Pay to the order of:
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a. Employee's SSN | |||||||||
b. Employer Identification Number (EIN) | 1. Wages, tips, other compensation | 2. Federal income tax withheld | |||||||
c. Employer's name, address and ZIP code | 3. Social security wages | 4. Social security tax withheld | |||||||
5. Medicare wages and tips | 6. Medicare tax withheld | ||||||||
7. Social security tips | 8. Allocated tips | ||||||||
d. Control number | 9. | 10. Dependent care benefits | |||||||
e. Employee's name, address and ZIP code | 11. Nonqualified plans | 12a.
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13. (A) (B) (C) | 12b.
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14. Other | 12c.
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12d.
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Name (as shown on tax return) | |
Business name/disregarded entity name, if different from above | |
Federal tax classification Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited Liability Company. Tax classification: Other: | Exempt payee code |
Exemption | |
Address | Requester's name and address |
City, state and ZIP code | |
Account numbers | |
Social Security Number | |
Employer Identification Number | |
Signed? | Signature date |
Pay to the order of:
Date:
Date
Memo:
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