Employer (Legal Entity) Name & Address

Final Paycheck Worksheet & Pay Stub*

______

______

Employee Name Employee ID or last 4 digits of employee’s social security no.

______

Prepared By Date

Employee previously paid through: ______This check is for pay earned from ______to ______

Date

Termination Date: ______Last Day Worked: ______

Date Date

# of Hours Rate of Pay Description x Hourly Rate = Wages to be Paid

_____ Regular time = 1.0 x $______= $______

_____ Overtime = 1.5 x $______= $______

_____ Double time = 2.0 x $______= $______

_____ Piece Rate x $______= $______

_____ Vacation or PTO x $______= $______

_____ Other ______x $______= $______

Vacation or PTO Pay

If the employee accrues vacation or PTO, you must calculate vacation/PTO pay due to the employee and pay the accrued, unused hours upon separation. Refer to your company policy regarding the rate of accrual.

Payment must be made for other items the employer owes to the employee or which are due by policy ( i.e., accrued and payable sick leave, personal days, severance, expenses advanced by the employee on behalf of the employer etc.)

Final Paycheck Calculation

Total Wages to be Paid: Withholding:

Regular Hours $______Federal Income Tax $______

Overtime Hours $______Social Security $______

Double time Hours $______Medicare Tax $______

Piece Rate Hours $______State Income Tax $______

Vacation Hours $______SDI/UI $______

Other ______$______Health Insurance $______

Other ______$______Other $______

Other $______

Total Gross Wages $______Total Withholdings $______

Final check # ______Final Check Amount $______

(Net Earnings)

*By providing this completed worksheet with the final paycheck you are meeting the DLSE pay stub requirements.