W-2 Wage and Tax Statement: I I I I
W-2 Wage and Tax Statement: I I I I
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 may be imposed on you if this income is taxable and you fail to report it.
7 Social security tips 1 Wages, tips, other comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9I 5 Medicare wages and tips 6 Medicare tax withheld
57020.64 826.80
165 CAPITOL AVENUE 10 Dependent care benefits 11 Nonqualified plans 12a See instructions for box 12
HARTFORD CT 06106-1667 C
o
d
e G I 1040.00
e Employee’s name, address, and ZIP code Statutory Retirement Third-party
13 employee plan sick pay 14 Other 12b
C
7 Social security tips 1 Wages, tips, other comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9 5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 1 Wages, tips, other comp. 2 Federal income tax withheld
Form W-2 Wage and Tax Statement 2021 I 52200.92 3015.13
c Employer’s name, address, and ZIP code 8 Allocated tips 3 Social security wages 4 Social security tax withheld
STATE OF CONNECTICUT 57020.64 3535.28
OFFICE OF THE STATE COMPTROLLER 9 5 Medicare wages and tips 6 Medicare tax withheld