Employee First Name	Employee Middle Name	Employee Last Name	Employee SSN#	Employee Street Address (Line 1)	Street Address (Line 2)	Street Address (Line 3)	Employee City	Employee State	Employee Zip Code	Employee Date of Birth	Employee Start Date	Employee State of Hire	Independent Contractor?	Employer FEIN	Employer Name	Employer Street Address (Line 1)	Street Address (Line 2)	Street Address (Line 3)	Employer City	Employer State	Employer Zip Code	Employer Contact Name	Employer Contact Phone Number