CO. FILE DEPT. CLOCK VCHR. NO.

STX 001963 084121 0000291605 1

Earnings Statement
1675-0001
THE STAMFORD HOSPITAL Period Beginning: 07/07/2019
ONE HOSPITAL PLAZA, PO BOX 9317 Period Ending: 07/13/2019
STAMFORD, CT 06904 Pay Date: 07/19/2019

Taxable Marital Status: Married LEONARDO R. HERMOSURA

Exemptions/Allowances: 83 CRESTVIEW AVE.
Federal: 0,$50 Additional Tax
CT: Filing Status A,$20 Additional Tax
STAMFORD CT 06907

rate hours this period year to date

Regular 37 4496 37 50 1 404 36 31 263 66
Your federal taxable wages this period are
Overtime 113 06
$1 288 88
Gross Pay $1 404 36 42 801 88
Your CT taxable wages this period are
$1 288 88
Statutory
Other Benefits and
Federal Income Tax -169 98 5 183 54
this period total to date
Social Security Tax -87 74 2 671 82
Gtl 80 82 2 307 40
Medicare Tax -20 52 624 86
CT State Income Tax -84 92 2 593 29 Eib Hours 428 75
Pto Hours 198 66

Charles Warner -34 13 989 77

Dental -8 88* 257 52
Medical -60 22* 1 734 34
Std -14 Day -20 75 601 75
Unum Accident -3 85
Unum Crt Illn -17 08
Vision Plan -0 81* 23 49
403B Ee Flat $ -126 39* 3 725 75
403B Loan 1 -104 29 3 024 41
403B Loan 2 -162 28 4 706 12

Net Pay $502 52

Savings 1 -502 52

Net Check $0 00

Excluded from federal taxable wages

2000 A DP, LLC

THE STAMFORD HOSPITAL Advice number: 00000291605

ONE HOSPITAL PLAZA PO BOX 9317 Pay date: 07/19/2019
STAMFORD CT 06904

Deposited to the account of account number transit ABA amount

LEONARDO R. HERMOSURA 2110 xxxx xxxx $502 52

NON-NEGOTIABLE