EARNINGS HOURS AMOUNT DEDUCTION AMOUNT YTD DEDUCT EMPLR CONTRIB.

CURRENT GROSS
FICA 229.50 459.00
3,000.00
Base Salary 3,000.00 Medicare 24.00 48.00
State WH 210.00 420.00 YTD TAXABLE
Overtime 0.00 Fed Tax 450.00 900.00
6,000.00
Health Insurance 145.00 290.00 CURRENT NET

Life Insurance 10.00 20.00

1,941.50
Retirement 194.15 388.30
TOTAL 3,000.00 PERIOD ENDING
LEAVE BALANCE TAKEN YTD 2/15//10

Sick 8.50
1.50 PAY DATE

Personal 2.00
0.00
2/20/10

TOTAL
1,262.65 2,525.30

Statement of Earnings and Deductions Please Remove and Keep for Your Records

001253
YOUR EMPLOYER Fake Bank of Arkansas, Inc. CHECK NO.
$ P.O. Box
2/20/10
Ozark, AR. 72949 DATE
 One Thousand Nine Hundred Forty-One and 50/100------------------------------------------------------------------------------ 1,941.50
PAY AMOUNT

VOID AFTER 90 DAYS

TO THE
John Smith
ORDER
308 West Vine St.
OF Searcy, AR 72143

AUTHORIZED SIGNATURE