STATE OF FLORIDA



| |STATE OF FLORIDA |W-4 |EMPLOYEE: |

| |OFFICE OF THE COMPTROLLER | |PLEASE COMPETE |

| |BUREAU OF STATE PAYROLLS | |UNSHADED AREAS ONLY |

| |SOC. SEC. NUM. (9) |FIRST NAME (14) |M.I. (1) |LAST NAME (16) |

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| |ADDRESS (30) |CITY (15) |STATE (2) ZIP CODE (5 or 9) |OR FOREIGN COUNTRY (13) |

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| | |RACE |SEX | |MARITAL STATUS |NUMBER OF |ADDITIONAL |FOR AGENCY USE ONLY |

| |BIRTH DATE |CODE |(M=MALE) | |(S=SINGLE) |W/H |AMOUNT | |

| | |(SEE |(F=FEMALE) | |(M=MARRIED) |ALLOW. |WHOLE DOLLARS | |

| | |BELOW) | | |(X=MARRIED CLAIMING SINGLE) |(2) | | |

| | | | | | | | | ORGANIZATION |

| |MM |DD |YYYY |

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|ATTACH A COPY OF SOCIAL SECURITY CARD HERE. | | MM DD YYYY | |

|(DAA003 REV. OCT. 30, 1997) OMB NO. 1545-0010 | |SIGNATURE DATE SIGNED | |

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