Northridge Pharmaceuticals

7649F Diamond Hts Blvd

San Francisco

(415) 872-9214

STATEMENT OF MONTHLY INCOME

Employee Name | ${col0}
Employee ID | ${col1}
Social Security # | ${col2}
Pay Period | <#if col3?is_date>${col3?string("MM/dd/yy")}<#else>${col3}
Department | ${col4}
Position/Grade | ${col5}

EARNINGS | AMOUNT | TAXES/DEDUCTIONS | AMOUNT
Basic Salary | ${col6} | Federal Tax | ${col7}
Bonuses | ${col8} | Social Security Tax | ${col9}
|  | Medicare Tax | ${col10}
|  | State Tax | ${col11}
|  | Medical | ${col12}
|  | Dental | ${col13}
Total Earnings | ${col14} | Total Deductions | ${col15}

Net Pay ${col16}
Employee signature:
Director: