Copy B — To Be Filed With Employee's FEDERAL Tax Return
a Employee's social security number
XXX-XX-4522
1 Wages, tips, other compensation
17,245.00
b Employer identification number (EIN)
87-1017981
2 Federal income tax withheld
0.00
c Employer's name, address, and ZIP code
CAPITAL BOOKS
1011 K ST
SACRAMENTO, CA 95814
3 Social security wages
17,245.00
4 Social security tax withheld
1,069.19
d Control number
5 Medicare wages and tips
17,245.00
6 Medicare tax withheld
250.05
e Employee's first name and initial Last name
ZOE CECIL
f Employee's address and ZIP code
2115 22ND STREET, APT 6, SACRAMENTO, CA 95818
7 Social security tips
8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans
12a See instructions for box 12
13
☐ Statutory employee ☐ Retirement plan ☐ Third-party sick pay
12b
14 Other
15 State
CA
Employer's state ID number
152-7601-7
16 State wages, tips, etc.
17,245.00
17 State income tax
0.00
18 Local wages, tips, etc.
19 Local income tax
20 Locality name
Copy C — For EMPLOYEE'S RECORDS
a Employee's social security number
XXX-XX-4522
1 Wages, tips, other compensation
17,245.00
b Employer identification number (EIN)
87-1017981
2 Federal income tax withheld
0.00
c Employer's name, address, and ZIP code
CAPITAL BOOKS
1011 K ST
SACRAMENTO, CA 95814
3 Social security wages
17,245.00
4 Social security tax withheld
1,069.19
d Control number
5 Medicare wages and tips
17,245.00
6 Medicare tax withheld
250.05
e Employee's first name and initial Last name
ZOE CECIL
f Employee's address and ZIP code
2115 22ND STREET, APT 6, SACRAMENTO, CA 95818
7 Social security tips
8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans
12a See instructions for box 12
13
☐ Statutory employee ☐ Retirement plan ☐ Third-party sick pay
12b
14 Other
15 State
CA
Employer's state ID number
152-7601-7
16 State wages, tips, etc.
17,245.00
17 State income tax
0.00
18 Local wages, tips, etc.
19 Local income tax
20 Locality name