2021 W-2 and EARNINGS SUMMARY

Employee Reference Copy This summary section is included with your W-2 to help describe this
portion in more detail. The reverse side includes general information that
Wage and Tax
W-2 Statement
Copy C for employee’s records.
2021
OMB No. 1545-0008
you may also find helpful. The following reflects your final pay stub, plus
any adjustments made by your employer.
d Control number Dept. Corp. Employer use only GROSS PAY 3,939.25 SOCIAL SECURITY 244.22
0000001724 TM5 TAX WITHHELD
USJ2 1142
BOX 04 OF W-2
c Employer’s name, address, and ZIP code
FED. INCOME 148.43 MEDICARE TAX 57.10
LEED STAFFING LA BASIN LLC TAX WITHHELD WITHHELD
3401 WEST CYPRESS ST STE 101 BOX 02 OF W-2 BOX 06 OF W-2
TAMPA, FL 33607
STATE INCOME TAX 0.00 SUI/SDI 47.26
BOX 17 OF W-2 BOX 14 OF W-2
LOCAL INCOME TAX 0.00
BOX 19 OF W-2
e/f Employee’s name, address, and ZIP code
MARIA E MARISCAL ROCHA
1815 GROVE STREET
APT 15
NATIONAL CITY, CA 91950
b Employer’s FED ID number a Employee’s SSA number
27-4002912 XXX-XX-4536
1 Wages, tips, other comp. 2 Federal income tax withheld
3939.25 148.43
3 Social security wages 4 Social security tax withheld
3939.25 244.22
5 Medicare wages and tips 6 Medicare tax withheld
3939.25 57.10
7 Social security tips 8 Allocated tips To change your employee W-4 profile information
file a new W-4 with your payroll department
9 10 Dependent care benefits

11 Nonqualified plans 12a See instructions for box 12

DD 122.00 Social Security Number: XXX-XX-4536
14 Other 47.26 CA SDI 12b MARIA E MARISCAL ROCHA
12c
12d
1815 GROVE STREET
13 Stat emp. Ret. plan 3rd party sick pay APT 15
NATIONAL CITY, CA 91950
15 State Employer’s state ID no. 16 State wages, tips, etc.
CA 316-0552 0 3939.25
17 State income tax 18 Local wages, tips, etc.

19 Local income tax 20 Locality name ¤ 2021 ADP, Inc.

PAGE 01 OF 01

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
3939.25 148.43 3939.25 148.43 3939.25 148.43
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
3939.25 244.22 3939.25 244.22 3939.25 244.22
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
3939.25 57.10 3939.25 57.10 3939.25 57.10
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
0000001724 TM5 USJ2 1142 0000001724 TM5 USJ2 1142 0000001724 TM5 USJ2 1142
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
LEED STAFFING LA BASIN LLC LEED STAFFING LA BASIN LLC LEED STAFFING LA BASIN LLC
3401 WEST CYPRESS ST STE 101 3401 WEST CYPRESS ST STE 101 3401 WEST CYPRESS ST STE 101
TAMPA, FL 33607 TAMPA, FL 33607 TAMPA, FL 33607

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 a Employee’s SSA number
27-4002912 XXX-XX-4536 27-4002912 XXX-XX-4536 27-4002912 XXX-XX-4536
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 instructions for box 12 11 Nonqualified plans 12a
12 11 Nonqualified plans 12a
DD 122.00 DD 122.00 DD 122.00
14 Other 47.26 CA SDI 12b 14 Other 47.26 CA SDI 12b 14 Other 47.26 CA SDI 12b
12c 12c 12c
12d 12d 12d
13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay

