a Employee's social security number

22222 443-92-1478 OMB No. 1545-0008

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

84-0821335 20844.21 1022.94

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

CASEY D SEBERT 20844.21 1292.33

5 Medicare wages and tips 6 Medicare tax withheld
406 S 11TH ST
20844.21 302.26
7 Social security tips
8 Allocated tips
NORFOLK NE 687010000

d Control number 9
10 Dependent care benefits

e Employee's first name and initial Last name Suff. 12a

11 Nonqualified plans C [br]
o
CASEY D SEBERT d
e

406 S 11TH ST 13 12b

C
o
Statutoryemployee Retirementplan Third-
d
partysick pay e

14 Other 12c
NORFOLK NE 687010000 C
o
d
e [br]
C [br]
o
d
e

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
CO 2216790 20844.21 794.00

Wage and Tax Department of the Treasury - Internal Revenue Service

 Form
Copy 1- For State, City, or Local Tax Department W-2 Statement 2020

2020 Department of the Treasury - Internal Revenue Service

 a Employee's social security number Visit the IRS website at
443-92-1478 OMB No. 1545-0008 www.irs.gov/efile
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

84-0821335 20844.21 1022.94

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

CASEY D SEBERT 20844.21 1292.33

5 Medicare wages and tips 6 Medicare tax withheld
406 S 11TH ST
20844.21 302.26
7 Social security tips
8 Allocated tips
NORFOLK NE 687010000

d Control number 9
10 Dependent care benefits

e Employee's first name and initial Last name Suff. 12a See instructions for box 12
11 Nonqualified plans C
o
CASEY D SEBERT d
e

406 S 11TH ST 13 12b

C
o
Statutoryemployee Retirementplan Third-
d
partysick pay e

14 Other 12c
NORFOLK NE 687010000 C
o
d
e

12 d
C
o
d
f Employee's address and ZIP code e

State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 19 Local income tax 20 Locality name
18 Local wages, tips, etc.
CO 2216790 20844.21 794.00

Wage and Tax

Form W-2
 Statement
Copy B- To Be Filed With Employee`s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.

2020 Department of the Treasury - Internal Revenue Service

Notice to Employee

Do you have to file?Refer to the instructions for Forms 1040 to correct any name, SSN, or money amount error and
1040-SR to determine if you are required to file a tax return. reported to the SSA on Form W -2. Be sure to get your
Even if you don't have to file a tax return, you may be Statement, with the Social Security Administration (SSA)
eligible fora refund if box 2 shows an amount or if you are copies of Form W-2c from your employer for all
eligible for corrections made so you may file them with your tax
any credit. return. If your name and SSN are correct but are not the
Earned income credit (EIC). You may be able to take the same as shown on your social security card, you should
EIC for 2020 if your adjusted gross income (AGI) is less ask for a new card that displays your correct name at any
than a certain amount. The amount of the credit is based SSA office or by calling 1-800-772-1213. You also may
on income and family size. Workers without children could visit the SSA at www.socialsecurity.gov.
qualify for a smaller credit. You and any qualifying Cost of employer-sponsored health coverage (if such
childrenmust have valid social security numbers (SSNs). cost is provided by the employer). The reporting in box
12 , using Code DD, of the cost of employer-sponsored
You cannot take the EIC if your investment income is health coverage is for your information only. The amount
more than the specified amount for 2020 or if income is reported with Code DD is not taxable.
earned for services provided while you were an inmate at
a penal Credit for excess taxes. If you had more than one
institution. For 2020 income limits and more information, employer in 2020 and more than $8,537.40 in social
visit . Also see Pub. 596, Earned security and/or Tier 1 railroad retirement (RRTA) taxes
Incomewww.irs.gov/eitc were withheld, you may be able to claim a credit for the
Credit. Any EIC that is more than your tax liability is excess against your federal income tax. If you had more
refunded to you, but only if you file a tax return. than one railroad employer and more than $5,012.70in
Clergy and religious workers. If you are not subject to Tier 2 RRTA tax was withheld, you also may be able to
social security and Medicare taxes, see Pub. 517, Social claim a credit. See your Form 1040 instructions and Pub.
Security and Other Information for Members of the Clergy 505 , Tax Withholding and Estimated Tax.
and Religious Workers.
Corrections. If your name, SSN, or address is incorrect, (Also see Instructions for Employee on the back of Copy C.)
correct Copies B, C, and 2 and ask your employer to
correct your employment record. Be sure to ask the
employer to file Form W-2c, Corrected Wage and Tax
 This information is being furnished to the Internal Revenue Service. If you
a Employee's social security number
OMB No. 1545-0008 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.
443-92-1478
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
84-0821335 20844.21 1022.94
c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CASEY D SEBERT 20844.21 1292.33
406 S 11TH ST 5 Medicare wages and tips 6 Medicare tax withheld

