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Type Company Name
Type Company Full Address
Employee Name
WORK LOCATION
Advice No.
63645
Employee ID
Tax ID
Federal Status
State Work
State Res Status
Advice Date
1
11-1234567
Single
Resident
05/19/2026
EARNINGS STATEMENT
Period Begin
Period End
Total Earnings
Total Taxes
Total Deductions
Net Amount
05/11/2026
05/17/2026
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
840.00
9,634.80
Taxes
Fica
28.45
597.45
Fica Medicare
6.65
139.65
Federal Tax
19.25
404.25
0.00
Totals
54.35
STATEMENT OF EARNINGS AND DEDUCTIONS • DETACH AND KEEP FOR YOUR RECORDS
Pay
** 404 ** ** DOLLARS AND ** 45 ** cents
To the order of:
Check Date
Check Number
05/19/2026
63645
THIS IS NOT A CHECK
Non-Negotiable
VOID
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