22222

Void 

Employee's social security number

For Official Use Only

575-78-8765

OMB No. 1545-0008

b Employer identification number (EIN)

1

Wages, tips, other compensation

2 Federal income tax withheld

454714518

49,742.76

3,726.55

c Employer's name, address and ZIP code

3 Social security wages

4 Social security tax withheld

REDMAN VAN & STORAGE

49,742.76

3,084.05

2571 WEST 2590 SOUTH

5

Medicare wages and tips

6 Medicare tax withheld

SALT LAKE CITY, UT 84119

49,742.76

721.27

7

Social security tips

8 Allocated tips

d Control number

9

10 Dependant care

150

e Employee's first name and initial

Last name

Suff.

11

Nonqualified plans

12a See instructions for box 12

FAGOTA

SIAUMAU

355 W 200 S #104

13 Statutory Employee

Retiremant Plan

Third party sick pay

12b

WASHINGTON , UT 84780

14

Other

12c

125 CAFETERIA PLAN 1,492.24

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

49,742.76

2,086.36

Form

W-2

Wage and Tax Statement

2021

Department of the Treasury-Internal Revenue Service For Privacy Act and Paperwork Reduction

Copy A for Social Security Administration - Send this page with

Act Notice, see separate instructions.

Form W-3 to the Social Security Administration; photocopies are not acceptable.

41-0852411

LW2A

5201