Employer FEIN	Employer Name	Employer Address Line 1	Employer Address line 2	Employer City	Employer State	Employer Zip Code	Employer Zip+4	Employer Country	Employer International Postal Code	Employee SSN	Employee Last Name	Employee First Name	Employee Middle Name	Employee Address Line 1	Employee Address Line 2	Employee City	Employee State	Employee Zip Code	Employee Zip+4	Employee Country	Employee International Postal Code	Employee Date of Birth	Employee Date of Hire	Employee State of Hire
111222334	My Company, Inc	123 Somewhere St		Frankfort	KY	40601	0601			411223333	Smith-Jones	Sue		456 Somewhere Else St		Frankfort	KY	40601				20010611	20200627	KY