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

13.

14. Other

Name (as shown on tax return)

Business name/disregarded entity name, if different from above

Federal tax classification

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