NAME:

ADDRESS:

SOCIAL SECURITY #

                                                 DATE OF BIRTH:

PHONE #

COUNTY

SCHOOL DISTRICT

TWP or BORO

WITHHOLDING INFORMATION

CIRCLE ONE

SINGLE            MARRIED            MARRIED claiming single rate

# of exemptions claimed (if none, enter a “0”)

Enter added tax deduction per pay period, if any

Exempt from withholding (give reason)

DIRECT PAYROLL DEPOSIT INFORMATION

BANK NAME

BANK ADDRESS

CIRCLE ONE

CHECKING                    SAVINGS

BANK Number  (9 digit #, 1^st # lower left corner of check)

ACCOUNT #

Please attach a photocopy of a blank check.  Write “VOID” on the photocopy.

You are paid every                                                                    .  If you have any problems, contact  .

Please sign & date below:

Signature:                                                                                              Date:

Office USE Only

Rate of Pay

Salary:

Hourly:

Commission:

Local Tax:           Yes           No

OPT Tax:       Yes               No

Other Deductions:

Other Income:

DATE OF HIRE: