7 Social security tips 1 Wages, tips, other compensation 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2019 1861.32
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STAFFMARK INVESTMENT LLC 1861.32 115.40
1A L99
201 EAST 4TH STREET 9 5 Medicare wages and tips 6 Medicare tax withheld
1861.32 26.99
SUITE 800 10 Dependent care benefits 11 Nonqualified plans C
12a See instructions for box 12
o
CINCINNATI OH 45202 d
e
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
d
e
NITKITKIA DURHAM JAMES b Employer identification number (EIN) C
12c
o
1238 WALTON ST 71-0842216 d
e
a Employee’s social security number 12d
NEW IBERIA LA 70560 435-41-4755
C
o
d
e
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
LA 4615514001 1861.32 23.86
Copy B-To Be Filed With Employee’s FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. Dept. of the Treasury - IRS
OMB No. 1545-0008 Visit the IRS website at www.irs.gov/efile.
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 and you fail to report it.
7 Social security tips 1 Wages, tips, other compensation 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2019 1861.32
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STAFFMARK INVESTMENT LLC 1861.32 115.40
9 5 Medicare wages and tips 6 Medicare tax withheld
201 EAST 4TH STREET 26.99
1861.32
SUITE 800 10 Dependent care benefits 11 Nonqualified plans 12a See instructions for box 12
C
CINCINNATI OH 45202 o
d
e
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
d
NITKITKIA DURHAM JAMES e
12c
b Employer identification number (EIN) C
1238 WALTON ST 71-0842216 o
d
e
a Employee’s social security number 12d
NEW IBERIA LA 70560 C
o
435-41-4755 d
e
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
LA 4615514001 1861.32 23.86
Copy C-For EMPLOYEE’S RECORDS (See Notice to Employee on the back of Copy B.) OMB No. 1545-0008 Dept. of the Treasury - IRS
Visit the IRS website at www.irs.gov/efile.
7 Social security tips 1 Wages, tips, other compensation 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2019 1861.32
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STAFFMARK INVESTMENT LLC 1861.32 115.40
9 5 Medicare wages and tips 6 Medicare tax withheld
201 EAST 4TH STREET 1861.32 26.99
SUITE 800 10 Dependent care benefits 11 Nonqualified plans 12a
C
o
CINCINNATI OH 45202 d
e
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
d
e
NITKITKIA DURHAM JAMES b Employer identification number (EIN) 12c
C
1238 WALTON ST 71-0842216 o
d
e
a Employee’s social security number 12d
NEW IBERIA LA 70560 C
o
435-41-4755 d
e
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
LA 4615514001 1861.32 23.86
Copy 2-To Be Filed With Employee’s State, City, or Local Income Tax Return OMB No. 1545-0008 Dept. of the Treasury - IRS
7 Social security tips 1 Wages, tips, other compensation 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2019 1861.32
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STAFFMARK INVESTMENT LLC 1861.32 115.40
201 EAST 4TH STREET 9 5 Medicare wages and tips 6 Medicare tax withheld
1861.32 26.99
SUITE 800 10 Dependent care benefits 11 Nonqualified plans 12a
C
CINCINNATI OH 45202 o
d
e
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
d
e
NITKITKIA DURHAM JAMES b Employer identification number (EIN) 12c
C
1238 WALTON ST 71-0842216 o
d
e
a Employee’s social security number 12d
NEW IBERIA LA 70560
FORM # LW28700
C
8403000753
o
435-41-4755 d
e
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
LA 4615514001 1861.32 23.86
Copy 2-To Be Filed With Employee’s State, City, or Local Income Tax Return OMB No. 1545-0008 Dept. of the Treasury - IRS