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Ho LCD m b Jo h n s t o n, N. D. Phone: (406)585911343 8 E. M e node NH all S t. Fax: (406)5859103Boz e m an, M T 5 9 7 15PEDIATRIC INTAKE FORM (Birth to 5 YEARS) Patients Name: Today's Date: Date

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Ho lco m b stands for Household Employee's Withholding Allowance Certificate.

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The purpose of Ho lco m b is to determine the amount of federal income tax to withhold from a household employee's paycheck.

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Ho lco m b requires information such as name, address, social security number, and withholding allowances.

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