Did any employee contribute to a 401k this calendar year
EMPLOYEE MASTER
Company Name: ____________________________________________________________
Social Security Number: ________________________________________________________
Employee ID # _____________________
Employee Last Name: __________________________________________________________
Employee First Name: _______________________________ Middle Initial: _____________
Employee Street Address: _______________________________________________________
Employee City – State – Zip: ____________________________________________________
Employee Telephone: ___________________________________________________________
Gender: (Circle one) Male Female
Date of Birth: ____________________ Hire Date: ______________________
Employee Under Age 18? Yes No If yes, year employee will reach age 18? _________
Circle One: Full Time Part Time
Branch: _______________________ Home Dept: _______________________
Rate of Pay for Home Department: $________________
2nd Dept: __________ Rate of Pay : $__________ 3rd Dept: __________ Rate of Pay: $__________
Misc Deductions: ______________________________________________________________
Federal W-4 (Circle One) Single Married Exempt
Fed Dependents: _______________ W-4 Total Dependents Tax Credit: _______________
Other Income: _______________ Deductions: _______________ Addtl Withholding: _______________
State WT-4 (Circle One) Single Married Exempt
State Dependents: _______________ Addtl Withholding: _______________
Please fax to 888-423-9007 or email to service@
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