a Employee's SSN 1 Wages, tips, other compensation 2 Federal income tax withheld a Employee's SSN 1 Wages, tips, other
a Employee's SSN 1 Wages, tips, other compensation 2 Federal income tax withheld
405-51-5662 2926.56 61.77 405-51-5662 2926.56 61.77
OMB No. 1545-0008 3 Social security wages 4 Social security tax withheld OMB No. 1545-0008 3 Social security wages 4 Social security tax withheld
2926.56 181.47 2926.56 181.47
b Employer identification number 5 Medicare wages and tips 6 Medicare tax withheld b Employer identification number 5 Medicare wages and tips 6 Medicare tax withheld
46-2937120 2926.56 42.43 46-2937120 2926.56 42.43
c Employer's name, address, and ZIP code REISSUED STATEMENT c Employer's name, address, and ZIP code REISSUED STATEMENT
Gaming Captain Entertainment Gaming Captain Entertainment
2235 Emerson Ave 2235 Emerson Ave
Louisville KY 40205 Louisville KY 40205
d Control number 7 Social security tips 8 Allocated tips
e Employee's first name and initial Last name Suff.
Isabella Pearson e Employee's first name and initial Last name Suff.
727 E. Oak St Isabella Pearson
Louisville KY 40203 727 E. Oak St
f Employee's address and ZIP code
d Control number 7 Social security tips 8 Allocated tips Louisville KY 40203
f Employee's address and ZIP code
9 10 Dependent care benefits 11 Nonqualified plans 13 Statutory Retirement Third-party
employee plan sick pay
14 Other 9 10 Dependent care benefits 11 Nonqualified plans
12a
12b 12a 14 Other
12c 12b
12d 12c
13 Statutory Retirement Third-party 12d
employee plan sick pay
15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax
KY 349075 2926.56 84.14 KY 349075 2926.56 84.14
18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
2926.56 64.39 LOU 2926.56 64.39 LOU
2926.56 21.95 StMatt 2926.56 21.95 StMatt
Form
W-2 Wage and Tax Statement 2022 Department of the Treasury-Internal Revenue Service Form
W-2 Wage and Tax Statement 2022 Department of the Treasury-Internal Revenue Service
Copy B - To Be Filed With Employee's FEDERAL Tax Return. Copy 2 - To Be Filed With Employee's State, City, or Local Income Tax Return.
a Employee's SSN 1 Wages, tips, other compensation 2 Federal income tax withheld a Employee's SSN 1 Wages, tips, other compensation 2 Federal income tax withheld
405-51-5662 2926.56 61.77 405-51-5662 2926.56 61.77
OMB No. 1545-0008 3 Social security wages 4 Social security tax withheld OMB No. 1545-0008 3 Social security wages 4 Social security tax withheld
2926.56 181.47 2926.56 181.47
b Employer identification number 5 Medicare wages and tips 6 Medicare tax withheld b Employer identification number 5 Medicare wages and tips 6 Medicare tax withheld
46-2937120 2926.56 42.43 46-2937120 2926.56 42.43
c Employer's name, address, and ZIP code REISSUED STATEMENT c Employer's name, address, and ZIP code REISSUED STATEMENT
Gaming Captain Entertainment Gaming Captain Entertainment
2235 Emerson Ave 2235 Emerson Ave
Louisville KY 40205 Louisville KY 40205
e Employee's first name and initial Last name Suff. e Employee's first name and initial Last name Suff.
Isabella Pearson Isabella Pearson
727 E. Oak St 727 E. Oak St
Louisville KY 40203 Louisville KY 40203
f Employee's address and ZIP code f Employee's address and ZIP code
d Control number 7 Social security tips 8 Allocated tips d Control number 7 Social security tips 8 Allocated tips
9 10 Dependent care benefits 11 Nonqualified plans 9 10 Dependent care benefits 11 Nonqualified plans
12a 14 Other 12a 14 Other
12b 12b
12c 12c
12d 12d
13 Statutory Retirement Third-party 13 Statutory Retirement Third-party
employee plan sick pay employee plan sick pay
15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax
KY 349075 2926.56 84.14 KY 349075 2926.56 84.14
18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
2926.56 64.39 LOU 2926.56 64.39 LOU
2926.56 21.95 StMatt 2926.56 21.95 StMatt
Form
W-2 Wage and Tax Statement
2022 Copy C - For EMPLOYEE'S RECORDS. Form
W-2 Wage and Tax Statement
2022 Department of the Treasury-Internal Revenue Service
Copy 2 - To Be Filed With Employee's State, City, or Local Income Tax Return.
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.
