Form Wage and Tax Statement

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

Department of the Treasury-Internal Revenue Service Form Wage and Tax Statement Form W-2 Wage and Tax Statement

Department of the Treasury-Internal Revenue Service Form W-2Wage and Tax Statement

Department of the Treasury-Internal Revenue Service Copy 2 - To Be Filed With Employee's State, City, or Local Income Tax Return. Copy C - For EMPLOYEE'S RECORDS.

2022

1 2 Federal income tax withheld

3 Social security wages 4 Social security tax withheld 5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits 11 Nonqualified plans 12a

12b

12c

12d

Statutory

employee

Retirement

plan

Third-party

sick pay

13

14 Other

15 State 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name b Employer identification number

c Employer's name, address, and ZIP code

Employer's state ID number

e Last name

2022

2022

2022

OMB No. 1545-0008

1 2 Federal income tax withheld

3 Social security wages 4 Social security tax withheld 5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits 11 Nonqualified plans 12a

12b

12c

12d

Statutory

employee

Retirement

plan

Third-party

sick pay

13

14 Other

15 State 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name b Employer identification number

c Employer's name, address, and ZIP code

Employee's SSN

f Employee's address and ZIP code

Employer's state ID number

e Last name

OMB No. 1545-0008

1

3 Social security wages

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits 11 Nonqualified plans 12a

12b

12c

12d

Statutory

employee

Retirement

plan

Third-party

sick pay

13

14 Other

15 State 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name b Employer identification number

c Employer's name, address, and ZIP code

f Employee's address and ZIP code

Employer's state ID number

e Last name

OMB No. 1545-0008

1

3 Social security wages

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits 11 Nonqualified plans 12a

12b

12c

12d

Statutory

employee

Retirement

plan

Third-party

sick pay

13

14 Other

15 State 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name b Employer identification number

c Employer's name, address, and ZIP code

f Employee's address and ZIP code

Employer's state ID number

e Last name

OMB No. 1545-0008

2 Federal income tax withheld

4 Social security tax withheld

2 Federal income tax withheld

4 Social security tax withheld

W-2 W-2

Suff.

Suff.

Suff. Suff.

Copy 2 - To Be Filed With Employee's State, City, or Local Income Tax Return. This information is being furnished to the Internal Revenue Service. If you are required to file a tax a a Employee's SSN

a Employee's SSN a Employee's SSN

d Control number

d Control number d Control number

d Control number

Wages, tips, other compensation Wages, tips, other compensation Wages, tips, other compensation Wages, tips, other compensation Employee's first name and initial

Employee's first name and initial

Employee's first name and initial Employee's first name and initial return, a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it.

f Employee's address and ZIP code

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

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

6392.40 6392.40

6392.40 6392.40

32.70 32.70

32.70 32.70

6392.40 6392.40

6392.40 6392.40

396.32 396.32

396.32 396.32

63-0440641 63-0440641

63-0440641 63-0440641

6392.40 6392.40

6392.40 6392.40

92.69 92.69

92.69 92.69

JACKS FAMILY RESTAURANTS LP JACKS FAMILY RESTAURANTS LP JACKS FAMILY RESTAURANTS LP JACKS FAMILY RESTAURANTS LP 124 WEST OXMOOR ROAD 124 WEST OXMOOR ROAD

124 WEST OXMOOR ROAD 124 WEST OXMOOR ROAD

BIRMINGHAM, AL 35209 BIRMINGHAM, AL 35209

BIRMINGHAM, AL 35209 BIRMINGHAM, AL 35209

BRANDY

BRANDY

BRANDY BRANDY

C

C

C C

JOHNSON

JOHNSON

JOHNSON JOHNSON

1915 RUFUS STREET

1915 RUFUS STREET

1915 RUFUS STREET 1915 RUFUS STREET

A

A

A A

DYERSBURG, TN 38024

DYERSBURG, TN 38024

DYERSBURG, TN 38024 DYERSBURG, TN 38024

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