22222
b c
a Void
Employees social security number
234-19-4571
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation
2 4 6 8 10
Federal income tax withheld
54-2097669
Employers name, address, and ZIP code
1825.64
3 5 7
Social security wages
152.00
Social security tax withheld
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name
1825.64
Medicare wages and tips Medicare tax withheld
84.13 26.47
Allocated tips Dependent care benefits
1825.64
Social security tips
WV 25213
9
Suff.
11 13
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
JEREMY A
DALEY
Statutory employee Other Retirement plan
12 b 12 c 12 d
3228 KANAWHA TERR. APT. 5
14
ST. ALBANS
f
Employees address and ZIP code 15 State Employers state ID number
WV 25177
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc
19 Local income tax
20
Locality name
WV 1033-8239
1825.64
67.00
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11
Do Not Cut, Fold, or Staple Forms on This Page
22222
b c
a Void
Employees social security number
234-33-3221
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation
2 4 6 8 10
Federal income tax withheld
54-2097669
Employers name, address, and ZIP code
1838.25
3 5 7
Social security wages
164.00
Social security tax withheld
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name
1838.25
Medicare wages and tips Medicare tax withheld
77.21 26.65
Allocated tips Dependent care benefits
1838.25
Social security tips
WV 25213
9
Suff.
11 13
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
JOSH
FULKS
Statutory employee Other Retirement plan
12 b 12 c 12 d
2539 KANAWHA FOREST DR.
14
CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number
WV 25314
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc
19 Local income tax
20
Locality name
WV 1033-8239
1838.25
64.00
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
22222
b c
a Void
Employees social security number
235-35-6343
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation
2 4 6 8 10
Federal income tax withheld
54-2097669
Employers name, address, and ZIP code
575.00
3 5 7
Social security wages
26.00
Social security tax withheld
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name
575.00
Medicare wages and tips Medicare tax withheld
24.15 8.34
Allocated tips Dependent care benefits
575.00
Social security tips
WV 25213
9
Suff.
11 13
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
CHRISTOPHER 7028 HICKORY DR.
HARRISON
Statutory employee Other Retirement plan
12 b 12 c 12 d
14
SISSONVILLE
f
Employees address and ZIP code 15 State Employers state ID number
WV 25320
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc
19 Local income tax
20
Locality name
WV 1033-8239
575.00
19.00
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11
Do Not Cut, Fold, or Staple Forms on This Page
22222
b c
a Void
Employees social security number
235-35-5053
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation
2 4 6 8 10
Federal income tax withheld
54-2097669
Employers name, address, and ZIP code
211.50
3 5 7
Social security wages
17.00
Social security tax withheld
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name
211.50
Medicare wages and tips Medicare tax withheld
8.88 3.07
Allocated tips Dependent care benefits
211.50
Social security tips
WV 25213
9
Suff.
11 13
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
CODY B
JARRETT
Statutory employee Other Retirement plan
12 b 12 c 12 d
1918 B. PINEWOOD DR.
14
CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number
WY 25320
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc
19 Local income tax
20
Locality name
WV 1033-8239
211.50
7.00
211.50
0.00 City Ta
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
22222
b c
a Void
Employees social security number
234-31-0230
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation
2 4 6 8 10
Federal income tax withheld
54-2097669
Employers name, address, and ZIP code
7242.75
3 5 7
Social security wages
757.00
Social security tax withheld
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name
7242.75
Medicare wages and tips
304.20
Medicare tax withheld
7242.75
Social security tips Allocated tips
105.02
Dependent care benefits
WV 25213
9
Suff.
11 13
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
CARLTON A
TAYLOR
Statutory employee Other Retirement plan
12 b 12 c 12 d
5010 KENTUCKY ST.
14
SO. CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number
WV 25309
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc
19 Local income tax
20
Locality name
WV 1033-8239
7242.75
273.00
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11
Do Not Cut, Fold, or Staple Forms on This Page
22222
b c
a Void
Employees social security number
Employer identification number (EIN)
For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation 3 5 7
Social security wages
2 4 6 8 10
Federal income tax withheld
Employers name, address, and ZIP code
Social security tax withheld
Medicare wages and tips
Medicare tax withheld
Social security tips
Allocated tips
d e
Control number
9
Last name Suff.
