Copy B-To Be Filed With Employee's Federal Tax Return. a Employee's soc. sec. no. 1 Wages, tips, other comp. 111-11-1111 3 Social security wages 41-0852411 OMB No. 1545-0008 2 Federal income tax withheld 2248.78 359.77 4 Social security tax withheld 2318.33 b Employer ID number (EIN) 5 Medicare wages and tips 95-1234567 143.74 Copy 2-To Be Filed With Employee's State, City, or Local Income Tax Return. a Employee's soc. sec. no. 1 Wages, tips, other comp. 111-11-1111 3 Social security wages 2248.78 5 Medicare wages and tips 33.62 c Employer's name, address, and ZIP code 95-1234567 2318.33 CA ROB INDUSTRIES 100 MAIN ST. STE. 125 PASADENA 91106 d Control number 33.62 CA 91106 d Control number 1 1 e Employee's name, address, and ZIP code ROMAN 1459 LOCUST LOS ANGELES Suff. EDDINGTON CA 7 Social security tips 10 Dependent care benefits 90045 8 Allocated tips 9 Advance EIC payment 11 Nonqualified plans 12a Code Retirement plan Suff. EDDINGTON CA 7 Social security tips 10 Dependent care benefits 9 Advance EIC payment 11 Nonqualified plans 12a Code D 13 Statutory employee 69.55 12b Code 14 Other Retirement plan 12c Code X 90045 8 Allocated tips 69.55 12b Code 14 Other e Employee's name, address, and ZIP code ROMAN 1459 LOCUST LOS ANGELES D 12c Code X Third-party sick pay Third-party sick pay 12d Code CA 95-1234567 2248.78 15 State Employer's state ID number 16 State wages, tips, etc. 18 Local wages, tips, etc. 19 Local income tax 2318.33 25.50 104.05 17 State income tax 20 Locality name 12d Code CA 95-1234567 2248.78 15 State Employer's state ID number 16 State wages, tips, etc. 18 Local wages, tips, etc. 19 Local income tax CA - SDI 2318.33 2009 25.50 Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS This information is being furnished to the Internal Revenue Service. Form W-2 Wage and Tax Statement DAA DAA Copy C-For EMPLOYEE'S RECORDS (See Notice to Employeeon the back of Copy B.) a Employee's soc. sec. no. 41-0852411 OMB No. 1545-0008 2 Federal income tax withheld 1 Wages, tips, other comp. 2248.78 111-11-1111 3 Social security wages 359.77 4 Social security tax withheld 2318.33 b Employer ID number (EIN) 5 Medicare wages and tips 95-1234567 143.74 2318.33 2009 a Employee's soc. sec. no. 1 Wages, tips, other comp. 111-11-1111 3 Social security wages CA - SDI 41-0852411 OMB No. 1545-0008 2 Federal income tax withheld 2248.78 359.77 4 Social security tax withheld 2318.33 b Employer ID number (EIN) 5 Medicare wages and tips 33.62 104.05 17 State income tax 20 Locality name Dept. of the Treasury -- IRS Copy 2-To Be Filed With Employee's State, City, or Local Income Tax Return. 6 Medicare tax withheld c Employer's name, address, and ZIP code 95-1234567 143.74 6 Medicare tax withheld 2318.33 33.62 c Employer's name, address, and ZIP code ROB INDUSTRIES 100 MAIN ST. STE. 125 PASADENA CA ROB INDUSTRIES 100 MAIN ST. STE. 125 PASADENA 91106 d Control number CA 91106 d Control number 1 1 e Employee's name, address, and ZIP code ROMAN 1459 LOCUST LOS ANGELES 10 Dependent care benefits Suff. EDDINGTON CA 7 Social security tips 90045 8 Allocated tips 9 Advance EIC payment 11 Nonqualified plans 12a Code 10 Dependent care benefits Retirement plan Suff. EDDINGTON CA 7 Social security tips 90045 8 Allocated tips 9 Advance EIC payment 11 Nonqualified plans 12a Code 69.55 12b Code 14 Other e Employee's name, address, and ZIP code ROMAN 1459 LOCUST LOS ANGELES D 13 Statutory employee 143.74 6 Medicare tax withheld c Employer's name, address, and ZIP code ROB INDUSTRIES 100 MAIN ST. STE. 125 PASADENA 13 Statutory employee 359.77 4 Social security tax withheld 2318.33 b Employer ID number (EIN) 6 Medicare tax withheld 2318.33 41-0852411 OMB No. 1545-0008 2 Federal income tax withheld D 13 Statutory employee Retirement plan 12c Code X 69.55 12b Code 14 Other 12c Code X Third-party sick pay CA 95-1234567 2248.78 15 State Employer's state ID number 16 State wages, tips, etc. 18 Local wages, tips, etc. 19 Local income tax 2318.33 Form W-2 Wage and Tax Statement Third-party sick pay 12d Code 25.50 2009 104.05 17 State income tax 20 Locality name CA 95-1234567 2248.78 15 State Employer's state ID number 16 State wages, tips, etc. 18 Local wages, tips, etc. 19 Local income tax CA - SDI 2318.33 Dept. of the Treasury -- IRS This information is being furnished to the IRS. If you are required to file a tax return, a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it. 12d Code DAA Form W-2 Wage and Tax Statement DAA 25.50 2009 104.05 17 State income tax 20 Locality name CA - SDI Dept. of the Treasury -- IRS
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