a. Employee's Social Security Number OMB No.

1545-0008
245-67-7624
b. Employer's Identification Number (EIN) d. Control number 1 Wages, Tips, and other compensation 2 Federal Income Tax withheld
35-9990000 28891.68 2816.64
c. Employer's Name, Address, and ZIP Code 3 Social Security Wages 4 Social Security Tax withheld
DFAS ATTN:DFASIN/JAREA 29077.60 1802.81
8899 EAST 56TH STREET 5 Medicare Wages and Tips 6 Medicare Tax withheld
INDIANAPOLIS IN 46249-2410 29077.60 421.63
7 Social Security tips 8 Allocated Tips

e/f. Employee's Name, Address, and ZIP Code 9 10 Dependent Care Benefits
RACHELLE S FOREHAND
TP10VF1K 3891 12 See instructions for box 12 14 See instructions for box 14

D 19 145.92

13
Statutory Retirement Third-party
Employee Plan sick pay
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
NY 359990000 28891.68 1103.95
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

Wage and Tax Department of the Treasury - Internal Revenue Service

Form
W-2 Statement 2019 Copy B To Be Filed With Employee's FEDERAL Tax Return
This information is being furnished to the Internal Revenue Service

a. Employee's Social Security Number OMB No. 1545-0008 This information is being furnished to the Internal Revenue Service. If you are required to file a tax
245-67-7624 return, a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it.

b. Employer's Identification Number (EIN) d. Control Number 1 Wages, Tips, other compensation 2 Federal Income Tax withheld
35-9990000 28891.68 2816.64
c. Employer's Name, Address, and ZIP Code 3 Social Security Wages 4 Social Security Tax withheld
DFAS ATTN:DFASIN/JAREA 29077.60 1802.81
8899 EAST 56TH STREET 5 Medicare Wages and Tips 6 Medicare Tax withheld
INDIANAPOLIS IN 46249-2410 29077.60 421.63
7 Social Security tips 8 Allocated Tips

e/f. Employee's Name, Address, and ZIP Code 9 10 Dependent Care Benefits
RACHELLE S FOREHAND
TP10VF1K 3891 12 See instructions for box 12 14 See instructions for box 14

D 19 145.92

13
Statutory Retirement Third-party
Employee Plan sick pay
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
NY 359990000 28891.68 1103.95
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

Department of the Treasury - Internal Revenue Service

Wage and Tax
Form
W-2 Statement
2019 Copy C For EMPLOYEE'S RECORDS (See Notice to Employee on Back of Copy B)
a. Employee's Social Security Number OMB No. 1545-0008
245-67-7624
b. Employer's Identification Number (EIN) d. Control number 1 Wages, Tips, and other compensation 2 Federal Income Tax withheld
35-9990000 28891.68 2816.64
c. Employer's Name, Address, and ZIP Code 3 Social Security Wages 4 Social Security Tax withheld
DFAS ATTN:DFASIN/JAREA 29077.60 1802.81
8899 EAST 56TH STREET 5 Medicare Wages and Tips 6 Medicare Tax withheld
INDIANAPOLIS IN 46249-2410 29077.60 421.63
7 Social Security tips 8 Allocated Tips

e/f. Employee's Name, Address, and ZIP Code 9 10 Dependent Care Benefits
RACHELLE S FOREHAND
TP10VF1K 3891 12 See instructions for box 12 14 See instructions for box 14

D 19 145.92

13 Statutory Retirement Third-party

Employee Plan sick pay
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
NY 359990000 28891.68 1103.95
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

Wage and Tax Department of the Treasury - Internal Revenue Service

Form
W-2 Statement 2019 Copy 2 To Be Filed With Employee's State, City, or Local Income Tax Return

a. Employee's Social Security Number OMB No. 1545-0008

245-67-7624
b. Employer's Identification Number (EIN) d. Control Number 1 Wages, Tips, other compensation 2 Federal Income Tax withheld
35-9990000 28891.68 2816.64
c. Employer's Name, Address, and ZIP Code 3 Social Security Wages 4 Social Security Tax withheld
DFAS ATTN:DFASIN/JAREA 29077.60 1802.81
8899 EAST 56TH STREET 5 Medicare Wages and Tips 6 Medicare Tax withheld
INDIANAPOLIS IN 46249-2410 29077.60 421.63
7 Social Security tips 8 Allocated Tips

e/f. Employee's Name, Address, and ZIP Code 9 10 Dependent Care Benefits
RACHELLE S FOREHAND
TP10VF1K 3891 12 See instructions for box 12 14 See instructions for box 14

D 19 145.92

13 Statutory Retirement Third-party

Employee Plan sick pay
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
NY 359990000 28891.68 1103.95
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

Department of the Treasury - Internal Revenue Service

Wage and Tax
Form
W-2 Statement
2019 Copy 2 To Be Filed With Employee's State, City, or Local Income Tax Return
Notice to Employee
Do you have to file? Refer to the Form 1040 Instructions Be sure to get your copies of Form W-2c from your
to determine if you are required to file a tax return. Even if employer for all corrections made so you may file them
you do not have to file a tax return, you may be eligible for with your tax return. If your name and SSN are correct but
a refund if box 2 shows an amount or if you are eligible for are not the same as shown on your social security card,
any credit. you should ask for a new card that displays your correct
name at any SSA office or by calling 1-800-772-1213. You
Earned income credit (EIC). You may be able to take the
EIC for 2018 if your adjusted gross income (AGI) is less also may visit the SSA at www.SSA.gov.
than a certain amount. The amount of the credit is based Cost of employer-sponsored health coverage (if such
on income and family size. Workers without children could cost is provided by the employer). The reporting in box
qualify for a smaller credit. You and any qualifying children 12, using code DD, of the cost of employer-sponsored
must have valid social security numbers (SSNs). You health coverage is for your information only. The amount
cannot take the EIC if your investment income is more than reported with code DD is not taxable.
the specified amount for 2018 or if income is earned for
Credit for excess taxes. If you had more than one
services provided while you were an inmate at a penal
employer in 2018 and more than $7,960.80 in social
institution. For 2018 income limits and more information,
security and/or Tier 1 railroad retirement (RRTA) taxes
visit www.irs.gov/eitc. Also see Pub. 596, Earned Income
were withheld, you may be able to claim a credit for the
Credit. Any EIC that is more than your tax liability is
excess against your federal income tax. If you had more
refunded to you, but only if you file a tax return.
than one railroad employer and more than $4,674.60 in
Corrections. If your name, SSN, or address is incorrect, Tier 2 RRTA tax was withheld, you also may be able to
correct Copies B, C, and 2 and ask your employer to claim a credit. See your Form 1040 or Form 1040A
correct your employment record. Be sure to ask the instructions and Pub. 505, Tax Withholding and Estimated
employer to file Form W-2c, Corrected Wage and Tax Tax.
Statement, with the Social Security Administration (SSA) (Also see Instructions for Employee on the back of Copy C.)
to correct any name, SSN, or money amount error
reported to the SSA on Form W-2.
Instructions for Employee (Also see Notice to Employee M - Uncollected Social Security or RRTA tax on taxable cost of group-term life
insurance over $50,000 (former employees only). See “Other Taxes” in the Form
on the back of Copy B.) 1040 instructions.
Box 1. Enter this amount on the wages line of your tax return. N - Uncollected Medicare tax on taxable cost of group-term life insurance over
Box 2. Enter this amount on the federal income tax withheld line of your tax $50,000 (former employees only). See “Other Taxes” in the Form 1040
return. instructions.
Box 5. You may be required to report this amount on Form 8959, Additional P - Excludable moving expense reimbursements paid directly to member of
Medicare Tax. See Form 1040 instructions to determine if you are required to Armed Forces (not included in boxes 1, 3, or 5).
complete Form 8959. Q - Nontaxable combat pay. See the instructions for Form 1040 or Form 1040A
Box 6. This amount includes the 1.45% Medicare Tax withheld on all Medicare for details on reporting this amount.
wages and tips shown in box 5, as well as the 0.9% Additional Medicare Tax on R - Employer contributions to your Archer MSA. Report on Form 8853, Archer
any of those Medicare wages and tips above $200,000. MSAs and Long-Term Care Insurance Contracts.
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on S - Employee salary reduction contributions under a section 408(p) SIMPLE
how to report tips on your tax return, see your Form 1040 instructions. plan (not included in box 1).
You must file Form 4137, Social Security and Medicare Tax on Unreported Tip T - Adoption benefits (not included in box 1). Complete Form 8839, Qualified
Income, with your income tax return to report at least the allocated tip amount Adoption Expenses, to compute any taxable and nontaxable amounts.
unless you can prove that you received a smaller amount. If you have records W - Employer contributions (including amounts the employee elected to
that show the actual amount of tips you received, report that amount even if it is contribute using a section 125 (cafeteria) plan) to your health savings account.
