a Employee's SSA number b Employer's FED ID number

589-39-9377 61-1273583 2019 W-2 and EARNINGS SUMMARY

1 Wages, tips, other comp. 2 Federal income tax withheld This form details your final 2019 Payroll Earnings
15,705.00 1,212.07
3 Social security wages 4 Social security tax withheld
16,202.61 1,004.56 Federal Taxable Wages (Box 1 of W2) Social Security Tax Withheld (Box 4 of W2) State Income Tax Withheld (Box 17 of W2)
5 Medicare wages and tips 6 Medicare tax withheld 15,705.00 1,004.56
16,202.61 234.94
d Control number Dept. Corp. Employer use only
75-2482249 Federal Income Tax Withheld (Box 2 of W2) Medicare Tax Withheld (Box 6 of W2) Local Income Tax Withheld (Box 19 of W2)
c Employer's name, address, and ZIP code 1,212.07 234.94
CHC PAYROLL AGENT, INC
COL HOS CORP OF S BROWAR
WESTSIDE REG MED CTR
6451 126TH AVENUE NORTH
LARGO FL 33773
7 Social security tips 8 Allocated tips
W-2 Wage Reconciliation

9 10 Dependent care benefits

Federal Wages SS Wages Medicare Wages

11 Nonqualified plans 12a See instruction for box 12
Gross Pay 16,658.26 16,658.26 16,658.26
497.61 D
Less Med&Dent 438.21 438.21 438.21
13 Stat. emp. Ret. plan 3rd Pty sick pay 12b
LTD 17.44 17.44 17.44
X 4,466.13 DD
401K % 497.61
14 Other 12c

W2 WAGES 15,705.00 16,202.61 16,202.61

12d

e/f Employee's name, address, and ZIP code

Wendy Charles
6503 Winfield blvd
Apt 216
Margate FL 33063 Employee W-4 information. Contact your HR or applicable department for changes to your W-4 form.
15 State Employer's state ID no. 16 State wages, tips, etc. **** 2019 Social Security Wage base is $132,900 ***

17 State income tax 18 Local wages, tips, etc.

Social Security Number:589-39-9377

19 Local income tax 20 Locality name Wendy Charles
6503 Winfield blvd
Marital Status: Single
Employee Reference Copy Apt 216
Wage and Tax Statement Margate FL 33063
W2 2019 Federal Exemption Allowances: 03
Copy C for employee's records
Department of Treasury - Internal Revenue Service

a Employee's SSA number b Employer's FED ID number a Employee's SSA number b Employer's FED ID number a Employee's SSA number b Employer's FED ID number
589-39-9377 61-1273583 589-39-9377 61-1273583 589-39-9377 61-1273583
1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld
15,705.00 1,212.07 15,705.00 1,212.07 15,705.00 1,212.07
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
16,202.61 1,004.56 16,202.61 1,004.56 16,202.61 1,004.56
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
16,202.61 234.94 16,202.61 234.94 16,202.61 234.94
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only

75-2482249 75-2482249 75-2482249

c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code

CHC PAYROLL AGENT, INC CHC PAYROLL AGENT, INC CHC PAYROLL AGENT, INC
COL HOS CORP OF S BROWAR COL HOS CORP OF S BROWAR COL HOS CORP OF S BROWAR
WESTSIDE REG MED CTR WESTSIDE REG MED CTR WESTSIDE REG MED CTR
6451 126TH AVENUE NORTH 6451 126TH AVENUE NORTH 6451 126TH AVENUE NORTH
LARGO FL 33773 LARGO FL 33773 LARGO FL 33773
7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips

9 10 Dependent care benefits 9 10 Dependent care benefits 9 10 Dependent care benefits

11 Nonqualified plans 12a See instruction for box 12 11 Nonqualified plans 12a See instruction for box 12 11 Nonqualified plans 12a See instruction for box 12
497.61 D 497.61 D 497.61 D
13 Stat. emp. Ret. plan 3rd Pty sick pay 12b 13 Stat. emp. Ret. plan 3rd Pty sick pay 12b 13 Stat. emp. Ret. plan 3rd Pty sick pay 12b

