Publication 517 - Social Security And Other Information For Members Of The Clergy And Religious Workers - 2011 Page 14

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a Employee’s social security number
Safe, accurate,
Visit the IRS website at
FAST! Use
22222
011-00-2222
OMB No. 1545-0008
b Employer identi cation number (EIN)
1 Wages, tips, other compensation
2 Federal income tax withheld
00-0246810
31000.00
c Employer’s name, address, and ZIP code
3 Social security wages
4 Social security tax withheld
First United Church
5 Medicare wages and tips
6 Medicare tax withheld
1042 Main Street
Hometown, TX 77099
7 Social security tips
8 Allocated tips
d Control number
9
10 Dependent care bene ts
e Employee’s rst name and initial
Last name
Suff.
11 Nonquali ed plans
12a See instructions for box 12
C
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
C
o
John E. White
d
e
12c
14 Other
1040 Main Street
C
Parsonage Allowance
o
Hometown, TX 77099
d
e
9600.00
12d
C
Utilities Allowance
o
d
e
1200.00
f Employee’s address and ZIP code
15
Employer’s state ID number
16
17 State income tax
18
19
20
State wages, tips, etc.
Local wages, tips, etc.
Local income tax
State
Locality name
W-2
Wage and Tax
Department of the Treasury—Internal Revenue Service
2011
Statement
Form
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
Safe, accurate,
Visit the IRS website at
FAST! Use
22222
011-00-2222
OMB No. 1545-0008
b Employer identi cation number (EIN)
1 Wages, tips, other compensation
2 Federal income tax withheld
00-1357913
3400.00
272.00
c Employer’s name, address, and ZIP code
3 Social security wages
4 Social security tax withheld
3400.00
142.80
Hometown College
5 Medicare wages and tips
6 Medicare tax withheld
40 Honor Road
3400.00
49.30
Hometown, TX 77099
7 Social security tips
8 Allocated tips
d Control number
9
10 Dependent care bene ts
e Employee’s rst name and initial
Last name
Suff.
11 Nonquali ed plans
12a See instructions for box 12
C
o
d
e
13
Statutory
Third-party
Retirement
12b
employee
sick pay
plan
C
John E. White
o
d
e
1040 Main Street
14 Other
12c
C
Hometown, TX 77099
o
d
e
12d
C
o
d
e
f Employee’s address and ZIP code
15
Employer’s state ID number
16
17 State income tax
18
19
20
State
State wages, tips, etc.
Local wages, tips, etc.
Local income tax
Locality name
W-2
Wage and Tax
Department of the Treasury—Internal Revenue Service
2011
Statement
Form
Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.
Publication 517 (2011)
Page 14

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