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Deduction Amount or of Gross Medical Vision Dental Pre-tax medical Pre-tax vision Pre-tax dental Simple 401 k Simple IRA SARSEP Medical expense FSA Dependent care FSA Loan Repayment Cash Advance Is this employee subject to wage garnishments such as a federal tax or child support garnishment Yes If so attach copies of all garnishment orders Sick and Vacation No. of Hours Earned Per Year Max. If so please complete the Authorization of Direct Deposit form No Tax Information Please attach or...

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