Fillable Printable Pay Stub Sample

Pay Stub Sample

Wage Statement (pay stub): Required Information under Section 195.3

This sample wage statement shows the basic requirements under Section 195.3 for a non-exempt employee

paid by the hour, covered by the Miscellaneous Wage Order. Please note that there may be additional

requirements based upon the specific pay agreement and/or wage order coverage.

LS 49 (12-15)

ABC Company, Inc. Pay Period: 4/10/16 - 4/16/16 Pay Date: 4/19/16 No: 0001

1 Main Street Any town, NY 10000 Ph: 518-457-9000

Employee: John Doe

Rate: Hourly Hours Hours Allowance/ Gross Gross Deductions Deductions Vacation

Regular Overtime Credit Current Year to Date Current Year to Date Net Pay Year to Date

9.00 40 360.00 1080.00

13.50 5 67.50 202.50

FICA -33.36 -100.08

Fed WT -44.80 -134.40

NY WT -13.44 -40.32

Disability -.60 -1.80

Garnishment -35.00 -105.00

Uniform pay $11.20 11.20 33.60

Meals (3) $9.30 9.30 27.90 - 9.30 -27.90

Vacation Hours Earned .75 2.25

448.00 1344.00 -136.50 -409.50 $311.50

1. Employer name, address, and phone number

2. Employee name

3. Dates covered by payment

4. Basis of payment

(hourly, salary, etc.)

5. Rates paid (regular and

overtime)

6. Hours worked (regular

and overtime)

7. Allowances or Credits

8. Gross wages

9. Any deductions from

wages

10. Net wages