Payroll Company Information

Submitted by: Your Email Address:

Company Name      Company Type
Federal ID No         State Withholding ID Number
State Unemployment ID Number     Rate
Telephone                Alt Telephone
Address 1
Address 2
City                     State Zip Code

Payroll Items: (Select All That Apply)
     Regular Pay      Bonuses - Based on
     Sick Pay             Mileage - Based on
     Vacation Pay

Company Totals and Prior Payments of Taxes and Liabilities - All Employees

As of:
Qtr to Date

Year to Date

     Company Gross Payroll

     Total Federal Withheld Income Taxes Paid

     Total Social Security Taxes Paid (Co & Employee)

     Medicare Taxes Paid (Co & Employee)

     State Withheld Income Taxes Paid
ST

     2nd State Withheld Income Taxes Paid
ST

     State Unemployment Taxes Paid
ST

     2nd State Unemployment Taxes Paid
ST

     Health Insurance Payments

     401k Contributions Deposited in Employee Accounts

     Pension Contributions Made

     Other:

Other Information, Comments, Questions:

*As of:*		Qtr to Date	Year to Date
Company Gross Payroll
Total Federal Withheld Income Taxes Paid
Total Social Security Taxes Paid (Co & Employee)
Medicare Taxes Paid (Co & Employee)
State Withheld Income Taxes Paid	ST
2nd State Withheld Income Taxes Paid	ST
State Unemployment Taxes Paid	ST
2nd State Unemployment Taxes Paid	ST
Health Insurance Payments
401k Contributions Deposited in Employee Accounts
Pension Contributions Made
Other: