First Name
Last Name
Date
Cell Phone
Home Phone
Email Address
Social Security Number
Name
Relationship
Phone
Signature
Date
Signature
Date
Today's Date
Social Security Number
Last
First
Middle
Maiden
No.
Street
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Pager/Alt Phone
Valid Driver's License #
State Issued
Exp. Date
Make & Year of Vehicle
Auto Insurance Co
Policy Number
Auto Insurance Agent
Phone Number
Name
City State
Major Subject
# of Yrs Attended
Did You Graduate
Name
City State
Major Subject
# of Yrs Attended
Did You Graduate
Name
City State
Major Subject
# of Yrs Attended
Did You Graduate
Name
City State
Major Subject
# of Yrs Attended
Did You Graduate
Incident Charge #1
City/State #1
Incident Charge #2
City/State #2
Company Name
City
State
Phone Number
From
To
Job Title
Name of Supervisor
Duties
Salary
Per
Reason for Leaving
Comments
Signature
Date
Name
Agency Email Address
Maiden Name and/or Other Names Known by
Street
City
State
Zip Code
DOB
SS#
Signature
Date
Perpetrator's Name
Date Substantiated
Initial
Date
Email
Encrypted Email
FEIN
First, Middle, Last Name
Other Names Used (Any/all aliases, married, maiden, nicknames, etc. "N/A" if none used)
Date of Birth
Race
Social Security #
Current Address
City, State, Zip
Phone
Email
Signature
Date
(a) First name and middle initial
Last name
(b) Social security number
Address
City or town, state, and ZIP code
Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500
Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here
(a) Other Income (not from jobs}. If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other Income here. This may Include interest, dividends, and retirement income
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here
(c) Extra withholding. Enter any additional tax you want withheld each pay period
Employee's signature (This form is not valid unless you sign it)
Date
Employer's name and address
First date of employment
Employer identification number (EIN)
Full Name
Social Security Number
Home Address (Number and Street or Rural Route)
City or Town
State
ZIP Code
2. Additional wilhholding: If you expect to have a balance due (as a result of interest income. dividends. income from a part-lime job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each pay period. To calculate the amount needed, divide the amount of the expected tax by the number of pay periods in a year. Enter the additional amount to be withheld each pay period on line 2
3. Reduced withholding: if you expect to receive a refund (as a result of itemized deductions, modifications or tax credits) on your tax return, you may direct your employer to only withhold the amount indicated on line 3. Your employer will not use the standard calculations for withholding. If you designate an amount that is too low, it could result in you being under withheld. To calculate the amount needed, divide the amount of your expected tax by the number or pay periods in a year. Enter the amount to be withheld instead of the standard calculation. If no amount is indicated on line 3, the standard calculations will be used
4. Exempt Status: Select the appropriate reason you are claiming an exemption from withholding below and indicate EXEMPT on line 4
Employee's Signature (Form is not valid until you signed it)
Date
Employer's Name
Employer's Address
City
State
ZIP Code
Date Services for Pay First Performed by Employee
Federal Employer I.D. Number
Missouri Tax Identification Number
B Enter "0" or "1" if you are married or single and no one else can claim you as a dependent (entering "0" may help you avoid having too little tax withheld)
C Enter "0" or "1" if you are married and only have one job, and your spouse does not work (entering "0" may help you avoid having too little tax withheld)
D Enter "2" if you will file head of household on your tax return (see conditions under Head of household above)
E Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or dependents that your spouse has already claimed on their form K-4
F Add lines B through E and enter the total here
1 Print your First Name and Middle Initial
Last Name
2 Social Security Number
Mailing address
4 Total number of allowances you are claiming (from Line F above)
5 Enter any additional amount you want withheld from each paycheck (this is optional}
6 I claim exemption from withholding. (You must meet the conditions explained in the "Exemption from wlthholding" instructions above.) If you meet the conditions above, write "Exempt" on this line
SIGN HERE
Date
7 Employer's Name and Address
8 EIN (Employer ID Number)
Last Name {Family Name)
First Name (Given Name)
Middle Initial (if any)
Other Last Names Used (If any)
Address (Street Number and Name)
Apt. Number (if any)
City or Town
State
ZIP Code
Date of Birth
U.S. Social Security Number
Employee's Email Address
Employee's Telephone Number
USCIS A-Number
Form 1-94 Admission Number
Foreign Passport Number and Country of Issuance
Signature of Employee
Today's Date
Document Title 1 - List A
Document Title 1 - List B
Document Title 1 - List C
Issuing Authority - List A
Issuing Authority - List B
Issuing Authority - List C
Document Number - List A
Document Number - List B
Document Number - List C
Expiration Date - List A
Expiration Date - List B
Expiration Date - List C
Document Title 2 (If any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Document Title 3 (If any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Additional Information
First Day of Employment
Last Name, First Name and Title of Employer or Authorized Representative
Signature of Employer or Authorized Representative
Today's Date
Employer's Business or Organization Name
Employer's Business or Organization Address, City or Town, State, ZIP Code
