Employer FEIN	Filler1	Employer Name	Employer Address Line 1	Employer Address Line 2	Employer City	Employer State	Employer Zip	Employer Zip 4	Employer CC	Employee First Name 	Employee Middle Name	Employee Last Name	Employee SSN	Address Line 1	Address Line 2	City	State	Zip	Zip 4	DOB	DOH	SOH	Independent Contractor?(Y/N)	Filler3	Employer Contact #	Employer Contact Name
123406789		Fake Company	123 Main Street	#2	Denver	CO	80202	1234	US	Jane	Ann	Doe	012355678	345 Main Lane	#20	Denver	CO	80202	4321	01/01/90	08/05/20	CO	Y		3035555555	Bob Jones																	
123406789		Fake Company	123 Main Street	#2	Denver	CO	80202	1234	US	John	Bob	Doe	111223333	123 Pickle St.		Denver	CO	80202	1234	01/01/88	08/05/20	CO	N		3035555555	Bob Jones