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Quarterly Payroll Change

Instructions:

Step 1: Review your Quarterly Payroll Statement and identify pay periods in which your actual payroll differed from the standard amounts.

Step 2: Enter total GROSS WAGES and total NET PAY for every pay period identified in Step 1. Calculate Net Pay by multiplying Gross Wages by the multiplier for that particular pay period (see Quarterly Payroll Statement for 5-digit multiplier value). If employee is paid on a Net Pay basis, enter Net Pay and calculate Gross Wages (Gross Wages = Net Pay divided by the multiplier).

Step 3: If no wages were paid in the pay period, enter a value of 0 (zero). Do NOT leave blank -- a blank entry means standard payroll as scheduled.

Pay Frequency:


Breedlove Account No.* ex. SMIT1234
Employer Name*
Contact Phone Number*
Employee's Name*

* Required Information

Pay Period EndingGross WagesNet Wages