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Annual Salary

State

🏛️

Marital Status

22222

a Employee’s social security number

OMB No. 1545-0008

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

5 Medicare wages and tips

7 Social security tips

4 Social security tax withheld

5 Medicare tax

8 Allocated tips

d Control number

9

10 Dependent care benefits

e Employee’s first name and initial

Last name

Suff.

f Employee’s address and ZIP code

11 Nonqualified plans

13

Statutory employee

Retirement Plan

Third-Party Sick Pay

14 Other

12a

Code

[Code]

12b

Code

[Code]

12c

Code

[Code]

12d

Code

[Code]

15 State

Employer's state ID number

16 State wages, tips, etc.

17 State income tax

18 Local wages, tips, etc.

19 Local income tax

20 Locality name