2019 Year-End Owner Payroll Data Form
Information Due by December 31, 2020
Business Name
*
Name of Person Filling Out This Form
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Best number to reach you at
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Section 1
Owner Information
Please list Owner Names with yearly total amounts for all of the following that apply: Wages; Health, dental, vision, or long term care insurance premiums paid through the business; Retirement Account Contributions
Owner Name
Wages
Health Premiums
Dental premiums
Vision Premiums
Long Term Care Premiums
Life Insurance (List benefit amount in $)
Retirement Contributions
Retirement Account Type
Owner 1
Owner 2
Owner 3
Owner 4
Owner 5
Section 2
Child Employees
Please list children of owners that worked in the business
Child Name
Child Date of Birth
Wages Paid
Child 1
Child 2
Child 3
Child 4
Section 3
Personal Use of Business Vehicles
Please list vehicles that are owned by the business and used for personal use by owners or employees
Vehicle Description
Person using it
Personal Miles
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
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