LINE 15 MONTHLY RECONCILIATION
Year / employer / internal employee reference:
Plan / eligibility group:

MONTHLY ROW
Month | Line 14 code | Amount applicable? | Rate source/version | Effective dates | Reviewed calculation | Expected amount | Prepared amount | Difference | Resolution
Jan | | | | | | | | |
Feb | | | | | | | | |
Mar | | | | | | | | |
Apr | | | | | | | | |
May | | | | | | | | |
Jun | | | | | | | | |
Jul | | | | | | | | |
Aug | | | | | | | | |
Sep | | | | | | | | |
Oct | | | | | | | | |
Nov | | | | | | | | |
Dec | | | | | | | | |

REVIEW
Payroll deduction comparison and explanation:
Special arrangement / reviewer:
Intentional blanks / zeros confirmed:
Shared mapping changes / affected population:
Approved output version / reviewer / date: