EFTA00176008¶
| a Control number 0001 66/LMB | Void | OMB No. 1545-0008 LMB | 0001 | |||||
|---|---|---|---|---|---|---|---|---|
| b Employer identification number (EIN) 13-3643429 | 1 Wages, tips, other compensation 60000.00 | 2 Federal income tax withheld 6834.27 | ||||||
| c Employer's name, address, end ZIP code EPSTEIN INTERESTS 457 MADISON AVENUE NEW YORK, NY 10022 | 3 Social security wages 60000.00 | 4 Social security tax withheld 3720.00 | ||||||
| 5 Medicare wages and tips 60000.00 | 6 Medicare tax withhold 870.00 | |||||||
| 7 Social security tips | 8 Allocated tips | |||||||
| 9 Advance EIC payment | 10 Dependent care benefits | |||||||
| d Employee's social security number 451-11-5768 | 11 Nonqualified plans | 12a See instructions for box 12 | ||||||
| 13 Statutory employees □ | Retirement plan □ | Third-party sick pay | 12b | |||||
| e Employee's first name and initial LESLEY GROFF 120 OAK STREET NEW CANAAN, CT 06840 | 14 Other 28.80 NYDD | 12c | ||||||
| f Employee's address and ZIP code | 12d | |||||||
| 15 State Employer's state ID number NY 13-3643429 | 16 State wages, tips, etc. 60000.00 | 17 State income tax 3173.41 | 18 Local wages, tips, etc. | 19 Local income tax | 20 Locality name | |||
Form W-2 Wage and Tax Statement¶
Department of the Treasury—Internal Revenue Service¶
2005¶
For Privacy Act and Paperwork Reduction Act Notice, see back of Copy D.¶
Copy D—For Employer.¶
| a Control number | Void | OMB No. 1546-0008 | ||||
|---|---|---|---|---|---|---|
| b Employer identification number (EIN) | 1 Wages, tips, other compensation | 2 Federal income tax withheld | ||||
| c Employer's name, address, and ZIP code | 3 Social security wages | 4 Social security tax withheld | ||||
| 5 Medicare wages and tips | 6 Medicare tax withheld | |||||
| 7 Social security tips | 8 Allocated tips | |||||
| d Employee's social security number | 9 Advance EIC payment | 10 Dependent care benefits | ||||
| e Employee's first name and Initial Last name f Employee's address and ZIP code | 11 Nonqualified plans | 12a See Instructions for box 12 | ||||
| 13 State only Retirement plan Third-party tax pay | 12b | |||||
| 12c | ||||||
| 14 Other | 12d | |||||
| 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 | |
Form W-2 Wage and Tax Statement¶
2005¶
Copy D—For Employer.¶
Department of the Treasury—Internal Revenue Service¶
For Privacy Act and Paperwork Reduction Act Notice, see back of Copy D.¶
E1004¶
EFTA00176009¶
Return this entire page to the Internal Revenue Service. Photocopies are not acceptable.¶
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 ▶ Title ▶ Date ▶¶
Instructions¶
Purpose of form. Use this form to transmit paper Forms 1099, 1098, 5498, and W-2G to the Internal Revenue Service. Do not use Form 1096 to transmit electronically or magnetically. For magnetic media, see Form 4804, Transmission of Information Returns Reported Magnetically; for electronic submissions, see Pub. 1220, Specifications for Filing Forms 1098,1099, 5498 and W-2G Electronically or Magnetically.¶
Who must file. The name, address, and TIN of the filer on this form must be the same as those you enter in the upper left area of Forms 1099, 1098, 5498, or W-2G. A filer includes a payer; a recipient of mortgage interest payments (including points) or student loan Interest; an educational institution; a broker; a barter exchange; a creditor; a person reporting real estate transactions; a trustee or issuer of any individual retirement arrangement; a Coverdell ESA, an HSA, an Archer MSA (Including a Medicare Advantage MSA); certain corporations; certain donees of motor vehicles, boats, and airplanes; and a lender who acquires an interest in secured property or who has reason to know that the property has been abandoned.¶
Preaddressed Form 1096. If you received a preaddressed Form 1096 from the IRS with Package 1099, use it to transmit paper Forms 1099, 1098, 5498, and W-2G to the Internal Revenue Service. If any of the preprinted Information is Incorrect, make corrections on the form.¶
If you are not using a preaddressed form, enter the filer’s name, address (including room, suite, or other unit number), and TIN In the spaces provided on the form.¶
Where To File¶
Send all information returns filed on paper with Form 1096 to the following:¶
When to file. File Form 1096 with Forms 1099, 1098, or W-2G by February 26, 2006. File Form 1096 with Forms 5498, 5498-ESA, and 5498-SA by May 31, 2006.¶
| If your principal business, office or agency, or legal residence in the case of an individual, is located in | Use the following Internal Revenue Service Center address |
| Alabama, Arizona, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Texas | Austin, TX 73301 |
| Arkansas, Connecticut, Delaware, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Vermont, West | Cincinnati, OH 45999 |
| Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Wisconsin | Kansas City, MO 64999 |
For more information and the Privacy Act and Paperwork Reduction Act Notice, see the 2005 General Instructions for Forms 1099, 1098, 5498, and W-2G.¶
49-0971237¶
Form 1096 (Rev. 3-2005)¶
E1005¶