a Employee's social security number

22222 419-39-7521 OMB No. 1545-0008

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
84-0821335 20844.21 1022.94
c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CLARA CORPORATION 20844.21 1292.33
4855 Ward Rd. Suite #600 5 Medicare wages and tips 6 Medicare tax withheld
20844.21 302.26
Wheat Ridge CO 800330000 7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a
C [br]
o
d
TERRELL D SWORDS e

13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
C
o
1585 DUDLEY STREET d
e

LOT 5 14 Other 12c

C
o
LAKEWOOD CO 802150000 d
e [br]

C [br]
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
CO 2216790 20844.21 794.00

Department of the Treasury - Internal Revenue Service

Form
W-2 Wage and Tax
Statement
Copy 1 - For State, City, or Local Tax Department
2020
 a Employee's social security number Visit the IRS website at
419-39-7521 OMB No. 1545-0008 www.irs.gov/efile
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
84-0821335 20844.21 1022.94
c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CLARA CORPORATION 20844.21 1292.33
4855 Ward Rd. Suite #600 5 Medicare wages and tips 6 Medicare tax withheld
20844.21 302.26
Wheat Ridge CO 800330000 7 Social security tips 8 Allocated tips

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
d
TERRELL D SWORDS e

13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
C
o
1585 DUDLEY STREET d
e

LOT 5 14 Other 12c

C
o
LAKEWOOD CO 802150000 d
e

12d
C
o
d
e

f Employee's address and ZIP code

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
CO 2216790 20844.21 794.00

Department of the Treasury - Internal Revenue Service

Form
W-2 Wage and Tax
Statement
Copy B - To Be Filed With Employee`s FEDERAL Tax Return.
2020
This information is being furnished to the Internal Revenue Service.
Notice to Employee

Do you have to file? Refer to the instructions for Forms 1040 to correct any name, SSN, or money amount error
and 1040-SR to determine if you are required to file a tax return. reported to the SSA on Form W-2. Be sure to get your
Even if you don't have to file a tax return, you may be eligible copies of Form W-2c from your employer for all
a refund if box 2 shows an amount or if you are eligible for
for corrections made so you may file them with your tax
any credit. return. If your name and SSN are correct but are not the
Earned income credit (EIC). You may be able to take the same as shown on your social security card, you should
ask for a new card that displays your correct name at any
EIC for 2020 if your adjusted gross income (AGI) is less
than a certain amount. The amount of the credit is based SSA office or by calling 1-800-772-1213. You also may
on income and family size. Workers without children could visit the SSA at www.socialsecurity.gov.
qualify for a smaller credit. You and any qualifying Cost of employer-sponsored health coverage (if such
must have valid social security numbers (SSNs). You
children cost is provided by the employer). The reporting in box
cannot take the EIC if your investment income is more than 12, using Code DD, of the cost of employer-sponsored
the specified amount for 2020 or if income is earned for health coverage is for your information only. The amount
services provided while you were an inmate at a penal reported with Code DD is not taxable.
institution. For 2020 income limits and more information,
visit www.irs.gov/eitc . Also see Pub. 596, Earned Income Credit for excess taxes. If you had more than one
Credit. Any EIC that is more than your tax liability is employer in 2020 and more than $8,537.40 in social
refunded to you, but only if you file a tax return. security and/or Tier 1 railroad retirement (RRTA) taxes
were withheld, you may be able to claim a credit for the
Clergy and religious workers. If you are not 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 $5,012.70in
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.
Corrections. If your name, SSN, or address is incorrect, 505, Tax Withholding and Estimated Tax.
correct Copies B, C, and 2 and ask your employer to
correct your employment record. Be sure to ask the (Also see Instructions for Employee on the back of Copy C.)
employer to file Form W-2c, Corrected Wage and Tax
Statement, with the Social Security Administration (SSA)
 a Employee's social security number This information is being furnished to the Internal Revenue Service. If you
OMB No. 1545-0008 are required to file a tax return, a negligence penalty or other sanction
419-39-7521 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
84-0821335 20844.21 1022.94
c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

CLARA CORPORATION 20844.21 1292.33

4855 Ward Rd. Suite #600 5 Medicare wages and tips 6 Medicare tax withheld

20844.21 302.26
7 Social security tips 8 Allocated tips
Wheat Ridge CO 800330000

d Control number 9 Dependent care benefits

10

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box
C
o
d
TERRELL D SWORDS e 12
13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
C
o
1585 DUDLEY STREET d
e [br]

