Tax return

a Employee's social security number

22222 Void 111-22-3333 For Official Use Only

OMB No. 1545-0008

b Employer identification number 1 Wages, tips, other comp. 2 Federal income tax withheld

52-5555555 80000.00 18000.00 c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

Mickey's Burger Palace 85000.00 5270.00 1 MAIN STREET 5 Medicare wages and tips 6 Medicare tax withheld ROCKVILLE, MD 20850 85000.00 1232.50

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12

MICHAEL M MCDONALD D 5000.00 Statutory Retirement Third-party

13 employee plan sick pay

12b

X 2 WEST JEFFERSON STREET 14 Other 12c

SILVER SPRING MD 20904 12d

f Employee's address and ZIP code

15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

MD 80000.00 5600.00

Wage and Tax Statement Department of the Treasury—Internal Revenue Service

Form W-2 Statement 2016 For Privacy Act and Paperwork Reduction Copy A For Social Security Administration — Send this entire page with 0 0 0 0 / 1833 Act Notice, see the separate instructions. Form W-3 to the Social Security Administration; photocopies are not acceptable.

Do Not Cut, Fold, or Staple Forms on This Page

a Employee's social security number

22222 Void For Official Use Only

OMB No. 1545-0008

b Employer identification number 1 Wages, tips, other comp. 2 Federal income tax withheld

c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12

Statutory Retirement Third-party 13

employee plan sick pay 12b

14 Other 12c

12d

f Employee's address and ZIP code

15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

Wage and Tax Statement Department of the Treasury—Internal Revenue Service

Form W-2 Statement 2016 For Privacy Act and Paperwork Reduction Copy A For Social Security Administration — Send this entire page with 0 0 0 0 / 1833 Act Notice, see the separate instructions. Form W-3 to the Social Security Administration; photocopies are not acceptable.