PAYROLL USA - DATA COLLECTION FORM
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  (Employee Information may be entered directly on the screen, however this
       form may be helpful as a worksheet to collect that information)

SSN                 EMPL NUM                PREV EMPL NUM

SURNAME                       FIRST NAME

STREET                                       PHONE

TOWN

STATE                            ZIP CODE

SEX      MARRIED          YR BORN        MO BORN      DAY BORN      AGE

OCCUPATION                         EMPLOYEE TYPE        EMPLOYEE STATUS

YR LAST REVIEW         MO LAST REVIEW      DAY LAST REVIEW

YR NEXT REVIEW         MO NEXT REVIEW      DAY NEXT REVIEW

PAY METHOD     SALARY TERRITORY       SALARY LEVEL      SALARY PERFORMANCE

ANNUAL SALARY              HOURLY RATE           PAY FREQ

OVERTIME PERMITTED

VACATION ACCRUAL P'CENT          VACATION ALLOW         VACATION TAKEN

SICK ACCRUAL P'CENT              SICK ALLOW             SICK TAKEN

START YEAR         START MO       START DAY

END YEAR           END MO         END DAY           REASON TERMINATED

Bank A/c Info. only needed if pay is to be deposited directly into Bank A/c
instead of cash or instead of issuing a pay check. See MICR coding on personal
check.  Routing code normally 9 digits, account number normally 7 digits.

EMPLOYEE'S BANK ROUTING CODE                  BANK ACCOUNT NUMBER

EXEMPT FED TAX                        VOL FED ADDTNL WHOLDG

NUM OF FED EXEMPTIONS

EIC W5 FILED           EIC W5 SPOUSE FILED

EXEMPT SOCIAL SECURITY AND EXEMPT MEDICARE

FEDERAL OR STATE EMPLOYEE PAYING MEDICARE ONLY

EXEMPT FUTA

EXEMPT STATE TAX                      VOL STATE ADDTNL WHOLDG

NUM OF REG. STATE EXEMPTIONS          NUM OF ADDL. STATE EXEMPTIONS

EXEMPT SUTA

EXEMPT LOCAL TAX

NUM OF LOCAL EXEMPTIONS               NON RESIDENT FOR LOCAL