Copy B—To Be Filed With Employee’s

FEDERAL Tax Return.

Copy C—For EMPLOYEE’S RECORDS (See

Notice to Employee on the back of Copy B.)

Copy 2—To Be Filed With Employee’s State,

City, or Local Income Tax Return

Copy 2—To Be Filed With Employee’s State,

City, or Local Income Tax Return

OMB No. 1545-0008

OMB No. 1545-0008

OMB No. 1545-0008

OMB No. 1545-0008

a

a

a

a

Employee’s soc. sec. no.

Employee’s soc. sec. no.

Employee’s soc. sec. no.

Employee’s soc. sec. no.

b

b

b

b

Employer ID number (EIN)

Employer ID number (EIN)

Employer ID number (EIN)

Employer ID number (EIN)

c

c

c

c

Employer’s name, address, and ZIP code

Employer’s name, address, and ZIP code

Employer’s name, address, and ZIP code

Employer’s name, address, and ZIP code

d

d

d

d

Control number

Control number

Control number

Control number

e

e

e

e

Employee’s name, address, and ZIP code

Employee’s name, address, and ZIP code

Employee’s name, address, and ZIP code

Employee’s name, address, and ZIP code

7

7

7

7

Social security tips

Social security tips

Social security tips

Social security tips

8

8

8

8

Allocated tips

Allocated tips

Allocated tips

Allocated tips

9

9

9

9

10

10

10

10

Dependent care benefits

Dependent care benefits

Dependent care benefits

Dependent care benefits

11

11

11

11

Nonqualified plans

Nonqualified plans

Nonqualified plans

Nonqualified plans

12a

12a

12a

12a

Code

Code

Code

Code

See inst. for box 12

See inst. for box 12

13

13

13

13

Statutory employee

Statutory employee

Statutory employee

Statutory employee

14

14

14

14

Other

Other

Other

Other

12b

12b

12b

12b

Code

Code

Code

Code

Retirement plan

Retirement plan

Retirement plan

Retirement plan

12c

12c

12c

12c

Code

Code

Code

Code

12d

12d

12d

12d

Code

Code

Code

Code

Third-party sick pay

Third-party sick pay

Third-party sick pay

Third-party sick pay

15

15

15

15

State

State

State

State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16

16

16

16

State wages, tips, etc.

State wages, tips, etc.

State wages, tips, etc.

State wages, tips, etc.

17

17

17

17

State income tax

State income tax

State income tax

State income tax

18

18

18

18

Local wages, tips, etc.

Local wages, tips, etc.

Local wages, tips, etc.

Local wages, tips, etc.

19

19

19

19

Local income tax

Local income tax

Local income tax

Local income tax

20

20

20

20

Locality name

Locality name

Locality name

Locality name

Form W-2 Wage and Tax Statement

Form W-2 Wage and Tax Statement

Form W-2 Wage and Tax Statement

Form W-2 Wage and Tax Statement

Dept. of the Treasury - IRS

Dept. of the Treasury - IRS

Dept. of the Treasury - IRS

Dept. of the Treasury - IRS

This information is being furnished to the Internal Revenue Service. 1

1

1

1

Wages, tips, other comp.

Wages, tips, other comp.

Wages, tips, other comp.

Wages, tips, other comp.

2

2

2

2

Federal income tax withheld

Federal income tax withheld

Federal income tax withheld

Federal income tax withheld

3

3

3

3

Social security wages

Social security wages

Social security wages

Social security wages

4

4

4

4

Social security tax withheld

Social security tax withheld

Social security tax withheld

Social security tax withheld

5

5

5

5

Medicare wages and tips

Medicare wages and tips

Medicare wages and tips

Medicare wages and tips

6

6

6

6

Medicare tax withheld

Medicare tax withheld

Medicare tax withheld

Medicare tax withheld

BW24UP NTF 2585243 2 BW24UP

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. 415935366

200604101

1944.61 69.85

1944.61 120.57

1944.61 28.20

MyWorkChoice LLC

19720 JETTON RD.

STE. 201

CORNELIUS, NC 28031

1037313

Kennijah L McCullough

7881 West Hwy. 136

Chickamauga, GA 30707

GA 3333504 1944.61 28.30

415935366

200604101

1944.61 69.85

1944.61 120.57

1944.61 28.20

MyWorkChoice LLC

19720 JETTON RD.

STE. 201

CORNELIUS, NC 28031

1037313

Kennijah L McCullough

7881 West Hwy. 136

Chickamauga, GA 30707

GA 3333504 1944.61 28.30

415935366

200604101

1944.61 69.85

1944.61 120.57

1944.61 28.20

MyWorkChoice LLC

19720 JETTON RD.

STE. 201

CORNELIUS, NC 28031

1037313

Kennijah L McCullough

7881 West Hwy. 136

Chickamauga, GA 30707

GA 3333504 1944.61 28.30

415935366

200604101

1944.61 69.85

1944.61 120.57

1944.61 28.20

MyWorkChoice LLC

19720 JETTON RD.

STE. 201

CORNELIUS, NC 28031

1037313

Kennijah L McCullough

7881 West Hwy. 136

Chickamauga, GA 30707

GA 3333504 1944.61 28.30

Contact this candidate