Employer Information Sheet Employer Name and Tax No. ___________________________________________________ Notice to Employer: Please fill out completely and return to: _____________________________________________ EMPLOYEE INFORMATION Full name of employee: __________________________________________________________ Address: ______________________________________________________________________ SSN# : _______________ Date of Birth: _____________ Number of dependents: ___________ Date employed: __________________ Job Title:________________________ Rate of pay: $____________ per _________ Average number of hours per week: ____________ How often paid (check one): [ ] Weekly [ ] Bi-weekly [ ] Monthly [ ] Semi-monthly If paid Weekly/Bi-weekly, state day of the week paid: ___________________________ Date last paid: _______________________________ If paid Semi-monthly, state dates paid: __________________ Date last paid: ________________ If paid Monthly, state date paid: _______________________ Date last paid: ________________ Worksite address: _______________________________________________________________ Date Terminated: _______________________ If terminated, list the termination reason and the name and address of the new employer, if known: _____________________________________ ______________________________________________________________________________ Complete the Information below for the last four Pay Periods Date Paid Gross Wages Bonus/ Commission Federal Tax State Tax FICA Retirement Net Wages MEDICAL INSURANCE INFORMATION FOR MINOR CHILDREN [ ] Available as of ______________________ (Date) [ ] Not Available [ ] Will be Available as of _______________________________________________________ Insurance Company Name: _______________________________________________________ Insurance Company Address: _____________________________________________________ Insurance Company Telephone Number: ____________________________________________ Policy Number: ________________________ Employee certificate/ID#: __________________ Type of Coverage: ______________________ Amount of Deductible: $___________________ Cost to employee to cover self/dependents: $_________________________________________ Individuals covered/effective date: _________________________________________________ _____________________________________________________________________________ Completed by: ______________________ Title: ______________________ Date: _________ When complete, return to the address shown below. Employer Telephone Number: _________ _____________________________________________________________________________ _____________________________________________________________________________ WAKE-DOM-13 (Rev. 2/06) American LegalNet, Inc. www.USCourtForms.com