“*” indicates required fields New Hire / Employee ChangeBusiness Name* New employee or current employee change* New Employee (Fill out all information) Current Employee Change HUB Set-up:PTO/Only ESS Clock Employee Name* Social Security Number* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Main Dept Pay Rate* 2nd Dept Pay Rate Date of Hire* MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY Email* DOB & Email Required for HUB ActivationFederal Filing Status*Use information found on Form W-4 (do not send W-4 to PaySmart, keep in employee records) Single Married Head of Household Step 2 Option C Yes No Line 3Line 4 (a)Line 4 (b)Line 4 (c)Township School District PSD Code (optional) Township & School district are required information found on certificate of residency. Missing information will result in processing delays.Withhold LST? Yes No If No, must provide exemption formEligible for time off benefits? Yes No Payroll DeductionsDeductionAmountFrequencyStart DateBalance Due Add RemoveReminders: PaySmart is not responsible for omitted or incorrect information contained on this form DO NOT send W-4, I-9, or Certificate of Residency to PaySmart Keep W-4 and Certificate of Residency with your employee records Keep I-9s together in a separate file, retain for 3 years from hire date or 1 year from termination date, whichever is longer
