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10 Dividends ..................... <br />.................................... • 1J' ~ <br />11 Unemployment compensation. See ~,ctions, page 15 . . . . . . . . . . . . . . . . . . . . . . . • 1 ~ <br />12 Totai income. Add lines 8 through 11 . . . . . . . . . . • <br />+~ ~^^°~ ° oll adjustments which are included (+), <br />PLOYEE W-2 WAGE SUMMARY 1996 The thart below indicates your 1996 voluu~afederal wages (eox 1) and state' wages. <br />~~ excluded (-)~ ar did not affect (N/A) yo <br />;~ 0090-4104 OR WA6ES , <br />VOLUNTARY ADJUSTMENTS YTD AMOUNT FEDERAL WAGES <br />-.u SHOP & GO MARKET 185.05 N/A ; <br />EE CHRGE 6.14 N~A ' <br />1149 NW VAN BUREN WORK COMP N~p N/A <br />c a CORVALLIS OR 97330 WORK HOURS 558.00 <br />=~ fEDERAL WITHHOLDING EXEMPTIONS S 1 <br />' OR WITHHOLDING EXEMPTIONS <br />REGULAR WAGES for 1996 3013.20 <br />'`~' E HEINLE 0009-000100 <br />'P( <br />~ F YROLLS BY PAYCHEX' 97002 <br />:'~iF~ W-2 Wage and Tax Statement 1996 <br />Void Uepar[ment of the T' <br />vl mMnber OMB No. 1545-0008 <br />090-4104 0009-00010 ~ ~p~o er's name, ~een <br />,~ .,. °' roma~,.~,~ <br />ery yl.n nP~ amP. <br />~~.rn <br />Em01WK ~ txial ueuritY ~mber <br />.,... ~.,,~,~;~.~,~ ~,m~, a <br />.,.~3-1180863 542-04-8382 <br />;edc Mstrs. fa Box 13 14 Other <br />.. l :j <br />iC ~~:n <br />59.50 <br />~? conti <br />in ~ed <br />jm it fc <br />~.~Gl!~?lS <br />K Employer's stai <br />~ I 8311579 <br />This iniorma~wn is bel~g ~umished ~o ~he Intemal Fevenue Service <br />~py C, for ewp~oyee~s reeords <br />SH~P & GO MARKET <br />1149 NW VAN BUREN <br />CORVALLIS OR 97330 <br />e tI11PWYee~s iwme, .~..~...• _~ _.. -- <br />ERIC E HEINLE <br />2009 VAN BUREN STREET, NW <br />CORVALLIS OR 97330 <br />wages, tips, etc. <br />3013.20 <br />~e 20 Laal wages, tips, etc. <br />secu(ty tax ;i8 ~d 80 <br />re t~x withheld <br />43.69 <br />are <br />.__ .,,, ~.,~~ payment. ;,r."_ <br />Y~~~~`~~ <br />~~ ~~~G~b <br />/ ~~~ <br />124.23 <br />~ ~-' ' ' ~ 3013.20 <br />3 Saial S~~cy 3~~ 3. 20 <br />5 Meditare wages and tips <br />3013.20 <br />" ..~..- ---108 .13 <br />tax <br />