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State Zip

Email: Phone#

State

Payroll Schedule:

(Ex: Salary, Hourly, Commission, ect) (Ex: Bi-weekly, 1st of Month, 15th, ect)

CHECK

Bank Name Routing Number 100% or $

Bank Name Routing Number

# of Allowances Additional $ to withhold

Federal

State

Single Married Married but withhold at higher Single Rate


Filing Status

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