Copy B—To Be Filed With Employee’s Copy 2—To Be Filed With Employee’s State,

OMB No. 1545-0008 OMB No. 1545-0008

FEDERAL Tax Return. City, or Local Income Tax Return
a Employee’s soc. sec. no. 1 Wages, tips, other comp. 2 Federal income tax withheld a Employee’s soc. sec. no. 1 Wages, tips, other comp. 2 Federal income tax withheld
2720.25 126.44 2720.25 126.44
311909339 3 Social security wages 4 Social security tax withheld 311909339 3 Social security wages 4 Social security tax withheld
b Employer ID number (EIN) 2720.25 168.66 b Employer ID number (EIN) 2720.25 168.66
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
270318075 2720.25 39.44 270318075 2720.25 39.44
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
Surge Staffing Surge Staffing
4 EASTON OVAL 4 EASTON OVAL

Columbus, OH 43219 Columbus, OH 43219

d Control number d Control number
1001760382 1001760382
e Employee’s name, address, and ZIP code e Employee’s name, address, and ZIP code
Ryan A Oneal Ryan A Oneal
603 hillcrest 603 hillcrest

Seymour, IN 47274 Seymour, IN 47274

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code

13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code

Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code

IN 0152749934-001 2720.25 87.88 IN 0152749934-001 2720.25 87.88

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 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 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
2720.25 57.12 JACKSON 2720.25 57.12 JACKSON
Form W-2 Wage and Tax Statement  Dept. of the Treasury - IRS Form W-2 Wage and Tax Statement  Dept. of the Treasury - IRS
This information is being furnished to the Internal Revenue Service.

Copy C—For EMPLOYEE’S RECORDS (See Copy 2—To Be Filed With Employee’s State,
OMB No. 1545-0008 OMB No. 1545-0008
Notice to Employee on the back of Copy B.) City, or Local Income Tax Return
a Employee’s soc. sec. no. 1 Wages, tips, other comp. 2 Federal income tax withheld a Employee’s soc. sec. no. 1 Wages, tips, other comp. 2 Federal income tax withheld
2720.25 126.44 2720.25 126.44
311909339 3 Social security wages 4 Social security tax withheld 311909339 3 Social security wages 4 Social security tax withheld
b Employer ID number (EIN) 2720.25 168.66 b Employer ID number (EIN) 2720.25 168.66
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
270318075 2720.25 39.44 270318075 2720.25 39.44
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
Surge Staffing Surge Staffing
4 EASTON OVAL 4 EASTON OVAL

Columbus, OH 43219 Columbus, OH 43219

d Control number d Control number
1001760382 1001760382
e Employee’s name, address, and ZIP code e Employee’s name, address, and ZIP code
Ryan A Oneal Ryan A Oneal
603 hillcrest 603 hillcrest

Seymour, IN 47274 Seymour, IN 47274

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code

13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code

Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code

IN 0152749934-001 2720.25 87.88 IN 0152749934-001 2720.25 87.88

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 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 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
2720.25 57.12 JACKSON 2720.25 57.12 JACKSON
Form W-2 Wage and Tax Statement  Dept. of the Treasury - IRS Form W-2 Wage and Tax Statement  Dept. of the Treasury - IRS
This information is being furnished to the IRS. If you are 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. BW24UP NTF 2585243 2 BW24UP