20844.21 302.26
NORFOLK NE 687010000 7 Social security tips 8 Allocated tips

d Control number 9 Dependent care benefits

10

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box
C
o
CASEY D SEBERT d
e
12
406 S 11TH ST Statutory Retirement Third-party
12b
13 C
o
employee plan d
sick pay e [br]

NORFOLK NE 687010000 14 Other 12c

C
o
d
e

f Employee's address and ZIP code

12 d
C [br]
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
Locali
CO 2216790 20844.21 794.00 ty name

Wage and Tax

Form W-2
Statement
Copy C- For EMPLOYEE`S RECORDS
( See Notice to Employee on back of Copy B )

2020 Department of the Treasury - Internal Revenue Service

Instructions for Employee (Also see Notice to C -Taxable cost of group -term life insurance over $50,000 (included in boxes
Employee, on the back of Copy B.) 1 , 3 (up to social security wage base), and 5)
D - Elective deferrals to a section 401(k) cash or deferred arrangement. Also
Box 1. Enter this amount on the wages line of your tax return. Box
includes deferrals under a SIMPLE retirement account that is part of a
2. Enter this amount on the federal income tax withheld line of your section 401(k) arrangement.
tax return.
E - Elective deferrals under a section 403(b) salary reduction agreement
Box 5. You may be required to report this amount on Form 8959, Additioinal
Medicare Tax. See instructions for Forms 1040 and 1040 -SR to determine ( continued on back of Copy 2)
if you are required to complete Form 8959.
Box 6. This amount includes the 1.45% Medicare Tax withheld on all
Medicare wages and tips shown in Box 5, as well as the 0.9% Additional
Medicare Tax on any of those Medicare wages and tips above $200,000.
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on
how to report tips on your tax return, see your Form 1040 instructions.
You must file Form 4137, Social Security and Medicare Tax on
Unreported Tip Income, with your income tax return to report at least the
allocated tip amount unless you can prove that you received a smaller
amount. If you have records that show the actual amount of tips you
received, report that amount even if it is more or less than the allocated
tips. On Form 4137
you will figure the social security and Medicare tax owed on the allocated
tips shown on your Form(s) W-2 that you must report as income and on
other tips you did not report to your employer. By filing Form 4137, your
social
security tips will be credited to your social security record (used to figure
your benefits).
Box 10. This amount includes the total dependent care benefits that your
employer paid to you or incurred on your behalf (including amounts from a
section 125 (cafeteria) plan). Any amount over $5,000 is also included in box
1. Complete Form 2441, Child and Dependent Care Expenses, to compute
any taxable and nontaxable amounts.
Box 11. This amount is (a) reported in box 1 if it is a distribution made to you
from a nonqualified deferred compensation or nongovernmental section
457(b) plan or (b) included in box 3 and/or 5 if it is a prior year deferral under
a nonqualified or section 457(b) plan that became taxable for social security
and Medicare taxes this year because there is no longer a substantial risk of
forfeiture of your right to the deferred amount. This box should not be used if if
you had a deferral and a distribution in the same year. If you made a deferral
and received a distribution in the same calendar year, and you are or will be
age 62 by the end of the calendar year, your employer should file Form SSA-
131, Employer Report of Special Wage Payments, with the Social Security
Administration and give you a copy.
Box 12. The following list explains the codes shown in box 12. You may need
this information to complete your tax return. Elective deferrals (codes D, E, F,
and S) and designated Roth contributions (codes AA, BB and EE) under all
plans are generally limited to a total of $19,500 ($13,500 if you only have
SIMPLE plans; $22,500 for section 403(b) plans if you qualify for the 15- year
rule explained in Pub. 571). Deferrals under code G are limited to
$19,500. Deferrals under code H are limited to $7,000.
However, if you were at least age 50 in 2020, your employer may have
allowed an additional deferral of up to $6,500 ($3,000 for section 401(k)(11)
and 408(p) SIMPLE plans). This additional deferral amount is not subject to
the overall limit on elective deferrals. For code G, the limit on elective deferrals
may be higher for the last 3 years before you reach retirement age.
Contact your plan administrator for more information. Amounts in excess of
the overall elective deferral limit must be included in income. See the
"Wages, Salaries, Tips, etc.'' line instructions for Form 1040. Note. If a year
follows code D through H, S, Y, AA, BB, or EE, you made a make-up
pension contribution for a prior year(s) when you were in military service. To
figure whether you made excess deferrals, consider these amounts for the
year shown, not the current year. If no year is shown, the contributions are
for the current year.
A - Uncollected social security or RRTA tax on tips. Include this tax on From
1040 . See the Form 1040 Instructions
B - Uncollected Medicare tax on tips. Include this tax on Form 1040. See the
Form 1040 instructions.
 a Employee's social security number
443-92-1478 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

