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Get W-4 - Mediccom - Mediccom

Ith Federal employment (i.e. travel reimbursement, uniform allowance, etc). Employee must complete items 1,2,3 and 5. Complete item 4 only if you want to start, cancel or change the amount of a savings or discretionary allotment - see instructions on back of form. 1. EMPLOYEE INFORMATION (SSN) EMPLOYEE PAYROLL IDENTIFICATION NUMBER EMPLOYEE NAME (as on payroll records) (Last, First, Initials) TELEPHONE NUMBER (WORK) 2. TYPE OF ACCOUNT (HOME) 3. DIRECT DEPOSIT ACCOUNT INFORMATION - NET PAY/TR.

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