more or less than the allocated tips. On Form 4137 you will calculate the social Report on Form 8889, Health Savings Accounts (HSAs).
security and Medicare tax owed on the allocated tips shown on your Form(s)
AA - Designated Roth contributions under a section 401(k) plan.
W-2 that you must report as income and on other tips you did not report to your
employer. By filing Form 4137, your social security tips will be credited to your BB - Designated Roth contributions under a section 403(b) plan.
social security record (used to figure your benefits). DD - Cost of employer-sponsored health coverage. The amount reported with
Box 10. This amount includes the total dependent care benefits that your Code DD is not taxable.
employer paid to you or incurred on your behalf (including amounts from a EE - Designated Roth contributions under a governmental section 457(b) plan.
section 125 (cafeteria) plan). Any amount over $5,000 is also included in box 1. This amount does not apply to contributions under a tax-exempt organization
Complete Form 2441, Child and Dependent Care Expenses, to compute any section 457(b) plan.
taxable and nontaxable amounts. Box 13. If the “Retirement plan” box is checked, special limits may apply to the
Box 12. The following list explains the codes shown in box 12. You may need amount of traditional IRA contributions you may deduct. See Pub. 590-A,
this information to complete your tax return. Elective deferrals (codes D, E, F Contributions to Individual Retirement Arrangements (IRAs).
and S) and designated Roth contributions (codes AA, BB and EE) under all Box 14. Any amount in box 14 should be coded. The following explains the
plans are generally limited to a total of $18,500 ($12,500 if you only have codes.
SIMPLE plans, $21,500 for section 403(b) plans, if you qualify for the 15-year C - Taxable reimbursements for Permanent Change of Station (Included in Box 1)
rule explained in Pub. 571). E - Military TSP Contribution (Tax Exempt)
However, if you were at least age 50 in 2018, your employer may have allowed F - TIAA/CREF and Fidelity Retirement Contributions
an additional deferral of up to $6,000 ($3,000 for section 401(k)(11) and 408(p) G - Pre-Tax Transportation Equity Act Benefits
SIMPLE plans). This additional deferral amount is not subject to the overall limit
H - Home to Work Transportation Fringe Benefits. (Included in Box 1)
on elective deferrals. Contact your plan administrator for more information.
Amounts in excess of the overall elective deferral limit must be included in K - Pretax Vision and Dental Deduction
income. See the "Wages, Salaries, Tips, etc." line instructions for Form 1040. P - Parking Fringe Benefits/Employer Provided Vehicle. (Included in Box 1)
Note: If a year follows code D through H, S, Y, AA, BB or EE, you made a R - Retirement Deductions. (for Civilian Employees who have wages earned in
make-up pension contribution for a prior year(s) when you were in military Puerto Rico)
service. To figure whether you made excess deferrals, consider these amounts S - Federal Employee Health Benefit employee deduction for Civilian
for the year shown, not the current year. If no year is shown, the contributions Employees who have wages earned in Puerto Rico.
are for the current year. Your employer does not use codes G, H, K, V, Y, Z, FF, T - Cost of Living Allowance not included in box 1 or 16 for Civilian Employees
GG, HH. who have COLA included for wages in Alaska, Hawaii, Guam and the Northern
A - Uncollected social security or RRTA tax on tips. Include this tax on Form Mariana Islands, Puerto Rico and the U.S. Virgin Islands
1040. See "Other Taxes" in the Form 1040 instructions. U - Non-Cash Fringe Benefits (Included in Box 1)
B - Uncollected Medicare tax on tips. Include this tax on Form 1040. See "Other V - Pretax FEHB Incentive
Taxes" in the Form 1040 instructions. X - Occupational Tax/Local Services Tax (CIVILIAN)
C - Taxable cost of group-term life insurance over $50,000 (included in boxes 1, Y - Pretax Flexible Spending Accounts (CIVILIAN) Employee Contributions
3 (up to social security wage base), and 5).
Z - Retirement Deductions for Massachusetts Residents Only
D - Elective deferrals to a section 401(k) cash or deferred arrangement. Also
Note: Keep Copy C of Form W-2 for at least 3 years after the due date for filing
includes deferrals under a SIMPLE retirement account that is part of a section
your income tax return. However, to help protect your social security
401(k) arrangement.
benefits, keep Copy C until you begin receiving social security benefits, just in
E - Elective deferrals under a section 403(b) salary reduction agreement. case there is a question about your work record and/or earnings in a particular
F - Elective deferrals under a section 408(k)(6) salary reduction SEP. year.
J - Nontaxable sick pay (information only, not included in boxes 1, 3, or 5).
L - Substantiated employee business expense reimbursements (nontaxable).