X 4,466.13 DD X 4,466.13 DD X 4,466.13 DD

14 Other 12c 14 Other 12c 14 Other 12c

12d 12d 12d

e/f Employee's name, address, and ZIP code e/f Employee's name, address, and ZIP code e/f Employee's name, address, and ZIP code
Wendy Charles Wendy Charles Wendy Charles
6503 Winfield blvd 6503 Winfield blvd 6503 Winfield blvd
Apt 216 Apt 216 Apt 216
Margate FL 33063 Margate FL 33063 Margate FL 33063
15 State Employer's state ID no. 16 State wages, tips, etc. 15 State Employer's state ID no. 16 State wages, tips, etc. 15 State Employer's state ID no. 16 State wages, tips, etc.

17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.

19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name

Federal Filing Copy State Filing Copy City or Local Filing Copy
Wage and Tax Statement Wage and Tax Statement Wage and Tax Statement
W2 2019 W2 2019 W2 2019
Copy B to be filed with employee's Federal Income Tax Return Copy 1 to be filed with employee's State Income Tax Return Copy 2 to be filed with employee's City or Local Income Tax Return
Department of Treasury - Internal Revenue Service Department of Treasury - Internal Revenue Service Department of Treasury - Internal Revenue Service
Notice to Employee Instructions for Employee

