TX FILE DEPT. CLOCK VCHR. NO.

075
UB1 000079 000004 0000480112 1 Earnings Statement
Period Beginning: 02/09/2021
Chance Washington
1512 Disston St
Period Ending: 02/14/2021
Tallahassee, FL 32310 Pay Date: 02/15/2021

D Lane Agency Inc.

Filing Status: Single/Married filing separately 3348 Peachtree RD NE Suite 700
Exemptions/Allowances:
Federal: Standard Withholding Table Atlanta, GA 30326

Social Security Number: XXX-XX-1775

rate hours this period year to date Other Benefits and

Regular 62.50 40.00 2,500.00 15,000.00 this period total to date

Overtime 93.75 01.11 104.17 625.02

Gross Pay $2,604.17 15,625.02

Statutory
Federal Income Tax -307.50 -1,845.00
Social Security Tax -218.24 -1,552.48
Medicare Tax -36.25 -217.50
Health Care -68.75 -412.50
401K -62.50 -375.00 Taxable Marital Status:
TX: Single
LTD -6.00 -36.00 Exemptions/Allowances:
TX: 2
Dental -3.87 -23.22
Net Pay $1,901.06
Checking $1,901.06
Net Check 1,347.48

Your federal taxable wages this period are

$1,901.06

2000 ADP, LLC

Chance Washington Advice number: 00000480112

1512 Disston St Pay date: 02/15/2021
Tallahassee, FL 32310
75075

Deposited to the account

of account number transit ABA amount
D Lane Agency Inc xxxxxxxx xxxx xxx $1,901.06

NON-NEGOTIABLE