"Employee First Name"	"Employee Middle Initial"	"Employee Last Name"	"Employee Address (Line 1)"	"Employee Address (Line 2)"	"Employee City"	"Employee State"	"Employee Zip Code"	"Employee Zip Code +4"	"Employee Social Security Number or ITIN"	"Employer Name"	"Employer Address (Line 1)"	"Employer Address (Line 2)"	"Employer City"	"Employer State"	"Employer Zip Code"	"Employer Zip Code +4"	"Employer FEIN"	"Employer Payroll Address 1"	"Employer Payroll Address 2"	"Employer Payroll City"	"Employer Payroll State"	"Employer Payroll Zip Code"	"Employee Date of Hire"	"Left Your Employment During Period"	"Employee Date of Birth"	"Employee Gender"	"Employee State of Hire"	"Earned Income Tax Credit Indicator"	"Medical Insurance Available"	"Outlet or Store Number"