a Employee's social security number    For Official Use Only
123-XX-XXXX                             OMB No. 1545-0008
 b Employer Identification Number (EIN)                                            1 Wages, tips, other compensation 2 Federal income tax withheld
12-XXXXXXX                                                                        $5,505.00                          $336.00
 c Employer's name, address, and ZIP code                                          3 Social security wages                          4 Social secuity tax withheld
                                                                                  $5,505.00                                     $341.31
                                                                                   5 Medicare wages and tips                        6 Medicare tax withheld
                                                                                  $5,505.00                                     $79.82
Wynwood Pool Cleaning
999 Spellman Ave.                                                                  7 Social security tips                           8 Allocated tips
Los Angeles, CA 90004
 d Control number                                                                 9                                             10 Dependent care benefits
 e Employee's first name and initial   Last name                            Suff. 11 Nonqualfied plans                          12a See instructions for box 12
                                                                                                                                C
                                                                                                                                o
                                                                                                                                d
                                                                                                                                e
                                                                                       Statutory   Retirement   Third-party
                                                                                  13   employee    plan         sick pay        12b
                                                                                                                                C
                                                                                                                                o
                                                                                                                                d
                                                                                                                                e
                                                                                  14 Other                                      12c
                                                                                                                                C
                                                                                                                                o
                                                                                                                                d
                                                                                                                                e
                                                                                                                                12d
EDGAR J. FLORES                                                                                                                 C
111 West Main St.                                                                                                               o
                                                                                                                                d
Los Angeles, CA 90004                                                                                                           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
CA         12-XXXXXXX                                                 $5,505.00                     $55.05
                                                                                                                                                Department of the Treasury - IRS
                                                                                      2023