You asked us to hold back $ (1) from your checks each month because of you work. We will hold back this amount from
your checks for (2) through (3) .
What We Will Pay And When
You will receive $ (4) around (5) .
After that, you will receive $ (6) each month.
If you expect to earn more or less than $ (7) this year, please let us know right away. Any changes in the amount of money you
earn may change your payments.
At the end of the year, we will send you a form called the “Annual Report of Earnings.” You will need it to report how much you actually earn for the year. After you report,
we will make any necessary changes to your benefits because of the earnings.
If You Have Any Questions