| a. |
Control Number |
| |
123456789 |
|
| d. |
Employee Social Security No. |
| |
123-45-6789 |
|
| 1. |
Wages, tips, other compensation |
| |
12,723.36 |
|
| 2. |
Federal Income tax withheld |
| |
856.11 |
|
| c. |
Employer's name, address, and ZIP code |
| |
ALBERTSONS STORES
PAYROLL OFFICE
10920 WILSHIRE BLVD. #620
LOS ANGELES, CA 90024-6508 |
|
| 3. |
Social Security wages |
| |
.00 |
|
| 4. |
Social Security tax withheld |
| |
.00 |
|
| 5. |
Medicare wages and tips |
| |
13,755.00 |
|
| 6. |
Medicare tax withheld |
| |
199.45 |
|
| 9. |
Advance EIC payment |
| |
.00 |
|
| 10. |
Dependent care benefits |
| |
.00 |
|
| e. |
Employee's name (first, middle initial, last) |
| f. |
Employee's address and ZIP code |
| |
JOHN D DOE
123 TEST STREET
LAS VEGAS, NV 89119 |
|
| 12. |
See Instructions for Box 12 |
| 12a. |
|
| 12b. |
|
| 12c. |
|
|
| 14. |
Other |
| |
DCP-CAS |
1,031.64 |
|
|
|
| d. |
Employer's identification number |
| |
95-6006147-W |
|
This information is being furnished to the Internal Revenue Service. 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 & you fail to report it.
CMD No. 154-0008 Department of the Treasury - Internal Revenue Service |
FORM
W-2 2007 |
Wage and Tax
Statement |
 |
| Copy C for EMPLOYEE'S RECORDS (See Notice to Employee on back of Copy B) |
|
