a Employee’s social security number Safe, accurate, Visit the IRS website at

OMB No. 1545-0008 FAST! Use www.irs.gov/efile

160-78-9173
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
33-1171526 45000.00 4500.00
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

Ak Cleaning Services Inc 45000.00 2790.00

5 Medicare wages and tips 6 Medicare tax withheld
907 13th st
45000.00 652.50
7 Social security tips 8 Allocated tips
watervliet, NY 12189-3129
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
RANCER GOMEZ GARCIA d
e
13 Statutory Retirement Third-party
employee plan sick pay 12b
C
o
d
e

14 Other 12c
C
o
d
e

2224 AMSTERDAM AV, APT 12d

C
o
33NEW YORK, NY.10031 d
e

f Employee’s address and ZIP code

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 33-1171526 45000.00 2025.00

W-2 Wage and Tax

2019
Department of the Treasury—Internal Revenue Service
Form Statement
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

160-78-9173 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
33-1171526 45000.00 4500.00
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

Ak Cleaning Services Inc 45000.00 2790.00

5 Medicare wages and tips 6 Medicare tax withheld
907 13th st
45000.00 652.50
7 Social security tips 8 Allocated tips
watervliet, NY 12189-3129
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
RANCER GOMEZ GARCIA d
e
13 Statutory Retirement Third-party
12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

2224 AMSTERDAM AV, APT 12d

C
33NEW YORK, NY.10031 o
d
e

f Employee’s address and ZIP code

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 33-1171526 45000.00 2025.00

W-2 Wage and Tax

2019
Department of the Treasury—Internal Revenue Service
Form Statement
Copy 2—To Be Filed With Employee’s State, City, or Local
Income Tax Return
 a Employee’s social security number This information is being furnished to the Internal Revenue Service. If you
are required to file a tax return, a negligence penalty or other sanction
160-78-9173 OMB No. 1545-0008 may be imposed on you if this income is taxable and you fail to report it.
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
33-1171526 45000.00 4500.00
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
Ak Cleaning Services Inc 45000.00 2790.00
5 Medicare wages and tips 6 Medicare tax withheld
907 13th st
45000.00 652.50
7 Social security tips 8 Allocated tips
watervliet, NY 12189-3129
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
RANCER GOMEZ GARCIA d
e
13 Statutory Retirement Third-party
12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
2224 AMSTERDAM AV, APT C
o
d
33NEW YORK, NY.10031 e

f Employee’s address and ZIP code

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 33-1171526 45000.00 2025.00