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
MARIA E MARISCAL ROCHA MARIA E MARISCAL ROCHA MARIA E MARISCAL ROCHA
1815 GROVE STREET 1815 GROVE STREET 1815 GROVE STREET
APT 15 APT 15 APT 15
NATIONAL CITY, CA 91950 NATIONAL CITY, CA 91950 NATIONAL CITY, CA 91950
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.
CA 316-0552 0 3939.25 CA 316-0552 0 3939.25 CA 316-0552 0 3939.25
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 CA. State Filing Copy City or Local Filing Copy
Wage and Tax Wage and Tax Wage and Tax
W-2 Statement 2021
OMB No. 1545-0008
Copy B to be filed with employee’s Federal Income Tax Return.
W-2 Statement 2021
OMB No. 1545-0008
Copy 2 to be filed with employee’s State Income Tax Return.
W-2 Statement OMB
2021 No. 1545-0008
Copy 2 to be filed with employee’s City or Local Income Tax Return.
Instructions for Employee However, if you were at least age 50 in 2021, your employer may S—Employee salary reduction contributions under a section 408(p)
have allowed an additional deferral of up to $6,500 ($3,000 for section SIMPLE plan (not included in box 1)
Box 1. Enter this amount on the wages line of your tax return. 401(k)(11) and 408(p) SIMPLE plans). This additional deferral amount T—Adoption benefits (not included in box 1). Complete Form 8839, Qualified
Box 2. Enter this amount on the federal income tax withheld line of is not subject to the overall limit on elective deferrals. For code G, the Adoption Expenses, to figure any taxable and nontaxable amounts.
your tax return. limit on elective deferrals may be higher for the last 3 years before you V—Income from exercise of nonstatutory stock option(s) (included in
Box 5. You may be required to report this amount on Form 8959, reach retirement age. Contact your plan administrator for more boxes 1, 3 (up to the social security wage base), and 5). See Pub. 525,
Additional Medicare Tax. See the Instructions for Forms 1040 and information. Amounts in excess of the overall elective deferral limit must Taxable and Nontaxable Income, for reporting requirements.
1040-SR to determine if you are required to complete Form 8959. be included in income. See the Instructions for Forms 1040 and W—Employer contributions (including amounts the employee elected to
Box 6. This amount includes the 1.45% Medicare Tax withheld on all 1040-SR. contribute using a section 125 (cafeteria) plan) to your health savings
Medicare wages and tips shown in box 5, as well as the 0.9% Note: If a year follows code D through H, S, Y, AA, BB, or EE, you account. Report on Form 8889, Health Savings Accounts (HSAs).
Additional Medicare Tax on any of those Medicare wages and tips made a make-up pension contribution for a prior year(s) when you were Y—Deferrals under a section 409A nonqualified deferred compensation plan
above $200,000. in military service. To figure whether you made excess deferrals, Z—Income under a nonqualified deferred compensation plan that fails to
Box 8. This amount is not included in box 1, 3, 5, or 7. For consider these amounts for the year shown, not the current year. If no satisfy section 409A. This amount is also included in box 1. It is subject
information on how to report tips on your tax return, see the year is shown, the contributions are for the current year. to an additional 20% tax plus interest. See the Instructions for Forms
Instructions for Forms 1040 and 1040-SR. A—Uncollected social security or RRTA tax on tips. Include this tax on 1040 and 1040-SR.
You must file Form 4137, Social Security and Medicare Tax on Form 1040 or 1040-SR. See the Instructions for Forms 1040 and 1040-SR. AA—Designated Roth contributions under a section 401(k) plan
Unreported Tip Income, with your income tax return to report at least B—Uncollected Medicare tax on tips. Include this tax on Form 1040 or BB—Designated Roth contributions under a section 403(b) plan
the allocated tip amount unless you can prove with adequate records 1040-SR. See the Instructions for Forms 1040 and 1040-SR.
DD—Cost of employer-sponsored health coverage. The amount
that you received a smaller amount. If you have records that show C—Taxable cost of group-term life insurance over $50,000 (included in reported with code DD is not taxable.
the actual amount of tips you received, report that amount even if it boxes 1, 3 (up to the social security wage base), and 5)
is more or less than the allocated tips. Use Form 4137 to figure the EE—Designated Roth contributions under a governmental section
D—Elective deferrals to a section 401(k) cash or deferred arrangement. 457(b) plan. This amount does not apply to contributions under a
social security and Medicare tax owed on tips you didn’t report to Also includes deferrals under a SIMPLE retirement account that is part
your employer. Enter this amount on the wages line of your tax tax-exempt organization section 457(b) plan.
of a section 401(k) arrangement. FF—Permitted benefits under a qualified small employer health
return. By filing Form 4137, your social security tips will be credited
to your social security record (used to figure your benefits). E—Elective deferrals under a section 403(b) salary reduction agreement reimbursement arrangement
Box 10. This amount includes the total dependent care benefits that F—Elective deferrals under a section 408(k)(6) salary reduction SEP GG—Income from qualified equity grants under section 83(i)
your employer paid to you or incurred on your behalf (including G—Elective deferrals and employer contributions (including nonelective HH—Aggregate deferrals under section 83(i) elections as of the close
amounts from a section 125 (cafeteria) plan). Any amount over your deferrals) to a section 457(b) deferred compensation plan of the calendar year
employer’s plan limit is also included in box 1. See Form 2441. H—Elective deferrals to a section 501(c)(18)(D) tax-exempt Box 13. If the “Retirement plan” box is checked, special limits may apply
Box 11. This amount is (a) reported in box 1 if it is a distribution organization plan. See the Instructions for Forms 1040 and 1040-SR for to the amount of traditional IRA contributions you may deduct. See Pub.
made to you from a nonqualified deferred compensation or how to deduct. 590-A, Contributions to Individual Retirement Arrangements (IRAs).
nongovernmental section 457(b) plan, or (b) included in box 3 and/or J—Nontaxable sick pay (information only, not included in box 1, 3, or 5) Box 14. Employers may use this box to report information such as state
box 5 if it is a prior year deferral under a nonqualified or section K—20% excise tax on excess golden parachute payments. See the disability insurance taxes withheld, union dues, uniform payments,
457(b) plan that became taxable for social security and Medicare Instructions for Forms 1040 and 1040-SR. health insurance premiums deducted, nontaxable income, educational
taxes this year because there is no longer a substantial risk of assistance payments, or a member of the clergy’s parsonage allowance
forfeiture of your right to the deferred amount. This box shouldn’t be L—Substantiated employee business expense reimbursements and utilities. Railroad employers use this box to report railroad
used if you had a deferral and a distribution in the same calendar (nontaxable) retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax,
year. If you made a deferral and received a distribution in the same M—Uncollected social security or RRTA tax on taxable cost of and Additional Medicare Tax. Include tips reported by the employee to
calendar year, and you are or will be age 62 by the end of the group-term life insurance over $50,000 (former employees only). See the employer in railroad retirement (RRTA) compensation.
calendar year, your employer should file Form SSA-131, Employer the Instructions for Forms 1040 and 1040-SR. Note: Keep Copy C of Form W-2 for at least 3 years after the due date
Report of Special Wage Payments, with the Social Security N—Uncollected Medicare tax on taxable cost of group-term life for filing your income tax return. However, to help protect your social
Administration and give you a copy. insurance over $50,000 (former employees only). See the Instructions security benefits, keep Copy C until you begin receiving social
Box 12. The following list explains the codes shown in box 12. You for Forms 1040 and 1040-SR. security benefits, just in case there is a question about your work
may need this information to complete your tax return. Elective P—Excludable moving expense reimbursements paid directly to a record and/or earnings in a particular year.
deferrals (codes D, E, F, and S) and designated Roth contributions member of the U.S. Armed Forces (not included in box 1, 3, or 5)
(codes AA, BB, and EE) under all plans are generally limited to a Q—Nontaxable combat pay. See the Instructions for Forms 1040 and
total of $19,500 ($13,500 if you only have SIMPLE plans; $22,500 for 1040-SR for details on reporting this amount.
section 403(b) plans if you qualify for the 15-year rule explained in R—Employer contributions to your Archer MSA. Report on Form 8853,
Pub. 571). Deferrals under code G are limited to $19,500. Deferrals Archer MSAs and Long-Term Care Insurance Contracts.
under code H are limited to $7,000.
Department of the Treasury - Internal Revenue Service

