TX FILE DEPT. CLOCK VCHR. NO.

075
UB1 000079 000004 0000480112 1 Earnings Statement
Period Beginning: 04/08/2021
Chance Washington
1512 Disston St
Period Ending: 04/14/2021
Tallahassee, FL 32310 Pay Date: 04/15/2021

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 35,000.00 this period total to date

Overtime 93.75 01.11 104.17 1,458.38

Gross Pay $2,604.17 36,458.38

Statutory
Federal Income Tax -307.50 -4,305.00
Social Security Tax -218.24 -3,328.02
Medicare Tax -36.25 -507.50
Health Care -68.75 -962.52
401K -62.50 -875.00 Taxable Marital Status:
TX: Single
LTD -6.00 -84.00 Exemptions/Allowances:
TX: 2
Dental -3.87 -54.18
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: 04/15/2021
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