CO.
FILE
DEPT.
CLOCK
NUMBER

MCB
02470383 0
Taxable Marital Status:
Exemptions/Allowances:
Earnings Statement
Period start:
Period ending:
Pay date:
Emp #:
Earningsratehoursthis periodyear to date
Regular
Overtime
Holiday
Vacation*
Bonus*
Float*
Gross Pay
$
DeductionsStatutory
Federal Income Tax
Social Security Tax
Medicare
State Income Tax
%   SUI/SDI Tax
Net Pay

* Excluded from federal taxable wages

Other Benefits and
Informationthis periodtotal to date
Group Term Life0.000.00
Loan Amt Paid0.00
Vac Hrs Left0.00
Sick Hrs Left0.00
Title
 
Important
Notes

WE WILL BE STARTING OUR UNITED WAY FUND
DRIVE SOON AND LOOK FORWARD TO YOUR
PARTICIPATION.

60-162/433
Payroll check number:
Pay date
Social Security No.
Pay to the order of:
This amount:

SAMPLE
NON-NEGOTIABLE
VOID VOID VOID

VOID AFTER 180 DAYS

AUTHORIZED SIGNATURE