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 4,959.01 SOCIAL SECURITY 307.46
0000127144 V05 TAX WITHHELD
BG95 77482
BOX 04 OF W-2
c Employer’s name, address, and ZIP code
FED. INCOME 317.90 MEDICARE TAX 71.91
AMERICAN AIRLINES INC TAX WITHHELD WITHHELD
4000 E SKY HARBOR BLVD BOX 02 OF W-2 BOX 06 OF W-2
PHX-RWE-PAY
PHOENIX, AZ 85034 STATE INCOME TAX 187.00 SUI/SDI 0.00
BOX 17 OF W-2 BOX 14 OF W-2
LOCAL INCOME TAX 11.50
BOX 19 OF W-2
e/f Employee’s name, address, and ZIP code
MICHAEL F JONES
110 WESTWOOD WAY
ERIE, CO 80516

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

13-1502798 XXX-XX-6692
1 Wages, tips, other comp. 2 Federal income tax withheld
4719.17 317.90
3 Social security wages 4 Social security tax withheld
4959.01 307.46
5 Medicare wages and tips 6 Medicare tax withheld
4959.01 71.91
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

C 1.74 Social Security Number: XXX-XX-6692
14 Other
12b D 239.84 MICHAEL F JONES
12c L 287.43
12d DD
110 WESTWOOD WAY
153.82
13 Stat emp. Ret. plan 3rd party sick pay ERIE, CO 80516
X
15 State Employer’s state ID no. 16 State wages, tips, etc.
CO 08015888 4719.17
17 State income tax 18 Local wages, tips, etc.
187.00 1953.46
19 Local income tax 20 Locality name ¤ 2021 ADP, Inc.
11.50 DENVER 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
4719.17 317.90 4719.17 317.90 4719.17 317.90
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
4959.01 307.46 4959.01 307.46 4959.01 307.46
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
4959.01 71.91 4959.01 71.91 4959.01 71.91
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
0000127144 V05 BG95 77482 0000127144 V05 BG95 77482 0000127144 V05 BG95 77482
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
AMERICAN AIRLINES INC AMERICAN AIRLINES INC AMERICAN AIRLINES INC
4000 E SKY HARBOR BLVD 4000 E SKY HARBOR BLVD 4000 E SKY HARBOR BLVD
PHX-RWE-PAY PHX-RWE-PAY PHX-RWE-PAY
PHOENIX, AZ 85034 PHOENIX, AZ 85034 PHOENIX, AZ 85034

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
13-1502798 XXX-XX-6692 13-1502798 XXX-XX-6692 13-1502798 XXX-XX-6692
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
C 1.74 C 1.74 C 1.74
14 Other 12b D 239.84 14 Other 12b D 239.84 14 Other 12b D 239.84
12c L 287.43 12c L 287.43 12c L 287.43
12d DD 153.82 12d DD 153.82 12d DD 153.82
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
X X X
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
MICHAEL F JONES MICHAEL F JONES MICHAEL F JONES
110 WESTWOOD WAY 110 WESTWOOD WAY 110 WESTWOOD WAY
ERIE, CO 80516 ERIE, CO 80516 ERIE, CO 80516

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.
CO 08015888 4719.17 CO 08015888 4719.17 CO 08015888 4719.17
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.
187.00 1953.46 187.00 1953.46 187.00 1953.46
19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name
11.50 DENVER 11.50 DENVER 11.50 DENVER
Federal Filing Copy CO. State Filing Copy City or Local Filing Copy
Wage and Tax Wage and Tax Wage and Tax
W-2 Statement OMB
2021
Copy B to be filed with employee’s Federal Income Tax Return.
No. 1545-0008
W-2 Statement OMB
2021
Copy 2 to be filed with employee’s State Income Tax Return.
No. 1545-0008
W-2 Statement OMB
2021 No. 1545-0008
Copy 2 to be filed with employee’s City or Local Income Tax Return.