Do you have to file? Refer to the Form 1040 instructions to Box 1. Enter this amount on the wages line of your tax return. E – Elective deferrals under a section 403(b) salary reduction
determine if you are required to file a tax return. Even if you Box 2. Enter this amount on the federal income tax withheld line agreement
of your tax return. F – Elective deferrals under a section 408(k)(6) salary reduction SEP
don’t have to file a tax return, you may be eligible for a refund
Box 5. You may be required to report this amount on Form 8959, Additional G – Elective deferrals and employer contributions (including
if box 2 shows an amount or if you are eligible for any credit.
Medicare Tax. See the Form 1040 instructions to determine if you are nonelective deferrals) to a section 457(b) deferred compensation plan
required to complete Form 8959. H – Elective deferrals to a section 501(c)(18)(D) tax-exempt
Earned income credit (EIC). You may be able to take the EIC for Box 6. This amount includes the 1.45% Medicare Tax withheld on all organization plan. See the Form 1040 instructions for how to deduct.
2019 if your adjusted gross income (AGI) is less than a certain Medicare wages and tips shown in box 5, as well as the 0.9% Additional J – Nontaxable sick pay (information only, not included in box 1, 3, or 5)
amount. The amount of the credit is based on income and family Medicare Tax on any of those Medicare wages and tips above $200,000. K – 20% excise tax on excess golden parachute payments. See the
size. Workers without children could qualify for a smaller credit. Box 8. This amount is not included in box 1, 3, 5, or 7. For Form 1040 instructions.
You and any qualifying children must have valid social security information on how to report tips on your tax return, see your L – Substantiated employee business expense reimbursements
numbers (SSNs). You can’t take the EIC if your investment Form 1040 instructions. You must file Form 4137, Social Security and (nontaxable)
income is more than the specified amount for 2019 or if income is Medicare Tax on Unreported Tip Income, with your income tax return to M – Uncollected social security or RRTA tax on taxable cost of
earned for services provided while you were an inmate at a penal report at least the allocated tip amount unless you can prove that you group-term life insurance over $50,000 (former employees only). See
institution. For 2019 income limits and more information, visit received a smaller amount. If you have records that show the actual amount the Form 1040 instructions.
of tips you received, report that amount even if it is more or less than the N – Uncollected Medicare tax on taxable cost of group-term life
www.irs.gov/EITC. Also see Pub. 596, Earned Income Credit.
allocated tips. On Form 4137 you will calculate the social security and insurance over $50,000 (former employees only). See the Form 1040
Any EIC that is more than your tax liability is refunded to Medicare tax owed on the allocated tips shown on your Form(s) W-2 that you instructions.
you, but only if you file a tax return. must report as income and on other tips you did not report to your employer. P – Excludable moving expense reimbursements paid directly to
By filing Form 4137, your social security tips will be credited to your social a member of the U.S. Armed Forces (not included in box 1, 3, or 5)
Clergy and religious workers. If you aren’t subject to security record (used to figure your benefits). Q – Nontaxable combat pay. See the instructions for Form 1040 for details
social security and Medicare taxes, see Pub.517, Social Box 10. This amount includes the total dependent care benefits that on reporting this amount.
Security and Other Information for Members of the Clergy your employer paid to you or incurred on your behalf (including R – Employer contributions to your Archer MSA. Report on Form 8853,
and Religious Workers. amounts from a section 125 (cafeteria) plan). Any amount over Archer MSAs and Long-Term Care Insurance Contracts.
$5,000 also is included in box 1. Complete Form 2441, Child S – Employee salary reduction contributions under a section 408(p)
Corrections. If your name, SSN, or address is incorrect, and Dependent Care Expenses, to compute any taxable and SIMPLE plan (not included in box 1)
nontaxable amounts. T – Adoption benefits (not included in box 1). Complete Form
correct Copies B, C, and 2 and ask your employer to correct
Box 11. This amount is (a) reported in box 1 if it is a distribution made 8839, Qualified Adoption Expenses, to compute any taxable and
your employment record. Be sure to ask the employer to file
to you from a nonqualified deferred compensation or nongovernmental nontaxable amounts.
Form W-2c, Corrected Wage and Tax Statement, with the section 457(b) plan or (b) included in box 3 and/or 5 if it is a prior year V – Income from exercise of nonstatutory stock option(s)
Social Security Administration (SSA) to correct any name, deferral under a nonqualified or section 457(b) plan that became (included in boxes 1, 3 (up to social security wage base), and 5). See
SSN, or money amount error reported to the SSA on Form taxable for social security and Medicare taxes this year because there Pub. 525, Taxable and Nontaxable Income, for reporting
W-2. Be sure to get your copies of Form W-2c from your employer is no longer a substantial risk of forfeiture of your right to the deferred requirements.
for all corrections made so you may file them with your tax return. amount. This box shouldn’t be used if you had a deferral and a distribution in W – Employer contributions (including amounts the employee
If your name and SSN are correct but aren’t the same the same calendar year. If you made a deferral and received a distribution in elected to contribute using a section 125 (cafeteria) plan) to your health
as shown on your social security card, you should ask for the same calendar year, and you are or will be age 62 by the end of the savings account. Report on Form 8889, Health Savings Accounts (HSAs).
a new card that displays your correct name at any SSA office calendar year, your employer should file Form SSA-131, Employer Report of Y – Deferrals under a section 409A nonqualified deferred
or by calling 800-772-1213. You also may visit the SSA website Special Wage Payments, with the Social Security Administration and give compensation plan
at www.SSA.gov. you a copy. Z – Income under a nonqualified deferred
Box 12. The following list explains the codes shown in box 12. compensation plan that fails to satisfy section 409A. This amount also is
You may need this information to complete your tax return. included in box 1. It is subject to an additional 20% tax plus interest. See the
Cost of employer-sponsored health coverage (if such cost Elective deferrals (codes D, E, F, and S) and designated Roth Form 1040 instructions.
is provided by the employer). The reporting in box 12, using contributions (codes AA, BB, and EE) under all plans are generally AA – Designated Roth contributions under a section 401(k) plan
code DD, of the cost of employer-sponsored health coverage limited to a total of $19,000 ($13,000 if you only have SIMPLE BB – Designated Roth contributions under a section 403(b) plan
is for your information only. The amount reported with code DD plans; $22,000 for section 403(b) plans if you qualify for the 15-year rule DD – Cost of employer-sponsored health coverage. The amount
is not taxable. explained in Pub. 571). Deferrals under code G are limited to $19,000. reported with code DD is not taxable
Deferrals under code H are limited to $7,000. However, if you were at least EE – Designated Roth contributions under a governmental section
Credit for excess taxes. If you had more than one employer in 2019 age 50 in 2019, your employer may have allowed an additional deferral of up 457(b) plan. This amount does not apply to contributions under a tax-exempt
and more than $8,239.80 in social security and/or Tier 1 railroad to $6,000 ($3,000 for section 401(k)(11) and 408(p) SIMPLE plans). This organization section 457(b) plan.
retirement (RRTA) taxes were withheld, you may be able to claim a additional deferral amount is not subject to the overall limit on elective FF – Permitted benefits under a qualified small employer health
deferrals. For code G, the limit on elective deferrals may be higher for the reimbursement arrangement
credit for the excess against your federal income tax. If you had more
last 3 years before you reach retirement age. Contact your plan administrator GG – Income from qualified equity grants under section 83(i)
than one railroad employer and more than $4,836.30 in Tier 2 RRTA for more information. Amounts in excess of the overall elective deferral limit HH – Aggregate deferrals under section 83(i) elections as of the close of the
tax was withheld, you also may be able to claim a credit. See your must be included in income. See the instructions for Form 1040. calendar year
Form 1040 instructions and Pub. 505, Tax Withholding and
Estimated Tax Note: If a year follows code D through H, S, Y, AA, BB, or EE, you Box 13. If the “Retirement plan” box is checked, special limits
made a make-up pension contribution for a prior year(s) when may apply to the amount of traditional IRA contributions you may deduct.
you were in military service. To figure whether you made excess See Pub. 590-A, Contributions to Individual Retirement Arrangements
deferrals, consider these amounts for the year shown, not the current (IRAs).
year. If no year is shown, the contributions are for the current year. Box 14. Employers may use this box to report information such as state
disability insurance taxes withheld, union dues, uniform payments, health
A – Uncollected social security or RRTA tax on tips. Include this tax on insurance premiums deducted, nontaxable income, educational assistance
Form 1040. See the Form 1040 instructions. payments, or a member of the clergy's parsonage allowance and utilities.
B – Uncollected Medicare tax on tips. Include this tax on Form Railroad employers use this box to report railroad retirement (RRTA)
1040. See the Form 1040 instructions. compensation, Tier 1 tax, Tier 2 tax, Medicare tax and Additional Medicare
C – Taxable cost of group-term life insurance over $50,000 Tax. Include tips reported by the employee to the employer in railroad
(included in boxes 1, 3 (up to social security wage base), and 5) retirement (RRTA) compensation.
D – Elective deferrals to a section 401(k) cash or deferred Note: Keep Copy C of Form W-2 for at least 3 years after the
arrangement. Also includes deferrals under a SIMPLE retirement due date for filing your income tax return. However, to help
account that is part of a section 401(k) arrangement. protect your social security benefits, keep Copy C until you
begin receiving social security benefits, just in case there is a
question about your work record and/or earnings in a particular year.

