1.
1. Start Date Day/Month/Year
1. End Date Day/Month/Year
1. Regular Wages Earned During Week
2.
2. Start Date Day/Month/Year
2. End Date Day/Month/Year
2. Regular Wages Earned During Week
3.
3. Start Date Day/Month/Year
3. End Date Day/Month/Year
3. Regular Wages Earned During Week
4.
4. Start Date Day/Month/Year
4. End Date Day/Month/Year
4. Regular Wages Earned During Week
5.
5. Start Date Day/Month/Year
5. End Date Day/Month/Year
5. Regular Wages Earned During Week
6.
6. Start Date Day/Month/Year
6. End Date Day/Month/Year
6. Regular Wages Earned During Week
7.
7. Start Date Day/Month/Year
7. End Date Day/Month/Year
7. Regular Wages Earned During Week
8.
8. Start Date Day/Month/Year
8. End Date Day/Month/Year
8. Regular Wages Earned During Week
9.
9. Start Date Day/Month/Year
9. End Date Day/Month/Year
9. Regular Wages Earned During Week
10.
10. Start Date Day/Month/Year
10. End Date Day/Month/Year
10. Regular Wages Earned During Week
11.
11. Start Date Day/Month/Year
11. End Date Day/Month/Year
11. Regular Wages Earned During Week
12.
12. Start Date Day/Month/Year
12. End Date Day/Month/Year
12. Regular Wages Earned During Week
(A) Total regular wages earned during 12 weeks before severance
A) Total regular wages earned during 12 weeks before severance =1. Regular Wages Earned During Week + 2. Regular Wages Earned During Week + 3. Regular Wages Earned During Week + 4. Regular Wages Earned During Week + 5. Regular Wages Earned During Week + 6. Regular Wages Earned During Week + 7. Regular Wages Earned During Week + 8. Regular Wages Earned During Week + 9. Regular Wages Earned During Week + 10. Regular Wages Earned During Week + 11. Regular Wages Earned During Week + 12. Regular Wages Earned During Week $
(B) Regular weekly wage, or if you do not have a regular weekly wage Total regular wages (A) divided by number of weeks actually worked in the last 12 weeks before severance
(B) Regular weekly wage, or if you do not have a regular weekly wage Total regular wages (A) divided by number of weeks actually worked in the last 12 weeks before severance $
(C) Number of completed years of employment
(C) Number of completed years of employment
(D) Number of completed months of employment divided by 12 for a
year that is not completed
(D) Number of completed months of employment divided by 12 for a
year that is not completed
(E) Number of weeks of severance pay due (C) + (D) =
(E) Number of weeks of severance pay due (C) + (D) =
(F) Number of weeks of severance pay due (E) × regular weekly wage (B)
(F) Number of weeks of severance pay due (E) × regular weekly wage (B)
Total Amount Owed
Total Amount Owed = (F) $