Accrued Benefits Statement

Date:

Employee:

Department:

Benefits Accrued to date:

[ ] Accrued Vacation Days

[ ] Accrued Vacation Pay

[ ] Accrued Sick Days

[ ] Accrued Sick Pay

[ ] Cash Value Life insurance

[ ] Non-Vested Profit-Sharing

[ ] Vested Profit-Sharing

[ ] Stock Dividends

[ ] Company Shares

[ ] Vested Pension

[ ] Non-Vested Pension

[ ] Credit Union Balance

[ ] Severance Pay

[ ] Accrued Reimbursable Expenses

Other Benefits:

Total Benefits Accrued:

This is a(n) __ interim __ final statement.

THIS STATEMENT IS SUBJECT TO CORRECTION

__________________________

Signature

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