84-0821335 20844.21 1022.94

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

CASEY D SEBERT 20844.21 1292.33

5 Medicare wages and tips 6 Medicare tax withheld
406 S 11TH ST
20844.21 302.26
7 Social security tips 8 Allocated tips
NORFOLK NE 687010000
d Control number 9 10 Dependent care benefits

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a
C [br]
o
CASEY D SEBERT d
e

406 S 11TH ST 13 12b

C [br]
o
employeeStatutory Retirementplan Third-
d
partysick pay e [br]

14 Other 12c
NORFOLK NE 687010000 C [br]
o
d
e

12 d
C [br]
o
d
f Employee's address and ZIP code e

15 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
State
2216790 20844.21 794.00
CO

Wage and Tax

Form
W-2 Statement
Copy 2- To Be Filed With Employee`s State, City, or Local
Income Tax Return

2020 Department of the Treasury - Internal Revenue Service

Instructions for Employee ( continued from back of Copy C ) and Additional Medicare Tax. Include tips reported by the employee to
the employer in railroad retirement (RRTA) compensation.
Box 12 (continued)
F -Elective deferrals under a section 408(k)(6) salary reduction SEP Note. Keep Copy C of Form W-2 for at least 3 years after the due date for
filing your income tax return. However, to help protect your social
G -Elective deferrals and employer contributions (including nonelective
security benefits, keep Copy C until you begin receiving social security
deferrals) to a section 457(b) deferred compensation plan H - Elective
benefits, just in case there is a question about your work record and/or
deferrals to a section 501(c)(18)(D) tax-exempt organization plan. See
earnings in a particular year.
the Instructions for Forms 1040 and 1040-SR for how to deduct. J -
Nontaxable sick pay (information only, not included in boxes 1, 3, or 5) K
- 20% excise tax on excess golden parachute payments. See the
Instructions for Forms 1040 and 1040-SR.
L -Substantiated employee business expense reimbursements
(nontaxable)
M - Uncollected social security or RRTA tax on taxable cost of groupterm
life insurance over $50,000 (former employees only). See the
Instructions for Forms 1040 and 1040-SR.
N - Uncollected Medicare tax on taxable cost of group-term life insurance
over $50,000 (former employees only). See the intructions for Forms
1040 and 1040-SR.for
P - Excludable moving expense reimbursements paid directly to a member
of teh U.S. Armed Forces (not included in boxes 1, 3, or 5)
Q - Nontaxable combat pay. See the instructions for Form 1040 and
1040-SR for details on
R -reporting this amountEmployer contributions to your Archer MSA. Report
on Form 8853,
Archer MSAs and Long-Term Care Insurance Contracts.
S - Employee salary reduction contributions under a section 408(p) SIMPLE
plan (not included in box 1)
T -Adoption benefits (not included in box 1). Complete Form 8839, Qualified
Adoption Expenses, to compute any taxable and nontaxable amounts.
V - Income from exercise of nonstatutory stock option(s)
(included in boxes 1, 3 (up to social security wage base), and 5). See Pub.
525 Taxable and Nontaxable Income, for reporting requirements.
W - Employer contributions (including amounts the employee
elected to contribute using a section 125 (cafeteria) plan) to your health
savings account. Report on Form 8889, Health Savings Accounts (HSAs).
Y - Deferrals under a section 409A nonqualified deferred compensation
plan.
Z - Income under a nonqualified deferred compesation plan that fails to
satisty section 409A. This amount is also included in box 1. It is subject
to an additional 20% tax plus interest. See the instructions for Forms
1040 and 1040-SR.
AA - Designated Roth contributions under a section 401(k) plan
BB - Designated Roth contributions under a section 403(b) plan
DD - Cost of employer-sponsored health coverage.The amount reported
with Code DD is not taxable.
EE - Designated Roth contributions under a governmental section 457(b)
plan. This amount does not apply to contributions under a taxexempt
organization section 457(b) plan.
FF - Permitted benefits under a qualified small employer health
reimbursement arrangment.
GG - Income from qualified equity grants under section 83(i)
HH - Aggregate deferrals under section 83(i) elections as of the close of the
calendar year
Box 13. If the ''Retirement plan'' box is checked, special limits may apply
to the amount of traditional IRA contributions you may deduct. See
Pub590-A, Contributions to Individual Retirement Arrangements (IRAs).
Box 14. Employers may use this box to report information such as state
disability insurance taxes withheld, union dues, uniform payments, health
insurance premiums deducted, nontaxable income, educational
assistance payments, or a member of the clergy's parsonage allowance
and utilities. Railroad employers use this box to report railroad
retirement ( RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax