a Employee’s social security number Visit the IRS website at

364-13-4523 www.irs.gov/efile
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
37-1756977 30897.14 3056.78

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
30897.14 1915.60
DEPARTMENT OF SOCIAL & HEALTH SE
Payer for SANDRA WILLIAMS 5 Medicare wages and tips 6 Medicare tax withheld
PO BOX 45842 30897.14 447.99
OLYMPIA , WA 98504-5842
7 Social security tips 8 Allocated tips

d Control number WAPCS E094596 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
Joshlyn Tesler d
e

13 Statutory Retirement Third-party

plan sick pay
12b
employee C
o
d
e

14 Other 12c
PML 37.06 C
o
PFL 41.08 d
e

f Employee’s address and ZIP code

12d
146 17TH AVE,APT 3,LONGVIEW,WA,98632-1146 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

Wage and Tax

W-2 2020 Department of the Treasury—Internal Revenue Service

Form Statement
Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.
 a Employee’s social security number This information is being furnished to the Internal Revenue Service. If you
OMB No. 1545-0008 are required to file a tax return, a negligence penalty or other sanction
364-13-4523 may be imposed on you if this income is taxable and you fail to report it.

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
37-1756977 30897.14 3056.78

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
30897.14 1915.60
DEPARTMENT OF SOCIAL & HEALTH SE
Payer for SANDRA WILLIAMS 5 Medicare wages and tips 6 Medicare tax withheld
PO BOX 45842 30897.14 447.99
OLYMPIA , WA 98504-5842
7 Social security tips 8 Allocated tips

d Control number WAPCS E094596 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
Joshlyn Tesler d
e

13 Statutory Retirement Third-party

plan sick pay
12b
employee C
o
d
e

14 Other 12c
PML 37.06 C
o
PFL 41.08 d
e

f Employee’s address and ZIP code

12d
146 17TH AVE,APT 3,LONGVIEW,WA,98632-1146 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

Wage and Tax

Form W-2 Statement
2020 Department of the Treasury—Internal Revenue Service

Copy C—For EMPLOYEE’S RECORDS (See Notice to

Employee on the back of Copy B.)