W-2 Withholding Information Form

W-2 Withholding Information Form
Please complete this form to provide your withholding details for payroll and W-2 reporting.
Employee Full Name
First NameLast Name
Employee Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
Date
Last 4 Digits of Social Security Number
Employment Start Date
MonthDayYear
Date
Filing Status
Number of Allowances/Exemptions Claimed
Additional Amount to Withhold Each Pay Period (if any)
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
Employer Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employee Signature
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Date Signed
MonthDayYear
Date
Should be Empty: