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Employee Payroll Information

General Information

Employee Name:
Address:
City, State, Zip:
Email Address:
Birth Date:
Social Security No.:
Drivers License No.:
Gender:

Tax Information

Please attach or specify the following information:

Attach completed federal Form W-4. The form may be downloaded here: https://www.irs.gov/pub/irs-pdf/fw4.pdf

Attach completed state withholding Form DE-4. Only applicable if state income tax and filing status/allowances are different from federal. The form may be downloaded here: https://www.edd.ca.gov/pdf_pub_ctr/de4.pdf

Attach completed Employment Eligibility Verification Form I-9. The form may be downloaded here: https://www.uscis.gov/i-9

Specify any payroll taxes that you are exempt from, such as state unemployment, social security, or Medicare:

Specify any local taxes that need to be withheld from your paychecks:

Notes:

Are you subject to wage garnishments, such as a federal tax or child support garnishment?

Yes

If yes, attach all copies of garnishment orders:

Direct Deposit Information

Would you like to be paid by direct deposit? If yes, please complete the authorization section below.

Yes

AUTHORIZATION FOR DIRECT DEPOSIT

Complete the following section if you are electing to receive your paychecks via direct deposit.

I authorize Mehdiani Financial Management to deposit my pay automatically to the account(s) indicated below and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford Mehdiani Financial Management a reasonable opportunity to act on it.

Primary Direct Deposit

Name on bank account:
Bank account number:
Bank routing number:

Checking AccountSavings Account

Amount: $ or Entire Paycheck

*Balance of pay to:

$ Manual (paper check)

$ Secondary account described below

Secondary Direct Deposit (balance after direct deposit entry above)

Name on bank account:
Bank account number:
Bank routing number:

Checking AccountSavings Account

Important: Please attach a voided check for each bank account to which funds should be deposited.

Agreed to and accepted:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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November 20, 2019 1:42 pm PDT

Employee Payroll Information Uploaded by Alan Mehdiani - alan@mehdiani.com IP 172.112.146.175