STD Payment Detail Report
For the period: mm/dd/yyyy through mm/dd/yyyy
Contract: 123456 - Admin Unit: PORT - Status: ACTIVE
SSN/Claim Number Payment
From		 Payment
To		 Date Approved
Through		 Benefits Paid
To Date
JOHN SMITH
xxx-00-1111 / 00010001		 mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy $2,350.08
Activity: END OF USUAL RECOVERY PERIOD
Salary:
Gross Benefit:
Adjusted Net Benefit:
FICA:
Medicare Tax:
OREGON INCOME TAX:
FEDERAL INCOME TAX:
Payment:
Taxable:

Overpayment:
Current Balance:

Overpayment Adjustment:
Amount: 		$1,301.25
$1,301.25
$1,301.25
$80.68
$18.87
$91.09
$139.61
$971.00
$1,301.25


$0.00


$0.00