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| LSTNM | SSN | St | Type | Claim | Check# | Incptn | ||||||||||||||||||||||
| Pay | Pay | Expctd | Days | Date | Fed | SS | Medcr | Other | State | |||||||||||||||||||
| Term | Begin | End | Disabld | Return To | Paid | To | Days | Benefit | Tax | Tax | Tax | Tax | Tax | Net | ||||||||||||||
| Code | Date | Date | Date | Work Date | Date | Pay | Consd | Amt | Amt | Amt | Amt | Amt | Amt | Pmt | ||||||||||||||
| Group: 99999 | ||||||||||||||||||||||||||||
| Benefit Type: S | ||||||||||||||||||||||||||||
| DOE | 123456789 | MO | I | S | 12/13/2002 | 12/22/2002 | 12/13/2002 | 12/23/2002 | 3008035301 | 000073446 | 1/28/2003 | 3 | 3 | $53.57 | $0.00 | $1.99 | $0.47 | $0.00 | $0.00 | $51.11 | ||||||||
| TOTAL DOE | 3 | $53.57 | $0.00 | $1.99 | $0.47 | $0.00 | $0.00 | $51.11 | ||||||||||||||||||||
| DOE JR | 123456789 | MO | I | S | 2/5/2003 | 2/9/2003 | 12/18/2002 | 5/1/2003 | 2114264102 | 000072615 | 1/7/2003 | 6 | 45 | $107.14 | $0.00 | $3.99 | $0.93 | $0.00 | $0.00 | $102.22 | ||||||||
| 123456789 | MO | I | S | 2/5/2003 | 2/9/2003 | 12/18/2002 | 5/1/2003 | 2114264103 | 000073002 | 1/14/2003 | 7 | 45 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| 123456789 | MO | I | S | 2/5/2003 | 2/9/2003 | 12/18/2002 | 5/1/2003 | 2114264104 | 000073182 | 1/21/2003 | 7 | 45 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| 123456789 | MO | I | S | 2/5/2003 | 2/9/2003 | 12/18/2002 | 5/1/2003 | 2114264105 | 000073445 | 1/28/2003 | 7 | 45 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| TOTAL DOE JR | 27 | $482.14 | $0.00 | $17.94 | $4.20 | $0.00 | $0.00 | $460.00 | ||||||||||||||||||||
| DOE III | 123456789 | MO | I | S | 2/26/2003 | 3/2/2003 | 11/23/2002 | 5/1/2003 | 2107371206 | 000072614 | 1/7/2003 | 6 | 90 | $107.14 | $0.00 | $3.99 | $0.93 | $0.00 | $0.00 | $102.22 | ||||||||
| 123456789 | MO | I | S | 2/26/2003 | 3/2/2003 | 11/23/2002 | 5/1/2003 | 2107371207 | 000073001 | 1/14/2003 | 7 | 90 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| 123456789 | MO | I | S | 2/26/2003 | 3/2/2003 | 11/23/2002 | 5/1/2003 | 2107371208 | 000073181 | 1/21/2003 | 7 | 90 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| 123456789 | MO | I | S | 2/26/2003 | 3/2/2003 | 11/23/2002 | 5/1/2003 | 2107371209 | 000073444 | 1/28/2003 | 7 | 90 | $125.00 | $0.00 | $4.65 | $1.09 | $0.00 | $0.00 | $119.26 | |||||||||
| TOTAL DOE III | 27 | $482.14 | $0.00 | $17.94 | $4.20 | $0.00 | $0.00 | $460.00 | ||||||||||||||||||||
| DOE SR | 123456789 | MO | I | S | 2/26/2003 | 3/2/2003 | 1/13/2003 | 5/1/2003 | 3008036501 | 000073447 | 1/28/2003 | 9 | 42 | $160.71 | $0.00 | $5.98 | $1.40 | $0.00 | $0.00 | $153.33 | ||||||||
| TOTAL DOE SR | 9 | $160.71 | $0.00 | $5.98 | $1.40 | $0.00 | $0.00 | $153.33 | ||||||||||||||||||||
| TOTAL S | 66 | $1,178.56 | $0.00 | $43.85 | $10.27 | $0.00 | $0.00 | $1,124.44 | ||||||||||||||||||||
| LSTNM | SSN | St | Type | Claim | Check# | Incptn | ||||||||||||||||||||||
| Pay | Pay | Expctd | Days | Date | Fed | SS | Medcr | Other | State | |||||||||||||||||||
| Term | Begin | End | Disabld | Return To | Paid | To | Days | Benefit | Tax | Tax | Tax | Tax | Tax | Net | ||||||||||||||
| Code | Date | Date | Date | Work Date | Date | Pay | Consd | Amt | Amt | Amt | Amt | Amt | Amt | Pmt | ||||||||||||||
| TOTAL | 66 | $1,178.56 | $0.00 | $43.85 | $10.27 | $0.00 | $0.00 | $1,124.44 | ||||||||||||||||||||
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