxes: Filing Status: ❏ Single ❏ Married
# Exemptions: ____________Local Authority Name: ___________________________________
(To activate Direct Deposit, please complete attached
.
Direct Deposit Information
S P S I will create a live check if left blank. First check is always live for pre-note purposes.)
Check One:
❏
Checking
I wish to deposit:
❏
Entire Net Pay
❏
____________% of Net
❏
Savings
❏
$_____________
Recurring Deductions
Deduction Code / Name
Amount Per Pay Period
_______________________________________________________
___________________________________________________________
_______________________________________________________
___________________________________________________________
_______________________________________________________
___________________________________________________________
_______________________________________________________
___________________________________________________________
_________________________________________
_____________________________________________
Authorization Signature
Date

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