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Preliminary Payment Calculation Sheet

[DATE]
Name:Social Security No.:
Salary Band:
Hire DateYears Of Service:
Notification Date:Off-Payroll-Date:

Benefits Coverage Through:

You may elect to continue health insurance coverage for an extended period under C.O.B.R.A. federal benefits continuation regulations.  enrollment information and materials will be mailed to your home.

Base Salary: 
Incentive Amount: 
Total: 
Weekly Rate: 
Severance: 
Post-Employment Payment: 
Post-Employment Supplement (if applicable): 
Total: 
Release Bonus (if applicable) 
(33.3% of Total Severance): 
Total of Severance and Release: 
*Pay for unused vacation days, personal days, and floating holidays: 
Number of unused days: 
Grand Total: 

If you feel that any of the data on this sheet is inaccurate, please contact [specify name] at [specify address and/or phone number].


Copyright 1998 Steven M. Sack

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