W-2
Department of the Treasury—Internal Revenue Service

2019
Wage and Tax
Form Statement Safe, accurate,
FAST! Use
Copy C—For EMPLOYEE’S RECORDS

Notice to Employee employer to file Form W-2c, Corrected Wage and Tax
Do you have to file? Refer to the Form 1040 instructions Statement, with the Social Security Administration (SSA)
to determine if you are required to file a tax return. Even to correct any name, SSN, or money amount error
if you don’t have to file a tax return, you may be eligible reported to the SSA on Form W-2. Be sure to get your
for a refund if box 2 shows an amount or if you are copies of Form W-2c from your employer for all
eligible for any credit. corrections made so you may file them with your tax
return. If your name and SSN are correct but aren’t the
Earned income credit (EIC). You may be able to take the
same as shown on your social security card, you should
EIC for 2019 if your adjusted gross income (AGI) is less
ask for a new card that displays your correct name at any
than a certain amount. The amount of the credit is based
SSA office or by calling 800-772-1213. You also may visit
on income and family size. Workers without children
the SSA website at www.SSA.gov.
could qualify for a smaller credit. You and any qualifying
children must have valid social security numbers (SSNs). Cost of employer-sponsored health coverage (if such
You can’t take the EIC if your investment income is more cost is provided by the employer). The reporting in box
than the specified amount for 2019 or if income is earned 12, using code DD, of the cost of employer-sponsored
for services provided while you were an inmate at a penal health coverage is for your information only. The amount
institution. For 2019 income limits and more information, reported with code DD is not taxable.
visit www.irs.gov/EITC. Also see Pub. 596, Earned Credit for excess taxes. If you had more than one
Income Credit. Any EIC that is more than your tax employer in 2019 and more than $8,239.80 in social
liability is refunded to you, but only if you file a tax security and/or Tier 1 railroad retirement (RRTA) taxes
return. were withheld, you may be able to claim a credit for the
Clergy and religious workers. If you aren’t subject to excess against your federal income tax. If you had more
social security and Medicare taxes, see Pub. 517, Social than one railroad employer and more than $4,836.30 in
Security and Other Information for Members of the Clergy Tier 2 RRTA tax was withheld, you also may be able to
and Religious Workers. claim a credit. See your Form 1040 instructions 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 your employment record. Be sure to ask the
Instructions for Employee continued
Box 1. Enter this amount on the wages line of your tax return.
Box 2. Enter this amount on the federal income tax withheld line of your F—Elective deferrals under a section 408(k)(6) salary reduction SEP
tax return. G—Elective deferrals and employer contributions (including nonelective
Box 5. You may be required to report this amount on Form 8959, deferrals) to a section 457(b) deferred compensation plan
Additional Medicare Tax. See the Form 1040 instructions to determine if H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan.
you are required to complete Form 8959. See the Form 1040 instructions for how to deduct.
Box 6. This amount includes the 1.45% Medicare Tax withheld on all
Medicare wages and tips shown in box 5, as well as the 0.9% Additional J—Nontaxable sick pay (information only, not included in box 1, 3, or 5)
Medicare Tax on any of those Medicare wages and tips above K—20% excise tax on excess golden parachute payments. See the
$200,000. Form 1040 instructions.
Box 8. This amount is not included in box 1, 3, 5, or 7. For information L—Substantiated employee business expense reimbursements (nontaxable)
on how to report tips on your tax return, see your Form 1040
instructions. M—Uncollected social security or RRTA tax on taxable cost of group-
term life insurance over $50,000 (former employees only). See the Form
You must file Form 4137, Social Security and Medicare Tax on
Unreported Tip Income, with your income tax return to report at least the 1040 instructions.
allocated tip amount unless you can prove that you received a smaller N—Uncollected Medicare tax on taxable cost of group-term life
amount. If you have records that show the actual amount of tips you insurance over $50,000 (former employees only). See the Form 1040
received, report that amount even if it is more or less than the allocated instructions.
tips. On Form 4137, you will calculate the social security and Medicare
tax owed on the allocated tips shown on your Form(s) W-2 that you must P—Excludable moving expense reimbursements paid directly to a
report as income and on other tips you did not report to your employer. member of the U.S. Armed Forces (not included in box 1, 3, or 5)
By filing Form 4137, your social security tips will be credited to your Q—Nontaxable combat pay. See the instructions for Form 1040 for
social security record (used to figure your benefits). details on reporting this amount.
Box 10. This amount includes the total dependent care benefits that R—Employer contributions to your Archer MSA. Report on Form 8853,
your employer paid to you or incurred on your behalf (including amounts Archer MSAs and Long-Term Care Insurance Contracts.
from a section 125 (cafeteria) plan). Any amount over $5,000 also is
