SSA-L4201 Current Version.pdf - RegInfo.gov

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EMPLOYEE NAMESOCIAL SECURITY NUMBERREFERENCE NUMBERYEAR___________GROSS WAGESPAID IN MONTHCAFETERIA PLANDEDUCTIONSCHILD SUPPORTGARNISHMENTSOTHERJanuary __ JanuaryFebruary __ FebruaryMarch __ MarchApril __ AprilMay __ MayJune __ JuneJuly __ JulyAugust __ AugustSeptember __ SeptemberOctober __ OctoberNovember __ NovemberDecember __ December$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$YEAR___________GROSS WAGESPAID IN MONTHCAFETERIA PLANDEDUCTIONSCHILD SUPPORTGARNISHMENTSOTHERJanuary __ JanuaryFebruary __ FebruaryMarch __ MarchApril __ AprilMay __ MayJune __ JuneJuly __ JulyAugust __ AugustSeptember __ SeptemberOctober __ OctoberNovember __ NovemberDecember __ December$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$4. ADDITIONAL INFORMATION/COMMENTS:5. SignatureDate:Title:EmployerTelephone:FAX:Form <strong>SSA</strong>-<strong>L4201</strong> BK (07-2009) EF (07-2009)