Caregiver

**-******* **-*******

OMB No. ****-****

OMB No. 1545-0008

a Employee's soc. sec. no. 1 Wages, tips, other comp. 2 Fed. income tax withheld a Employee's soc. sec. no. 1 Wages, tips, other comp. 2 Fed. income tax withheld 3 Social security wages 4 Soc. sec. tax withheld 3 Social security wages 4 Soc. sec. tax withheld b Employer ID number (EIN) b Employer ID number (EIN) 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code d Control number d Control number

e Employee's name, address, and ZIP code e Employee's name, address, and ZIP code 7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9 10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code 13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code 15 State Employer's state ID no. 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS This information is being furnished to the Internal Revenue Service. Copyright 2016 Sage Payroll Services

This information is being furnished to IRS. If you are required to file a tax return, a negligence penalty/other sanction may be imposed on you if this income is taxable & you fail to report it. 38-2099803 38-2099803

OMB No. 1545-0008 OMB No. 1545-0008

a Employee's soc. sec. no. 1 Wages, tips, other comp. 2 Fed. income tax withheld a Employee's soc. sec. no. 1 Wages, tips, other comp. 2 Fed. income tax withheld 3 Social security wages 4 Soc. sec. tax withheld 3 Social security wages 4 Soc. sec. tax withheld b Employer ID number (EIN) b Employer ID number (EIN) 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code d Control number d Control number

e Employee's name, address, and ZIP code e Employee's name, address, and ZIP code 7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9 10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code 13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code 15 State Employer's state ID no. 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS Notice

to Employee.

Copy B--To Be Filed With Employee's Copy 2--To Be Filed With Employee's State, FEDERAL Tax Return.

City, or Local Income Tax Return

6USW2EM

Copy C--For EMPLOYEE'S RECORDS (See Copy 2--To Be Filed With Employee's State,

) City, or Local Income Tax Return

2016 2016

2016 2016

10739.00 10739.00

***-**-**** ***-**-****

10739.00 665.82 10739.00 665.82

35-2269369 35-2269369

10739.00 155.72 10739.00 155.72

ARIZONA CARE PROVIDERS LLC ARIZONA CARE PROVIDERS LLC 17020 N 32ND STREET 17020 N 32ND STREET

PHOENIX, AZ 85032 PHOENIX, AZ 85032

AZ06531 AZ06531

NORA V MADERO NORA V MADERO

7007 W INDIAN SCHOOL RDD 7007 W INDIAN SCHOOL RDD

#18-1171 #18-1171

PHOENIX, AZ 85033 PHOENIX, AZ 85033

AZ 35-2269369 10739.00 289.97 AZ 35-2269369 10739.00 289.97 4094

10739.00 10739.00

***-**-**** ***-**-****

10739.00 665.82 10739.00 665.82

35-2269369 35-2269369

10739.00 155.72 10739.00 155.72

ARIZONA CARE PROVIDERS LLC ARIZONA CARE PROVIDERS LLC 17020 N 32ND STREET 17020 N 32ND STREET

PHOENIX, AZ 85032 PHOENIX, AZ 85032

AZ06531 AZ06531

NORA V MADERO NORA V MADERO

7007 W INDIAN SCHOOL RDD 7007 W INDIAN SCHOOL RDD

#18-1171 #18-1171

PHOENIX, AZ 85033 PHOENIX, AZ 85033

AZ 35-2269369 10739.00 289.97 AZ 35-2269369 10739.00 289.97

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