Sample Company Name, Sample Company Address, ***** EARNINGS STATEMENT

EMPLOYEE NAME SOCIAL SEC.ID EMPLOYEE ID CHECK No. PAY PERIOD PAY DATE

James Robert YOOX-XX-656*-****** 259248 = 0123/14-0129/14 0131/14

INCOME RATE Ss CURRENT TOTAL DEDUCTIONS CURRENT TOTAL YEAR-TO-DATE

GROSS WAGES FICA MED TAX

FICA SS TAX

FED TAX

CA ST TAX

SDI

YTD GROSS YTD DEDCTIONS NET PAY

5,000.00 1,451.28 709.74