Mn.gov



Business Enterprises Program-Payroll and Earnings StatementEmployerEmployee NameEmployee NumberSalary For The Period:BeginningEndingEarningsSundayMondayTuesdayWednesdayThursdayFridaySaturdayTotal HoursRate Per HourTotalRegular Hours WorkedOvertime HoursNon Cash CompensationOther Amounts Due – Commission, Special Allowances Etc.Total Wages Or SalaryGratuity / Tips Received directly By The EmployeeTotal EarningsTax DeductionsFICAFederal Income Tax WithheldState Income Tax WithheldMedicareLess total Tax deductionsNet earnings after deductionsOther DeductionsNon Cash Compensation.Gratuity / Tips Received directly By The EmployeeTotal of all other deductionsPaid in Cash □ or Check □ or Account Transfer □ or other □ – Specify ___________ Net Amount Due :I certify the correctness of the above calculations and acknowledge the receipt of the net amount due to me.Employee’s Signature _____________________________________ Date _________________________ ................
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