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779 Ihh 403 H 6754020242226102101202
779 Ihh 403 H 6754020242226102101202
12b
MARIA ELENA MARISCAL
14 Other
12c 1815 GROVE STREET
1.04 SDI
12d APT 15
13 Stat emp. Ret. plan 3rd party sick pay NATIONAL CITY CA 91950
15 State Employer’s state ID no. 16 State wages, tips, etc.
CA 309-3661 1 104.00
17 State income tax 18 Local wages, tips, etc.
1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld
104.00 104.00 104.00
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
104.00 6.45 104.00 6.45 104.00 6.45
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
104.00 1.51 104.00 1.51 104.00 1.51
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
000304 NCTS/977 000200 T EIC 50 000304 NCTS/977 000200 T EIC 50 000304 NCTS/977 000200 T EIC 50
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
ADP TOTALSOURCE FL XVI ADP TOTALSOURCE FL XVI ADP TOTALSOURCE FL XVI
INC INC INC
BEE INTERNATIONAL INC BEE INTERNATIONAL INC BEE INTERNATIONAL INC
10200 SUNSET DRIVE 10200 SUNSET DRIVE 10200 SUNSET DRIVE
MIAMI FL 33173 MIAMI FL 33173 MIAMI FL 33173
b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number
65-0161093 XXX-XX-4536 65-0161093 XXX-XX-4536 65-0161093 XXX-XX-4536
7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips
11 Nonqualified plans 12a See instructions for box 12 11 Nonqualified plans 12a
12 11 Nonqualified plans 12a
e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code
MARIA ELENA MARISCAL MARIA ELENA MARISCAL MARIA ELENA MARISCAL
1815 GROVE STREET 1815 GROVE STREET 1815 GROVE STREET
APT 15 APT 15 APT 15
NATIONAL CITY CA 91950 NATIONAL CITY CA 91950 NATIONAL CITY CA 91950
15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc.
CA 309-3661 1 104.00 CA 309-3661 1 104.00 CA 309-3661 1 104.00
17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.
19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name
NOTE: THESE ARE SUBSTITUTE WAGE AND TAX STATEMENTS AND ARE ACCEPTABLE FOR FILING WITH YOUR FEDERAL, STATE AND LOCAL/CITY INCOME TAX RETURNS.
Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service