Audit Payroll Account

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					PAYROLL AUDIT REPORT OF WAGES                                                                                               Page 1 of 2




                                            PAYROLL AUDIT REPORT OF WAGES




 If you have attachments, we recommend you print the Payroll Audit Report of Wages and mail all documents together.
 If more space is needed to provide information, please complete additional pages, print, and submit via mail or via
 FAX (715) 539-4721.
 If you need help or have any questions on this audit, call (800)554-2642, Option 4, Extension 4000, or e-mail us at
 premiumaudit@churchmutual.com.

 *Required fields.
   Today's Date: April 05, 2010                                  *Insured Name:
   *Account Number: (requires 7 digits)                           Mary Jones
   1234567                                                       *Street Address:
   *Policy Number: (requires 6 digits)                            111 Your Street
   0 7 - 123456                                                  *City:                    *State: *Zip:
                                                                  Your Town                 WI       12345
   *Policy Period: Month       Date        Year
                                                                 *Contact Person:
             *To: Month        Date        Year
                                                                  Mary Jones
                                                                 *Title:
                                                                  Secretary
                                                                 *Daytime Phone:
                                                                  555-555-55555           (xxx-xxx-xxxx)
                                                                 *E-Mail Address:
                                                                  mjones@yahoo.com
                                                                 Web Site:




 Please enter number of employees: 2              and then click here to list employees and payroll information
                                                                                                     Rent-Free
                                                                                                       Living
      Name of Employees                                 Company Use        Total Gross Payroll
  #                                   Job Title                                                     Quarters or         Meals
        or Contractors                                   Only CODE          For Audit Period
                                                                                                      Housing
                                                                                                    Allowance

  1    John Smith         *     Caretaker          *                          20000           *      yes       *       no         *

  2    Bob Lynch          *     Supervisor         *                          30000           *      no        *       no         *

  Note: The number of employees can be changed (if more or fewer lines are needed).
  Change the number of employees to:              and then click here to update


     *YES, I hereby certify that the information provided is a true statement of gross earnings paid to all employees for
  the audit period.

  *Is this Audit complete?    Yes     No


http://www.churchmutual.com/audit/                                                                                            4/5/2010
PAYROLL AUDIT REPORT OF WAGES                                                                         Page 2 of 2

   (If No, explain below in the Comments box what additional information you plan to provide.)
  Comments:




 A print-ready version of this form will be presented after you click "Submit Audit for Processing" below.

                                               Submit Audit for Processing




http://www.churchmutual.com/audit/                                                                       4/5/2010

				
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