NOTE: THESE ARE SUBSTITUTE WAGE AND TAX STATEMENTS AND ARE ACCEPTABLE FOR FILING WITH YOUR FEDERAL, STATE AND LOCAL/CITY INCOME TAX RETURNS.
This information is being furnished to the Internal
Revenue Service. If you are required to file a tax Notice to Employee
return, a negligence penalty or other sanction may
be imposed on you if this income is taxable and Do you have to file? Refer to the Instructions for Forms your employment record. Be sure to ask the employer to
you fail to report it.
1040 and 1040-SR to determine if you are required to file file Form W-2c, Corrected Wage and Tax Statement, with
IMPORTANT NOTE: a tax return. Even if you don’t have to file a tax return, you the Social Security Administration (SSA) to correct any
In order to insure efficient processing,
may be eligible for a refund if box 2 shows an amount or if name, SSN, or money amount error reported to the SSA
attach this W-2 to your tax return like this
you are eligible for any credit. on Form W-2. Be sure to get your copies of Form W-2c
Earned income credit (EIC). You may be able to take the from your employer for all corrections made so you may file
(following agency instructions):
EIC for 2021 if your adjusted gross income (AGI) is less them with your tax return. If your name and SSN are
than a certain amount. The amount of the credit is based correct but aren’t the same as shown on your social
on income and family size. Workers without children could security card, you should ask for a new card that displays
qualify for a smaller credit. You and any qualifying children your correct name at any SSA office or by calling
must have valid social security numbers (SSNs). You can’t 800-772-1213. You may also visit the SSA website at
take the EIC if your investment income is more than the www.SSA.gov.
TAX RETURN specified amount for 2021 or if income is earned for Cost of employer-sponsored health coverage (if such
services provided while you were an inmate at a penal cost is provided by the employer). The reporting in box
institution. For 2021 income limits and more information, 12, using code DD, of the cost of employer-sponsored
visit www.irs.gov/EITC. See also Pub. 596, Earned Income health coverage is for your information only. The amount
THIS Credit. Any EIC that is more than your tax liability is reported with code DD is not taxable.
OTHER refunded to you, but only if you file a tax return.
FORM Credit for excess taxes. If you had more than one
W-2’S
W-2 Employee’s social security number (SSN). For your employer in 2021 and more than $8,853.60 in social
protection, this form may show only the last four digits of security and/or Tier 1 railroad retirement (RRTA) taxes
your SSN. However, your employer has reported your were withheld, you may be able to claim a credit for the
complete SSN to the IRS and SSA. excess against your federal income tax. If you had more
Clergy and religious workers. If you aren’t subject to than one railroad employer and more than $5,203.80 in
social security and Medicare taxes, see Pub. 517, Social Tier 2 RRTA tax was withheld, you may also be able to
Security and Other Information for Members of the Clergy claim a credit. See the Instructions for Forms 1040 and
and Religious Workers. 1040-SR and Pub. 505, Tax Withholding and Estimated
Tax.
Corrections. If your name, SSN, or address is incorrect,
correct Copies B, C, and 2 and ask your employer to correct

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