| Employee's information | |||
|---|---|---|---|
| Employee's social security number | XXX-XX-1234 | ||
| Employer identification number (EIN) | 12-3456789 | ||
| Employer's name, address, and ZIP code | Employer Inc. 123 Employer St. City, State 98765 |
||
| Employee's name | John Doe | ||
| Employee's address and ZIP code | 456 Employee Ave. City, State 12345 |
||
| Wages and taxes | Amount | ||
| 1 | Wages, tips, other compensation | $50,000.00 | |
| 2 | Federal income tax withheld | $5,000.00 | |
| 3 | Social security wages | $50,000.00 | |
| 4 | Social Security tax withheld | $3,100.00 | |
| 5 | Medicare wages and tips | $50,000.00 | |
| 6 | Medicare tax withheld | $725.00 | |
