DATE AMOUNT

PAY

PAY TO THE
ORDER OF
FILE RECORD
FILE RECORD
AUTHORIZED SIGNATURE

Employee Number: Pay Date: 10/25/2009

Department Number: Pay Period:
, Social Security Number: NET PAY: ***253.82
Withholding Allowances: M0

Earnings Taxes Deductions / Miscellaneous Items

Description Hours This Period Year-To-Date Description This Period Year-To-Date Description This Period Year-To-Date
SALARY 40 290.00 290.00 SOC SER TAX 17.98 17.98
HEALTH INSURAN 0.00 0.00 MEDICARE TAX 4.20 4.20
STATE INCOME TAX 14.00 14.00

Total Earnings 290.00 290.00 Total Taxes 36.18 36.18 Total Deductions 0.00 0.00

Employee Number: Pay Date: 10/25/2009

Department Number: Pay Period:
, Social Security Number: NET PAY: ***253.82
Withholding Allowances M0

Earnings Taxes Deductions / Miscellaneous Items

Description Hours This Period Year-To-Date Description This Period Year-To-Date Description This Period Year-To-Date
SALARY 40 290.00 290.00 SOC SER TAX 17.98 17.98
HEALTH INSURAN 0.00 0.00 MEDICARE TAX 4.20 4.20
STATE INCOME TAX 14.00 14.00

Total Earnings 290.00 290.00 Total Taxes 36.18 36.18 Total Deductions 0.00 0.00