Dependent care benefits
Employees first name and initial
11 13 14
Nonqualified plans
12 a
Third-party sick pay
See instructions for box 12
Statutory employee Other
Retirement plan
12 b 12 c 12 d
Employees address and ZIP code 16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc 19 Local income tax 20 Locality name
15 State Employers state ID number
Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.
W-2
2011
0 0 0 0 / 1 0 3 0D
Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
33333
b Kind of Payer
(Check one)
Control number
For Official Use Only G OMB No. 1545-0008
943 Medicare govt emp 944 None apply 501c non-govt.
941
Military Household emp
X
CT-1
Kind of Employer
(Check one)
X
State/local non 501c State/local 501c Federal govt.
Third-party sick pay (Check if applicable)
c e f
Total number of Forms W-2
Establishment number
1 3 5 7
Wages, tips, other compensation
2 4
Federal income tax withheld
5
Employer identification number (EIN) Social security wages
11693.14
Social security tax withheld
1116.00 498.57
6
Medicare tax withheld
54-2097669
Employers name Medicare wages and tips
11693.14 11693.14
Social security tips
THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
g h 15 16
Employers address and ZIP code Other EIN used this year
169.55
8 10
Allocated tips Dependent care benefits
9 11 13 14
Nonqualified plans
WV 25213
12 a 12 b
Deferred compensation
For third-party sick pay use only
State
Employers state ID number
Income tax withheld by payer of third-party sick pay
WV
Contact person
1033-8239
17
State income tax
State wages, tips, etc
18
Local wages, tips, etc
19
Local income tax
11693.14
Email address
430.00
Telephone number Fax number
211.50
For Official Use Only
0.00
(877) 230-9544 sharrison@wvglassblock.com (304) 205-0626 0000/1030D
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete.
Signature G Form
Title G
Date G
W-3
Transmittal of Wage and Tax Statements
2011
Department of the Treasury Internal Revenue Service
Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration. Do not send any payment (cash, checks, money orders, etc.) with Forms W-2 and W-3.
Reminder
Separate instructions. See the 2011 Instructions for Forms W-2 and W-3 for information on completing this form.
Purpose of Form
A Form W-3 Transmittal is completed only when paper Copy A of Form(s) W-2, Wage and Tax Statement, is being filed. Do not file Form W-3 alone. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the Social Security Administration (see below). All paper forms must comply with IRS standards and be machine readable. Photocopies are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and Form(s) W-2 show the correct tax year and Employer Identification Number (EIN). Make a copy of this form and keep it with Copy D (For Employer) of Form(s) W-2 for your records.
When to File
Mail any paper Forms W-2 under cover of this Form W-3 Transmittal by February 29, 2012. Electronic fill-in forms or uploads are filed through SSAs Business Services Online (BSO) Internet site and will be on time if submitted by April 2, 2012.
Electronic Filing
Where to File Paper Forms
Send this entire page with the entire Copy A page of Form(s) The Social Security Administration (SSA) strongly suggests W-2 to: employers report Form W-3 and W-2 Copy A electronically instead Social Security Administration of on paper. SSA provides two free options on its Business Services Data Operations Center Online (BSO) website: Wilkes-Barre, PA 18769-0001 ? W-2 Online. Use fill-in forms to create, save, print, and submit up to 20 Forms W-2 to SSA. Note. If you use Certified Mail to file, change the ZIP code ? File Upload. Upload wage files to SSA that you have created to 18769-0002. If you use an IRS-approved private delivery using payroll or tax software that formats the files according to service, add ATTN: W-2 Process, 1150 E Mountain Dr. to the SSAs Specifications for Filing Form W-2 Electronically (EFW2). address and change the ZIP code to 18702-7997. See For more information, go to www.socialsecurity.gov/employer and Publication 15 (Circular E), Employers Tax Guide, for a list select First Time Filers or Returning Filers under BEFORE YOU of IRS-approved private delivery services. FILE. For Privacy Act and Paperwork Reduction Act Notice, see instructions. FDWA0201
09/21/11