LOT 5 14 Other 12c

C
o
LAKEWOOD CO 802150000 d
e

12d
C [br]
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
CO 2216790 20844.21 794.00

Form
W-2 Wage and Tax
Statement
Copy C - For EMPLOYEE`S RECORDS
2020 Department of the Treasury - Internal Revenue Service

(See Notice to Employee on back of Copy B)

Instructions for Employee (Also see Notice to
Employee , on the back of Copy B.)
and received a distribution in the same calendar year, and you are or will be
Box 1. Enter this amount on the wages line of your tax return. age 62 by the end of the calendar year, your employer should file Form
Box 2. Enter this amount on the federal income tax withheld line of SSA-131, Employer Report of Special Wage Payments, with the Social
your tax return.
Security Administration and give you a copy.
Box 5. You may be required to report this amount on Form 8959, Additioinal
Box 12. The following list explains the codes shown in box 12. You may
Medicare Tax. See instructions for Forms 1040 and 1040-SR to determine
need this information to complete your tax return. Elective deferrals (codes
if you are required to complete Form 8959.
D, E, F, and S) and designated Roth contributions (codes AA, BB and EE)
Box 6. This amount includes the 1.45% Medicare Tax withheld on all
under all plans are generally limited to a total of $19,500 ($13,500 if you only
Medicare wages and tips shown in Box 5, as well as the 0.9% Additional
have SIMPLE plans; $22,500 for section 403(b) plans if you qualify for the
Medicare Tax on any of those Medicare wages and tips above $200,000.
15-year rule explained in Pub. 571). Deferrals under code G are limited to
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on
$19,500. Deferrals under code H are limited to $7,000.
how to report tips on your tax return, see your Form 1040 instructions.
However, if you were at least age 50 in 2020, your employer may have
You must file Form 4137, Social Security and Medicare Tax on Unreported allowed an additional deferral of up to $6,500 ($3,000 for section 401(k)(11)
Tip Income, with your income tax return to report at least the allocated tip and 408(p) SIMPLE plans). This additional deferral amount is not subject to
amount unless you can prove that you received a smaller amount. If the overall limit on elective deferrals. For code G, the limit on elective
you have records that show the actual amount of tips you received, report deferrals may be higher for the last 3 years before you reach retirement age.
that amount even if it is more or less than the allocated tips. On Form 4137 Contact your plan administrator for more information. Amounts in excess of
you will figure the social security and Medicare tax owed on the allocated the overall elective deferral limit must be included in income. See the
tips shown on your Form(s) W-2 that you must report as income and on other "Wages, Salaries, Tips, etc.'' line instructions for Form 1040.
tips you did not report to your employer. By filing Form 4137, your social Note. If a year follows code D through H, S, Y, AA, BB, or EE, you made a
security tips will be credited to your social security record (used to figure make-up pension contribution for a prior year(s) when you were in military
your benefits). service. To figure whether you made excess deferrals, consider these
Box 10. This amount includes the total dependent care benefits that your amounts for the year shown, not the current year. If no year is shown, the
employer paid to you or incurred on your behalf (including amounts from a contributions are for the current year.
section 125 (cafeteria) plan). Any amount over $5,000 is also included in box 1.
A - Uncollected social security or RRTA tax on tips. Include this tax on From
Complete Form 2441, Child and Dependent Care Expenses, to compute any
taxable and nontaxable amounts. 1040. See the Form 1040 Instructions
Box 11. This amount is (a) reported in box 1 if it is a distribution made to you B - Uncollected Medicare tax on tips. Include this tax on Form 1040. See the
from a nonqualified deferred compensation or nongovernmental section Form 1040 instructions.
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 for social security and C - Taxable cost of group-term life insurance over $50,000 (included in boxes
Medicare taxes this year because there is no longer a substantial risk of 1, 3 (up to social security wage base), and 5)
forfeiture of your right to the deferred amount. This box should not be used if D - Elective deferrals to a section 401(k) cash or deferred arrangement. Also
if you had a deferral and a distribution in the same year. If you made a deferral includes deferrals under a SIMPLE retirement account that is part of a
section 401(k) arrangement.
E - Elective deferrals under a section 403(b) salary reduction agreement

