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a EMPLOYEE STATUS REPORT "APPROVED BY Ee get MANAGER LocaTion AREAWANAGER HOME OFFICE NAME: DATE OF BIRTH n08 STARTING SALARY jereScTVeoAT eee a CHECK HERE IF REHIRE ‘STARTING WEEKLY SALARY. (OR HOURLY WAGE 2 RAISE REQUEST EFFECTIVE DATE. WEEKLY SALARY: FROM 10 HOURLY WAGE: FROM 10 ‘TRANSFER (SENT FROM NEW STORE) EFFECTIVE DATE FROM (LOCATION) To wocarion ie i TERMINATION EFFECTIVE DATE REASON FOR SEPARATION: INVOLUNTARY ___ VOLUNTARY omer EXPLANATION OTHER REMARKS. {FL OUT THEW FORMAT SAME TE THE APPLIGATON IS FLLED OUT) aW-4 epee oie Tes iar Raven (ev 202) Employee's | 's Withholding ‘Allowance Certificate 1 ype orp eure ane ad me Tast Name 2 Yur soa RT ame es ramet ors) 3 Csraje. Chvanies nares et mina a hater Sing te Noe rari a espa ae races cece Sr. Cay oo, Sate, and DP cade “youre ae irs th on your social ez cars, cack et and cal 80072-1218 foc aoa >t 3 Tal nanber of alawancas you ae Saning 5 6 Adctocl amu, any, you want wield tom each payheck 5/8 7 Leis exemption tom wiholding, and Icey that | meet BOTH othe folowing constions for exemption: ‘Last year nad argh a reluné of ALL Federal income tx wield because | had NOt bit AND ‘Ths year | expect refund ot ALL Feeraincome tax witelé because I oxpect a have NOx nb Md yeu meet both contns eter“EXEMPT” hee a ‘hd anaes of per, cay Wala er fo the rsnbe a wildy alovancesdaed on tis cortical relied eda exongt Sac Employee's signature > Date» [ Eien ada ng: Crean Fan oo) Fanaa ete) | 9 Oneame [10 per aan tar | * Sens ae ian

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