Courtesy Withholding Survey First Name and Last NameBusiness NameLocal Address*City, State, Zip*Email* Contact PersonPhone Number* Cell Number Fax NumberFederal ID # Social Security #Date Withholding Will StartWill You Be Sumitting Payments On A:Monthly Basis Quarterly Basis If No, What address would you like your forms mailed to if different from aboveAddressCity, State, ZipDo you use a payroll service:Yes No If yes, name of the payroll service:Name of Payroll ServiceHow Many Employees will you be withholding for?Name of Madeira EmployeeAddress of Madeira EmployeeName of Madeira EmployeeAddress of Madeira EmployeeName of Madeira EmployeeAddress of Madeira EmployeeI certify the above information to be true and accurateName of Person Completing Form Date