"Employee SSN#" "Last Name" "First Name" "Middle Initial" "Employee Street Address (Line 1)" "Street Address (Line 2)" "City" "State" "Postal Code" "Zip Code 4 (US Only)" "Employer Name" "Employer Street Address (Line 1)" "Street Address (Line 2)" "City" "State" "Postal Code" "Zip Code 4 (US Only)" "Employer FEIN" "Employer State EIN" "Employee Hire Date" "Employee Date of Birth" "Filler"