|
22222
|
Void
|
Employee's social security number
|
For Official Use Only
|
|
563-85-7806
|
OMB No. 1545-0008
|
|
b Employer identification number (EIN)
|
1
|
Wages, tips, other compensation
|
2 Federal income tax withheld
|
|
454714518
|
11,256.90
|
160.92
|
|
c Employer's name, address and ZIP code
|
3 Social security wages
|
4 Social security tax withheld
|
|
REDMAN VAN & STORAGE
|
11,256.90
|
697.93
|
|
2571 WEST 2590 SOUTH
|
5
|
Medicare wages and tips
|
6 Medicare tax withheld
|
|
SALT LAKE CITY, UT 84119
|
11,256.90
|
163.23
|
|
|
7
|
Social security tips
|
8 Allocated tips
|
|
|
|
|
|
d Control number
|
9
|
|
10 Dependant care
|
|
18
|
|
|
|
e Employee's first name and initial
|
Last name
|
Suff.
|
11
|
Nonqualified plans
|
12a See instructions for box 12
|
|
JOLI
|
BROWN
|
|
|
|
|
5250 WOODSTEP AVE
|
13 Statutory Employee
|
Retiremant Plan
|
Third party sick pay
|
12b
|
|
WEST VALLEY, UT 84120
|
|
|
|
|
14
|
Other
|
12c
|
|
|
|
|
|
|
|
|
|
12d
|
|
|
|
|
|
|
|
Employee's address and ZIP code
|
|
|
|
15 State Employer's state ID number
|
16 State Wages
|
17 State income tax
|
18 Local wages, tips, etc.
|
19 Local income tax
|
20 Locality name
|
|
UT
|
12529633002WTH
|
11,256.90
|
226.67
|
|
|
|