| Company name, address, EIN, phone and logo | Band: company, employee and stub number |
| Employee name, address and ID | Band: company, employee and stub number |
| Last four digits of the SSN | Band: company, employee and stub number |
| Pay period, pay date and pay frequency | Band: company, employee and stub number |
| Filing status and how the pay was made | Band: company, employee and stub number |
| Hours and rate, or the salary for the period | Earnings table |
| Overtime, bonus, commission and tips lines | Earnings table |
| Federal, state, Social Security and Medicare (estimated) | Deductions under Taxes and Other Deductions |
| Your own deductions (health plan, retirement, garnishment) | Deductions under Taxes and Other Deductions |
| Year-to-date totals | Summary grid: this period and year to date |
| Memo or notes | Reimbursement line and memo note |