a. Employee’s social security number This information is being furnished to the Internal Revenue Service.

If you are
343721804 OMB No. 1545-1872 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
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
75-1876650 9,200 50,000

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
2,400 2,000

ADAM S BURD 5 Medicare wages and tips 6 Medicare tax withheld

848 W LINCOLN BLVD, 500 2,200
FREEPORT, IL 61032-4914

d Social security tips 8 Allocated tips

300 500

d. Control number 9 10 Dependent care benefits

488999

e. Employee's first name and initial Last name Suff. 11 Nonqualified plans
12a See instructions for box 12
C | 417.49
d ta
ADAM S BURD 12b
Statutory Retirement Third-party
employee plan sick pay D I 131.25
□ Ӽ □ d
14 Other
1 2n
DD | 24,199.76
12d
CASDI 835
W | 1200.00
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y. Employee’s address and ZIP code 848 W LINCOLN
BLVD, FREEPORT, IL 61032-4914
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
IL ,I B630-0178-7147 6,000 50,100
................................................................

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Form W-2 Wage and Tax Statement 2020

(Notice to Employee on the back of Copy B.) Department of the

Treasury—Internal Revenue Service