|
22222
|
Void
|
Employee's social security number
|
For Official Use Only
|
|
646-42-3218
|
OMB No. 1545-0008
|
|
b Employer identification number (EIN)
|
1
|
Wages, tips, other compensation
|
2 Federal income tax withheld
|
|
454714518
|
17,190.00
|
1,586.35
|
|
c Employer's name, address and ZIP code
|
3 Social security wages
|
4 Social security tax withheld
|
|
REDMAN VAN & STORAGE
|
17,190.00
|
1,065.78
|
|
2571 WEST 2590 SOUTH
|
5
|
Medicare wages and tips
|
6 Medicare tax withheld
|
|
SALT LAKE CITY, UT 84119
|
17,190.00
|
249.26
|
|
|
7
|
Social security tips
|
8 Allocated tips
|
|
|
|
|
|
d Control number
|
9
|
|
10 Dependant care
|
|
90
|
|
|
|
e Employee's first name and initial
|
Last name
|
Suff.
|
11
|
Nonqualified plans
|
12a See instructions for box 12
|
|
AMBROSIA R.
|
LUCERO
|
|
|
|
|
1381 SOUTH EMERY STREET
|
13 Statutory Employee
|
Retiremant Plan
|
Third party sick pay
|
12b
|
|
SLC, UT 84104
|
|
|
|
|
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
|
17,190.00
|
720.58
|
|
|
|