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2. Withholdings Change Form

4. Please fill this form out if you have or are wanting to change your withholdings. Majority of the companies do no notify us that some of the deductions have changed so we do not know of any updates. This form will inform our office to change deductions from your paycheck.

6. First Name*
7. Last Name*
9. Email Address*
10. Phone Number*
12. Preferred Contact Method:*
    -- Select One --EmailCall
13. What company are you inquiring about?*
14. Have you contacted the agent?*

    1. Yes
    2. No
16. What was decided between you and the agent on the changes?
18. County Clerk's Office Contact Information

    If you have any questions or concerns please feel free to contact the Clerk's Office.

    Phone Number: 785-852-4282

    Email: wacoclk@fairpoint.net

20. I will contact you for further information.

    We will be in touch shortly after I have time to review this form and your policy information.

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field