NOTE: THESE ARE SUBSTITUTE WAGE AND TAX STATEMENTS AND ARE ACCEPTABLE FOR FILING WITH YOUR FEDERAL, STATE AND LOCAL/CITY INCOME TAX RETURNS.

Department of the Treasury – Internal Revenue Department of the Treasury – Internal Revenue Department of the Treasury – Internal Revenue
Service Service Service
This information is being furnished to the Internal This information is being furnished to the Internal This information is being furnished to the Internal
Revenue Service Revenue Service Revenue Service
IMPORTANT NOTE: IMPORTANT NOTE: IMPORTANT NOTE:
In order to insure efficient processing, In order to insure efficient processing, In order to insure efficient processing,
attach this W-2 to your tax return like this attach this W-2 to your tax return like this attach this W-2 to your tax return like this
(following city or local instructions): (following city or local instructions): (following city or local instructions):

TAX RETURN TAX RETURN TAX RETURN

THIS THIS THIS

FORM OTHER
FORM OTHER FORM OTHER
W-2’S
W-2 W-2 W-2’S W-2’S
W-2

NOTE: THESE ARE SUBSTITUTE WAGE AND NOTE: THESE ARE SUBSTITUTE WAGE AND NOTE: THESE ARE SUBSTITUTE WAGE AND
TAX STATEMENTS AND ARE ACCEPTABLE TAX STATEMENTS AND ARE ACCEPTABLE TAX STATEMENTS AND ARE ACCEPTABLE
FOR FILING WITH YOUR FEDERAL, STATE AND FOR FILING WITH YOUR FEDERAL, STATE AND FOR FILING WITH YOUR FEDERAL, STATE AND
LOCAL/CITY INCOME TAX RETURNS LOCAL/CITY INCOME TAX RETURNS LOCAL/CITY INCOME TAX RETURNS