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a Envioyee•s social security nurnber

085-58-5189
b nurnbet {EIN) Wages. tips, ottM comgwn:on Fatwa' n:ome tax withheld
59-2287155 $140,00000
2545.50
c Employers name. Socia security wages So:ial Security ux withheld
TINA BOGUTZSKI $140,00000 Sl 413.60
91 HOWARD AVE Medeare wage s an d OPS Mod':æe tax withheld
BINGHAMTON NY 13904 S330.60
8 Albcated tips

d Controa numW 10 Depenoent caro bonelils

e Employee's and initial Sun. 11 Nonqua•tied plans

TINA BOGUTZSKI
91 HOWARD AVE 13
BINGHAMTON NY 13904
othe'

Employee's address and ZIP Code


17 State income lax le Local wages. tips. etc. 19 Local income tax
$1,389.76

the Servke

Form W-2 Wage and Tax Statement æoæo


Copy I —For State, City, or Local Tax

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