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--- - <br />b Empbyer's identification number <br />~ '`.r' <br />c mpbyer's name, address, and ZIP code <br />; C~.~c~d~ r;~arfisc ~~~ . Ir~c . <br />~ Z4~Ci k~ ~!'>~I~^~ ~~~. <br />~~rClar~~d * !~r~. ~?~~~'~ <br />d Empbyee's social security number <br />~~~"~~~v~~~ <br />e Employee's name, address, and ZIP code <br />~riC ~la~~ <br />j~i,rlQ ~1"iC~'!lfQl'ft~ ~!'1". <br />~us~e~~. ~r. 9~4~1 <br /> cnd state wages. <br />1 Wages, [ips, other compensation -ederal income tax withheld <br />,~~ ~n ~ <br />R WAGES <br />3 Social security wages <br />~~ ~~j 4 Social security tax withheld <br />~ ~ . - N/A <br /> <br />5 Medicare wages and tips <br />o ~ <br />6 Medicare tax withheid <br />,~, N/A <br /> <br />f <br />7 Social security tips 8 Allocated tips ~ <br />i <br />9 Advance EIC payment 10 Dependent carebenefits , <br />1 <br />11 Nonqualified plans 12 Benefits included In bo~c 1' , i <br />13 See Instrs. for box 13 14 Othel , <br />15 Statutory Deceased Penswn Legal Hshld. Subtotal Deferred <br />empbyee plan rep. emp. compensation a 2 Federol income hx withh~ <br />^ ^ ^ ^ ^ ^ ^ ~ 108 <br />16 Sfate Employe~'s state I.D. No. 17 State wages, tips, etc. 18 State income tax 19 Locality name 20 Lceal wages, tips, etc. 21 Local income tax Social searity taz withhel. <br />~-~~.~-----x ~al ar-~--------------- -------~~~ . ~~ --- --------------------- ------------------- ------------------------ - -- ---- ' . , ss <br />-- ------ -- 6 Med~ure qK witld~eld43 <br />E W8 e and Tax Department of the Treasury-Internal Revenue Service <br />g lo Dependent cre <br />~ ~Z Statement 1996 This information is being furnished to the Internal Revenue Serv'~ce. H you are required to <br />file a tax return, a negligence penafty or other sanction may be imposed on you if this <br />Copy C For EMP,LOYEE'S RECORDS (See Notice on back.) income is taxable and you fail to report it. ~Z eene its Inc~w <br />~ ~ <br />21 Loal income lax <br />~-_i ~ ~ ~ ~ I <br />This inlormation is being ~umished to the Intemal Revenue Service <br />_ - -- • -.••• ~w on your paYment. ~ <br />