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Employee Name
WORK LOCATION
Advice No.
Default value
Default value
Correct value
Employee ID
Tax ID
Federal Status
State Work
State Res Status
Advice Date
Default value
Default value
EARNINGS STATEMENT
Period Begin
Period End
Total Earnings
Total Taxes
Total Deductions
Net Amount
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Earnings
TAXES - DEDUCTIONS - MISC
DESCRIPTION - RATE - MILES - HOURS - GROSS PAY
DESCRIPTION - CURRENT - YEAR-TO-DATE
Current Pay Rate
Regular
Total Hours Worked
Current Totals
Y-T-D Totals
Taxes
Fica
Fica Medicare
Federal Tax
Totals
Deductions
Pay
** 404 ** ** DOLLARS AND ** 45 ** cents
To the order of:
Check Date
Check Number
06/18/2026
84080
THIS IS NOT A CHECK
Non-Negotiable
VOID
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Type Company Name
Type Company Full Address
Employee Name
WORK LOCATION
Advice No.
84080
Employee ID
Tax ID
Federal Status
State Work
State Res Status
Advice Date
1
11-1234567
Single
Resident
06/18/2026
EARNINGS STATEMENT
Period Begin
Period End
Total Earnings
Total Taxes
Total Deductions
Net Amount
06/10/2026
06/16/2026
458.80
54.35
0.00
404.45
Earnings
TAXES - DEDUCTIONS - MISC
DESCRIPTION - RATE - MILES - HOURS - GROSS PAY
DESCRIPTION - CURRENT - YEAR-TO-DATE
Current Pay Rate
11.47
Regular
458.80
Total Hours Worked
40.00
Current Totals
458.80
Y-T-D Totals
1,000.00
11,470.00
Taxes
Fica
28.45
711.25
Fica Medicare
6.65
166.25
Federal Tax
19.25
481.25
0.00
Totals
54.35
Pay
** 404 ** ** DOLLARS AND ** 45 ** cents
To the order of:
Check Date
Check Number
06/18/2026
84080
THIS IS NOT A CHECK
Non-Negotiable
VOID
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