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DocuSign Envelope ID: EA6C45CD-7691-43D8-B939-A4300A7DD233 <br /> FSA IIIIG'°Iay Cydb IIII Bill VIII IIIIF ti <br /> Field Pic Length <br /> Employee ID Number 999999999 9 <br /> Last Name X(25) 25 <br /> First Name X(15) 15 <br /> Address Line 1 X(30) 30 <br /> Address Line 2 X(30) 30 <br /> City X(20) 20 <br /> State X(2) 2 <br /> Zip X(9) 9 <br /> * PayFrequency X(1) 1 <br /> MRA Amount Withheld 9999V99 7 <br /> DCRA Amount Withheld 9999V99 7 <br /> HireDate (YYYYMMDD) 99999999 8 <br /> Term Date (YYYYMMDD) 99999999 8 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Premium 99999V99 7 <br /> ** Company Location 9999 4 <br /> * <br /> Record Length 224 <br /> * Pay Frequency Values: <br /> B - Bi-Weekly, W-Weekly <br /> S-Semi-Monthly, M—Monthly <br /> ** Please indicate a name for each premium <br /> *** A 4 digit code indicating the location or division where the employee is employed. <br /> ORANGE COUNTY 9 Flores <br />