Gross Pay
Gross Salary YTD
Pay Frequency
Federal Filing Status
# of Federal Allowances
Additional Fed. Withholding
Round Federal Withholding
I am exempt from:
% of Federal
Additional State W/H
Employee 401(k) Contribution
Employer 401(k) Contribution
Employer 401(k) Contribution Limit
Are you 50 or older?
Deduction #2 Name
Deduction #2 Amount
Ded. #2 Exempt from: