EMPLOYEE'S NAME

S.S.#

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RATE

MARITAL STATUS

SINGLE

MARRIED

EXEMPTIONS

EMPLOYED FROM

TERMINATION DATE

REASON OF TERMINATION

OCCUPATION

DATE

PERIOD

CHECK

HRS

GROSS

S.S.TAX

MED.TAX

FED.

MN

TOTAL

NET

PAID

END

NUMBER

0.062

0.0145

TAX

TAX

DED.

PAY

TOTAL

JAN

TOTAL

FEB

TOTAL

MAR

TOTAL

1ST Q.

TOTAL

APR

TOTAL

MAY

TOTAL

JUNE

TOTAL

2ND Q.

TOTAL

JULY

TOTAL

AUG

TOTAL

SEP

TOTAL

3RD Q.

TOTAL

OCT

TOTAL

NOV

TOTAL

DEC

TOTAL

4TH Q.

TOTAL

YEAR