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a. Employee's SSN
123-45-6879
b. EIN (Employer Identification Number)
46-1234567
1. Wages, tips, other compensation
55,000.00
2. Federal income tax withheld
4,000.00
c. Employer's name, address and ZIP code
BESTEST HOSPITAL EVER, INC.
123 PAYNE LANE POSTCALL, NY 11111
3. Social security wages
60,000.00
4. Social security tax withheld
3,720.00
5. Medicare wages and tips
60,000.00
6. Medicare tax withheld
870.00
7. Social security tips
8. Allocated tips
d. Control number
9. Verification code
10. Dependent care benefits
e. Employee's name, address and ZIP code
DOCTORED B. MONEY
80 WORKHOURS WAY SLEEPLESS HOLLOW, NY 11222
11. Nonqualified plans
12a.
C | 45.50
13.
Statutory employee
Retirement plan ☑️
Third-party sick day
12b.
E | 5,000.00
14. Other
NY SDI     31.2    
12c.
DD | 9,800.57
12d.
15. State
NY
Employer's state ID number
None
16. State wages, tips, etc.
60,000.00
17. State income tax
1,500.00
18. Local wages, tips, etc.
60,000.00
19. Local income tax
500.00
20. Locality name
NYC