Employee:

Address:

Position:

Supervisor:

Date Hired:

Payroll Date:

Taxation Identification Number:

Number of Dependents:

Number of Excemptions:

Spouse's Taxation Identif. Number:

Exemptions from Federal/State taxes:

(Attach Certificates of Exemption)

The number of dependents claimed is accurate and I shall notify the personnel department of any change in dependents.

Date:

Signed: ______________________

Employee

CHANGE IN NUMBER OF DEPENDENTS

Employee

Initials Date

From ____ dependents to ____ dependents ________

From ____ dependents to ____ dependents ________

From ____ dependents to ____ dependents ________

From ____ dependents to ____ dependents ________

From ____ dependents to ____ dependents ________

From ____ dependents to ____ dependents ________