7 Social security tips 1 Wages, tips, other comp.

2 Federal income tax withheld

Form W-2 Wage and Tax Statement
c Employer’s name, address, and ZIP code
2021 I
8 Allocated tips 3 Social security wages
52200.92
4 Social security tax withheld
3015.13 I
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9 5 Medicare wages and tips 6 Medicare tax withheld
57020.64 826.80
165 CAPITOL AVENUE 10 Dependent care benefits 11 Nonqualified plans 12a See instructions for box 12
HARTFORD CT 06106-1667 C
o
d
e G I 1040.00
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
NATALIE CONCEPCION I ✔ I 414H 3779.72 d
e DD I 29046.78
b Employer identification number (EIN) 12c
118 HART ST C
o
06-6000798 d
e
EE I 650.00
DSS60000 DSS089530 036582 a Employee’s social security no.
C
12d
o

NEW BRITAIN CT 06052 XXX-XX-9551 d

e I
I
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
CT CT0502633-002 52200.92 1803.16
I I
Copy B To Be Filed With Employee’s FEDERAL Tax Return
I
This information is being furnished to the Internal Revenue Service.
I I
Dept. of the Treasury - IRS
OMB No. 1545-0008 Visit the IRS Web Site 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 comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9I 5 Medicare wages and tips 6 Medicare tax withheld
57020.64 826.80
165 CAPITOL AVENUE 10 Dependent care benefits 11 Nonqualified plans 12a See instructions for box 12
HARTFORD CT 06106-1667 C
o
d
e G I 1040.00
e Employee’s name, address, and ZIP code Statutory Retirement Third-party
13 employee plan sick pay 14 Other 12b
C

NATALIE CONCEPCION I ✔ I 414H 3779.72

o
d
e
DD I 29046.78
b Employer identification number (EIN) 12c
118 HART ST C
o
06-6000798 d
e
EE I 650.00
DSS60000 DSS089530 036582 a Employee’s social security no.
C
12d

NEW BRITAIN CT 06052 XXX-XX-9551 o

d
e I
I
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
CT CT0502633-002
I
Copy C For EMPLOYEE'S RECORDS (See Notice to Employee on back of Copy B)
52200.92 1803.16
I
OMB No. 1545-0008
I l
Dept. of the Treasury - IRS

7 Social security tips 1 Wages, tips, other comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9 5 Medicare wages and tips 6 Medicare tax withheld

165 CAPITOL AVENUE 57020.64 826.80

10 Dependent care benefits 11 Nonqualified plans 12a
HARTFORD CT 06106-1667 C
o
d
e G I 1040.00
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C
o
NATALIE CONCEPCION I ✔ I 414H 3779.72 d
e DD I 29046.78
b Employer identification number (EIN) 12c
118 HART ST C
o
06-6000798 d
e
EE I 650.00
DSS60000 DSS089530 036582 a Employee’s social security no.
C
12d
o
NEW BRITAIN CT 06052 XXX-XX-9551 d
e I
I
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
CT CT0502633-002
I l 52200.92
Copy 2 To Be Filed With Employee's State, City, or Local Income Tax Return
1803.16
I
OMB No. 1545-0008
I l
Dept. of the Treasury - IRS

7 Social security tips 1 Wages, tips, other comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9 5 Medicare wages and tips 6 Medicare tax withheld

165 CAPITOL AVENUE 57020.64 826.80

10 Dependent care benefits 11 Nonqualified plans 12a
HARTFORD CT 06106-1667 C
o
d
e G I 1040.00
Statutory Retirement Third-party
e Employee’s name, address, and ZIP code 13 employee plan sick pay 14 Other 12b
C

NATALIE CONCEPCION I ✔ I 414H 3779.72

o
d
e
DD I 29046.78
b Employer identification number (EIN) 12c
118 HART ST 06-6000798
C
o
EE 650.00
d
e I
DSS60000 DSS089530 036582 a Employee’s social security no.
C
12d
o

NEW BRITAIN CT 06052 XXX-XX-9551 d

e I
J
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
CT CT0502633-002 52200.92 1803.16
--------+ -------------------------------------------1-------------------------------------------------------------l -------------------------------l-----------------------------l--------------------
Copy 2 To Be Filed With Employee's State, City, or Local Income Tax Return L87 OMB No. 1545-0008 5206 Dept. of the Treasury - IRS