This form contains 60 fields organized into 17 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Accrual Information
Accruals Yes	Radiobutton	Check this box if accruals are applicable for the employee.
Accrual Rate	Number	Please provide the accrual rate for this employee. Fill only if 'Accruals Yes' is 'Yes'. Depends on: Accruals Yes
Accruals No	Radiobutton	Check this box if accruals are not applicable for the employee.
Base Rate 1
Base Rate 1	Number	Please enter the employee's base rate for the first rate.
Hourly Rate	Number	Please enter the employee's hourly rate.
Salary per Pay Period	Number	Please enter the employee's salary per pay period.
Base Rate 2
Rate 2 Name	Text	Please provide the name or identifier for Base Rate 2.
Rate 2 Amount	Number	Please provide the monetary amount for Base Rate 2.
Rate 2 Effective Date	Date	Please provide the effective date for Base Rate 2.
Client Information
Client Name	Text	Please provide the full name of the client.
Client Code	Text	Please provide the unique identification code for the client.
Current Pay Period Information
Hours	Number	Please enter the total number of hours worked during this current pay period.
Partial Salary Amount	Number	Please provide the partial salary amount for this current pay period.
Employee Address
Address Line 1	Text	Please enter the first line of the employee's street address.
Address Line 2	Text	Please enter the second line of the employee's street address, such as an apartment, suite, or unit number.
City	Text	Please enter the city where the employee resides.
State	Text	Please enter the two-letter abbreviation for the state where the employee resides.
Zip Code	Text	Please enter the employee's postal zip code.
Employee Identification
Employee Number	Text	Enter the unique identification number assigned to the employee.
Last Name	Text	Enter the full last name of the employee.
First Name	Text	Enter the full first name of the employee.
Middle Initial	Text	Enter the middle initial of the employee's name, if applicable.
Employee Personal Information
Phone Number	Text	Please provide the employee's contact phone number.
Sex: Male	Radiobutton	Check this box if the employee's sex is male.
Sex: Female	Radiobutton	Check this box if the employee's sex is female.
Social Security Number	Text	Please provide the employee's Social Security Number.
Birth Date	Date	Please provide the employee's birth date.
Employment Details
Home Department Number	Text	Please enter the employee's home department number.
Workers Compensation Code	Text	Please enter the workers' compensation code for the employee.
Hire Date	Date	Please enter the date the employee was hired.
Termination Date	Date	Please enter the date of employee termination. Fill only if 'Termination' is 'Yes'. Depends on: Termination
Federal Tax Withholding
Federal Exemptions	Text	Enter the number of federal tax exemptions you are claiming.
Fixed Federal Withholding	Number	Enter a fixed amount or percentage of federal income tax to be withheld from your pay.
EIC Code	Text	Enter your Earned Income Credit (EIC) code, if applicable.
Additional Federal Withholding	Number	Enter any additional federal income tax amount you wish to have withheld from your pay.
First Deduction
First Deduction Type	Text	Enter the type of the first deduction.
First Deduction Amount/Percentage	Number	Enter the amount or percentage for the first deduction.
First Other Earning
Other Earning Type	Text	Enter the type of this other earning.
Other Earning Amount/Percentage	Number	Provide the amount or percentage for this other earning.
Effective Date	Text
Frequency	Text
Other Earning Effective Date	Date	Enter the date this other earning becomes effective.
Other Earning Frequency	Text	Specify the frequency at which this other earning is disbursed.
Form Submission Purpose
New Employee	Checkbox	Check this box if the purpose of this form is to provide information for a new employee.
Change to Existing Employee	Checkbox	Check this box if the purpose of this form is to update information for an employee who is already on file.
Termination	Checkbox	Check this box if the purpose of this form is to report the termination of an employee.
General
Effective Date	Text
Frequency	Text
Effective Date	Text
Other Earnings Effective Date	Date	Enter the effective date for these other earnings.
Other Earnings Frequency	Text	Enter the frequency for these other earnings.
Second Deduction
Second Deduction Type	Text	Enter the type of the second deduction to be applied.
Second Deduction Amount or Percentage	Number	Enter the amount or percentage for the second deduction.
Second Other Earning
Second Other Earning Type	Text	Enter the type of the second other earning.
Second Other Earning Amount/Percentage	Number	Provide the amount or percentage for the second other earning.
State Tax Withholding
State Marital Status	Text	Please enter the employee's marital status for state tax withholding purposes.
State Exemptions	Number	Please enter the total number of state tax exemptions claimed by the employee.
Additional State Withholding	Number	Please enter any additional amount the employee wishes to have withheld for state tax.
Fixed State Withholding	Text	Please enter the fixed dollar amount or percentage the employee wishes to have withheld for state tax.
Work State	Text	Please enter the state where the employee primarily works if it is not California.

Employee Action Form Instructions