                       PAYROLL USA - DATA COLLECTION FORM
                       ----------------------------------
  (Employee Information may be entered directly on the screen, however this
       form may be helpful as a worksheet to collect that information)

SSN:                EMPLOYEE NUM:               PREVIOUS EMPL NUM:

EMPLOYEE SURNAME:                     FIRST NAME:

SPOUSE FIRST NAME:                   { Optional, for social invitations, etc. }

STREET:

TOWN:                                      STATE:

ZIP CODE:                PHONE:

DATE OF BIRTH ==> YEAR:        MONTH:      DAY:        AGE:        SEX:

OCCUPATION:                        W-2 EMPLOYEE TYPE:       EMPLOYEE STATUS:
 ------------------------------------------------------------------------------
RATING (OPTIONAL) 1 = Poor, 2 = Fair, 3 = Good, 4 = Very Good, 5 = Excellent
   WORK PERFORMANCE ==>     QUALITY:      QUANTITY:       JOB KNOWLEDGE:
   PERSONAL PERFORMANCE ==> CO-OPERATION:    RESOURSEFULNESS:    HABITS:
   Habits include such as Lates/Absences/Neatness. Also use comments screen.
 ------------------------------------------------------------------------------
SALARY TERRITORY:        SALARY LEVEL:       SALARY PERFORMANCE:
 { The above line only for companies with a structured grade/step salary plan }

DATE OF LAST PERFORMANCE OR PAY REVIEW ==>  YEAR:        MONTH:      DAY:

DATE NEXT PERFORMANCE OR PAY REVIEW DUE ==> YEAR:        MONTH:      DAY:
 ------------------------------------------------------------------------------
PAYS PER YEAR:       PAY METHOD:      ANNUAL SALARY:            { If salaried }

REGULAR (RATE#1) HOURLY RATE:             RATE#2:          IS OVERTIME:

RATE#3:          IS OVERTIME:             RATE#4:          IS OVERTIME:
 ------------------------------------------------------------------------------
BANK ROUTING:               BANK ACCOUNT:             {for Direct Deposit pay}

VACATION ACCRUAL PCENT:          VAC. DAYS ALLOW:        VAC. DAYS TAKEN:

SICK ACCRUAL PCENT:          SICK DAYS ALLOW:          SICK DAYS TAKEN:

DATE EMPLOYEE FIRST STARTED WORK ==> YEAR:        MONTH:      DAY:

DATE TERMINATED ==> YEAR:        MONTH:      DAY:       REASON TERMINATED:

PERSONAL INCOME TAX SETUP INFORMATION:
Marital status:    { Limited to range selected in Configuration of State Tax }
Exempt Federal Income Tax:
Num of Fed. Exemptions:      Voluntary Fed. Addtnl Wholdg (Per Pay):
Advance EIC, W-5 Filed:          Advance EIC, W-5 Spouse Filed:
Exempt Soc Sec:          Exempt Medicare:          Exempt Fed. Unempl:
Exempt State Income Tax:          Num of Regular State Exemptions:
Num of Additional State Exemptions:     { A few States only, example Calif. }
Voluntary State Additional Withholding (Per Pay):
Exempt State Unemployment:            Exempt Local Income Tax:
Num of Local Exemptions:              Non resident for Local Tax:
