Courtesy Withholding Survey

First Name and Last Name
Business Name
Local Address*
City, State, Zip*
Email*  Contact Person
Phone Number*  Cell Number  Fax Number
Federal ID #  Social Security #
Date Withholding Will Start

Will You Be Sumitting Payments On A:
Monthly Basis   Quarterly Basis 

If No, What address would you like your forms mailed to if different from above
Address
City, State, Zip

Do you use a payroll service:
Yes                No  
If yes, name of the payroll service:
Name of Payroll Service

How Many Employees will you be withholding for?
Name of Madeira EmployeeAddress of Madeira Employee
Name of Madeira EmployeeAddress of Madeira Employee
Name of Madeira EmployeeAddress of Madeira Employee

I certify the above information to be true and accurate
Name of Person Completing Form  Date