STATEMENT OF EARNINGS

STATE OF KANSAS
990 SW Jackson St., Landon Bldg., Rm 351S
Topeka, KS 66612-1220

Firstname M Lastname
1234 This Street
Kansas City, KS 66103
SSN: 000-00-0000
Employee ID: J0000012345
Check Date: 09/26/2003
Check No. 8718858
Pay Begin Date: 08/31/2003
Pay End Date: 09/13/2003
Net Pay: $0,0000.00
Pay Group: REG-Regents
Department: 6830000000-Univ of Ks Medical Center
 
--- Current --- --- YTD ---
Hours and Earnings Rate Hours Earnings Hours Earnings
Regular Earnings 18.50 5 0.00   0.00
Vacation Leave-Exempt 0.00   0.00
Sick Leave-Exempt 0.00   0.00
Longevity   0.00 0.00
Holiday Credit-Paid-Exempt 0.00   0.00
Discretionary Day-Exempt 8 0.00 0.00
TOTAL 13 0.00   0.00
Taxes Current YTD
Fed OASDI/EE xxx.xx xxx.xx
Fed Med/EE 24.84 226.57
Fed Withholding 105.99 953.91
KS Withholding 50.00 450.00
TOTAL xxx.xx xxx.xx
Before Tax Deductions Current YTD
Medical-Premier Blue HMO 106.20 968.77
Prescription Drug 24.84 226.57
TSA 105.99 953.91
VOL TSA 50.00 450.00
TOTAL xxx.xx xxx.xx
After Tax Deductions Current YTD
Optional Group Life xx.xx xxx.xx
Optional Group Life Admin Fee x.xx xx.xx
TOTAL xxx.xx xxx.xx
Leave as of 09/13/2003 Beg.
Balance		 Earned Taken Balance
Sick 262.95 3.70 4.0 262.65
Vacation 236.00 8.00 8.00 236.00
Direct Deposit Distribution
Institution Account # Deposit Amount
Checking xxxxxx853 xxxx.xx
Savings xxxxxx001 xxx.xx
Employer Paid Benefits Current YTD
Group Term Life TSA Reg Not Pa xxx.xx xxx.xx
Group Term Life TSA Reg Not Pa* 24.84 226.57
State Leave Assessment 105.99 953.91
Work Comp Insurance 50.00 450.00
Medical Premier Blue HMO 181.85 3,006.42
Dental 9.90 170.28
Prescription Drug 45.46 781.92
Prior Years Service Retirement 0.00 443.56
Group Term Life-TSA RegNotPart* 1.43 9.83
Tax Sheltered Annuity-TIAA CREF 176.27 3,483.80
*Taxable
Summary of Totals Current YTD
Total Gross xxx.xx xxx.xx
Fed Taxable Gross xxx.xx xxxx.xx
Total Taxes xxx.xx xxxx.xx
Total Deductions xxx.xx xxxx.xx
Net Pay xxx.xx xxxx.xx
 
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