Virginia Wage and Tax Statement

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Taxable year:*

Employer identification number (EIN):*

Employer name:*

Address:*

City, State and Zip code:*

Employee Count:

Full Address

SSN

First Name

Last Name

Wages

State Withholding

Name:*

Title:*

Date:*

Best daytime phone:*

Authorized signature:*

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Declaration and Signature: I declare that all information has been examined by me and to the best of my knowledge and belief is true, correct, and complete. I agree