included in box 1. Complete Form 2441, Child and Dependent Care S—Employee salary reduction contributions under a section 408(p)
Expenses, to compute any taxable and nontaxable amounts. SIMPLE plan (not included in box 1)
Box 11. This amount is (a) reported in box 1 if it is a distribution made to T—Adoption benefits (not included in box 1). Complete Form 8839, Qualified
you from a nonqualified deferred compensation or nongovernmental Adoption Expenses, to compute any taxable and nontaxable amounts.
section 457(b) plan, or (b) included in box 3 and/or 5 if it is a prior year
deferral under a nonqualified or section 457(b) plan that became taxable V—Income from exercise of nonstatutory stock option(s) (included in
for social security and Medicare taxes this year because there is no boxes 1, 3 (up to social security wage base), and 5). See Pub. 525,
longer a substantial risk of forfeiture of your right to the deferred amount. Taxable and Nontaxable Income, for reporting requirements.
This box shouldn’t be used if you had a deferral and a W—Employer contributions (including amounts the employee elected to
contribute using a section 125 (cafeteria) plan) to your health savings
distribution in the same calendar year. If you made a deferral and
received a distribution in the same calendar year, and you are or will be account. Report on Form 8889, Health Savings Accounts (HSAs).
age 62 by the end of the calendar year, your employer should file Form
SSA-131, Employer Report of Special Wage Payments, with the Social Y—Deferrals under a section 409A nonqualified deferred compensation plan
Security Administration and give you a copy. Z—Income under a nonqualified deferred compensation plan that fails
Box 12. The following list explains the codes shown in box 12. You may to satisfy section 409A. This amount also is included in box 1. It is
need this information to complete your tax return. Elective deferrals subject to an additional 20% tax plus interest. See the Form 1040
(codes D, E, F, and S) and designated Roth contributions (codes AA, instructions.
BB, and EE) under all plans are generally limited to a total of $19,000 AA—Designated Roth contributions under a section 401(k) plan
($13,000 if you only have SIMPLE plans; $22,000 for section 403(b)
plans if you qualify for the 15-year rule explained in Pub. 571). Deferrals BB—Designated Roth contributions under a section 403(b) plan
under code G are limited to $19,000. Deferrals under code H are limited DD—Cost of employer-sponsored health coverage. The amount
to $7,000. reported with code DD is not taxable.
However, if you were at least age 50 in 2019, your employer may have EE—Designated Roth contributions under a governmental section
allowed an additional deferral of up to $6,000 ($3,000 for section 401(k)
(11) and 408(p) SIMPLE plans). This additional deferral amount is not 457(b) plan. This amount does not apply to contributions under a tax-
subject to the overall limit on elective deferrals. For code G, the limit on exempt organization section 457(b) plan.
elective deferrals may be higher for the last 3 years before you reach FF—Permitted benefits under a qualified small employer health
retirement age. Contact your plan administrator for more information. reimbursement arrangement
Amounts in excess of the overall elective deferral limit must be included
in income. See the instructions for Form 1040. GG—Income from qualified equity grants under section 83(i)
Note: If a year follows code D through H, S, Y, AA, BB, or EE, you made HH—Aggregate deferrals under section 83(i) elections as of the close of
a make-up pension contribution for a prior year(s) when you were in the calendar year
military service. To figure whether you made excess deferrals, consider Box 13. If the “Retirement plan” box is checked, special limits may apply
these amounts for the year shown, not the current year. If no year is to the amount of traditional IRA con
contributions you may deduct. See
shown, the contributions are for the current year. Pub. 590-A, Contributions to Individual Retirement Arrangements (IRAs).
A—Uncollected social security or RRTA tax on tips. Include this tax on
Form 1040. See the Form 1040 instructions. Box 14. Employers may use this box to report information such as state
disability insurance taxes withheld, union dues, uniform payments,
B—Uncollected Medicare tax on tips. Include this tax on Form 1040.
See the Form 1040 instructions. health insurance premiums deducted, nontaxable income, educational
assistance payments, or a member of the clergy’s parsonage allowance
C—Taxable cost of group-term life insurance over $50,000 (included in
boxes 1, 3 (up to social security wage base), and 5) and utilities. Railroad employers use this box to report railroad
retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax,
D—Elective deferrals to a section 401(k) cash or deferred arrangement.
Also includes deferrals under a SIMPLE retirement account that is part and Additional Medicare Tax. Include tips reported by the employee to
of a section 401(k) arrangement. the employer in railroad retirement (RRTA) compensation.
E—Elective deferrals under a section 403(b) salary reduction agreement Note: Keep Copy C of Form W-2 for at least 3 years after the due date
for filing your income tax return. However, to help protect your social
security benefits, keep Copy C until you begin receiving social security
benefits, just in case there is a question about your work record and/or
earnings in a particular year.