(continued on back of Copy 2)

 a Employee's social security number
419-39-7521 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
84-0821335 20844.21 1022.94
c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CLARA CORPORATION 20844.21 1292.33
4855 Ward Rd. Suite #600 5 Medicare wages and tips 6 Medicare tax withheld
20844.21 302.26
Wheat Ridge CO 800330000 7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a
C [br]
o
d
TERRELL D SWORDS e

13 Statutory
employee
Retirement
plan
Third-party
sick pay 12b
C [br]
o
1585 DUDLEY STREET d
e [br]

LOT 5 14 Other 12c

C [br]
o
LAKEWOOD CO 802150000 d
e

12d
C [br]
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
CO 2216790 20844.21 794.00

Form
W-2 Wage and Tax
Statement
Copy 2 - To Be Filed With Employee`s State, City, or Local
2020 Department of the Treasury - Internal Revenue Service

Income Tax Return

Instructions for Employee (continued from back of Copy C)
Box 12 (continued) Y - Deferrals under a section 409A nonqualified deferred compensation plan.
F - Elective deferrals under a section 408(k)(6) salary reduction SEP Z - Income under a nonqualified deferred compesation plan that fails
G - Elective deferrals and employer contributions (including nonelective to satisty section 409A. This amount is also included in box 1. It is
deferrals) to a section 457(b) deferred compensation plan
subject to an additional 20% tax plus interest. See the instructions for
H - Elective deferrals to a section 501(c)(18)(D) tax-exempt organization Forms 1040 and 1040-SR.
plan. See the Instructions for Forms 1040 and 1040-SR for how to deduct.
AA - Designated Roth contributions under a section 401(k) plan
J - Nontaxable sick pay (information only, not included in boxes 1, 3, or 5)
K - 20% excise tax on excess golden parachute payments. See the BB - Designated Roth contributions under a section 403(b) plan
Instructions for Forms 1040 and 1040-SR. DD - Cost of employer-sponsored health coverage. The amount
L - Substantiated employee business expense reimbursements (nontaxable) reported with Code DD is not taxable.
M - Uncollected social security or RRTA tax on taxable cost of group- EE - Designated Roth contributions under a governmental section
term life insurance over $50,000 (former employees only). See the 457(b) plan. This amount does not apply to contributions under a tax-
Instructions for Forms 1040 and 1040-SR. exempt organization section 457(b) plan.
N - Uncollected Medicare tax on taxable cost of group-term life
FF - Permitted benefits under a qualified small employer health
insurance over $50,000 (former employees only). See the intructions
for Forms 1040 and 1040-SR. reimbursement arrangment.
for
GG - Income from qualified equity grants under section 83(i)
P - Excludable moving expense reimbursements paid directly to a
member of teh U.S. Armed Forces (not included in boxes 1, 3, or 5) HH - Aggregate deferrals under section 83(i) elections as of the close of
Q - Nontaxable combat pay. See the instructions for Form 1040 and the calendar year
1040-SR for details on Box 13. If the ''Retirement plan'' box is checked, special limits may
apply to the amount of traditional IRA contributions you may deduct. See
R - Employer
reporting contributions to your Archer MSA. Report on Form 8853,
this amount
Pub590-A, Contributions to Individual Retirement Arrangements (IRAs).
Archer MSAs and Long-Term Care Insurance Contracts.
Box 14. Employers may use this box to report information such as state
S - Employee salary reduction contributions under a section 408(p)
disability insurance taxes withheld, union dues, uniform payments,
SIMPLE plan (not included in box 1) health insurance premiums deducted, nontaxable income, educational
T - Adoption benefits (not included in box 1). Complete Form 8839, Qualified assistance payments, or a member of the clergy's parsonage allowance
Adoption Expenses, to compute any taxable and nontaxable amounts. and utilities. Railroad employers use this box to report railroad retirement
V - Income from exercise of nonstatutory stock option(s) (included in (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax and Additional
boxes 1, 3 (up to social security wage base), and 5). See Pub. 525 Medicare Tax. Include tips reported by the employee to the employer in
Taxable and Nontaxable Income, for reporting requirements. railroad retirement (RRTA) compensation.
Note. Keep Copy C of Form W-2 for at least 3 years after the due date
W - Employer contributions (including amounts the employee elected to
for filing your income tax return. However, to help protect your social
contribute using a section 125 (cafeteria) plan) to your health savings
security benefits, keep Copy C until you begin receiving social security
account. Report on Form 8889, Health Savings Accounts (HSAs).
benefits, just in case there is a question about your work record and/or
earnings in a particular year.