Form Rs 5120 - Monthly Salary And Service Certification Page 2
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1
2INSTRUCTIONS: (The following relates to each column bearing the same number)
(1) Indicate each calendar month during which wages were paid.
(2) Indicate for first entry only and thereafter only when change occurred.
(e.g.: $2.50 PER hour; $30.00 PER day; $10,000.00 PER year)
(3) Indicate for first entry and thereafter only when change occurred. (e.g.: Weekly, Bi-weekly, Semi-monthly, etc.)
(4) and (5) ENTER FOR EACH MONTH – Days worked must be based on time keeping records or a record of activities.
If No Record of days worked exists, enter NR.
For instructions on reporting school employees refer to the Employer Guide Section 5.
(6) Please indicate and identify any period of leave without pay OR at ½ pay. Also indicate any period covered by Worker’s Compensation,
changes in payroll titles and/or changes in the standard workday.
1 Example
2 Example
3 Example
4 Example
5 Example
6 Example
Periods of Leave Without Pay
or with Half Pay.
Frequency
Monthly
Days
Also list any changes in payroll titles
Month/Year
Rate of Pay
of
Gross
Worked
and/or standard workdays.
Payment
Salary Paid
Monthly
From
To
Type of
mm/dd/yyyyy
mm/dd/yyyyy
Leave
(Example)
(Example)
(Example)
(Example)
(Example)
(Example)
JUNE 07
$7.15 Per Hour
Weekly
972.40
17
6/11/99 6/14/99
–
Sick Leave
JULY 07
1,430.00
25
8/1/07 new title
– Sr. clerk –
SWD 7.5 hrs
Member’s Name: __________________________________ Registration #: ___________ Date Sent: ________ Loc Code: ________
1
2
3
4
5
6
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
You may photocopy this page if additional space is needed.
RS 5120 (Rev. 11/11)
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