Name Proposal Census Employee Data Name of Employer Date Sheet No. Contact Info Name * Email Address * 1 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 2 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 3 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 4 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 5 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 6 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 7 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 8 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 9 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 10 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 11 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 12 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 13 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 14 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 15 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 16 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 17 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 18 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 19 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship 20 S.S. Number Employee Name Date of Birth Date of Hire Sex Male Female Gross Pay Officer Yes No % of Ownership Relationship For any 5% or more owners assign a letter for that family and identify any family members. For family members of a 5% or more owners indicate the relationship (i.e. son, daughter etc.)
