2017

a Employee's social security number

OMB No. 1545-0008

2017
W2 & EARNINGS 291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
SUMMARY JUNGLE JIMS INTERNATIONAL MARKET, INC 17148.69 674.88
3 Social security wages 4 Social security tax
5440 DIXIE HWY
FAIRFIELD, OH 45014 17148.69 1063.21

Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld

Copy B to be filed with Employee's Federal Income Tax Return.

b Employer's identification number d Control Number 17148.69 248.67

Federal Filing Copy

JUNGLE JIMS INTERNATIONAL MARKET, I
31-0955124 22317-7799 7 Social security tips 8 Allocated tips
5440 DIXIE HWY
FAIRFIELD, OH 45014 e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST DD 4500.89
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick
W 673.91
14 Other
HEASAVE 673.91
ROBERT S SMITH

W2
15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
Filing Status Exemptions OH 51-534602 17148.69 236.45 13791.11 137.91 MilfrdJD
FITWH S 2
OH S 1
a Employee's social security number

OMB No. 1545-0008

2017
OTHER 291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
Description Amount Box 674.88
JUNGLE JIMS INTERNATIONAL MARKET, INC 17148.69
HeSvNoKN 673.91 12 3 Social security wages 4 Social security tax
5440 DIXIE HWY
HeaSavER 673.91 14 17148.69 1063.21
FAIRFIELD, OH 45014

Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld
b Employer's identification number
WAGES d Control Number 17148.69 248.67

Copy 2 to be filed with Employee's State Income Tax Return.

State Filing Copy
TOTAL GROSS WAGES 19122.06 31-0955124 22317-7799 7 Social security tips 8 Allocated tips

Description Amount Box e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits

Soc. Security Wages 17148.69 3 ROBERT S SMITH

11 Nonqualified plans 12 See instrs. for box 12
Medicare Wages 17148.69 5 98 SOUTH EAST ST DD 4500.89
Fed. Taxable Wages 17148.69 1 FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick
W 673.91
OH Taxable Wages 17148.69 16 14 Other

MilfrdJD Wages 13791.11 18 HEASAVE 673.91

MlfrdJD2 Wages 3357.58 18

W2
WITHHOLDINGS 15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
Description Amount Box OH 51-534602 17148.69 236.45 13791.11 137.91 MilfrdJD
Fed. Income Tax 674.88 2
Soc. Security Tax 1063.21 4
Medicare Tax 248.67 6
a Employee's social security number

OMB No. 1545-0008

2017
OH Income Tax 236.45 17 291-60-5185
MilfrdJD W/H 137.91 19 c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
JUNGLE JIMS INTERNATIONAL MARKET, INC 17148.69 674.88
MlfrdJD2 W/H 33.58 19 3 Social security wages 4 Social security tax
5440 DIXIE HWY
DEDUCTIONS 17148.69 1063.21
FAIRFIELD, OH 45014

Wage and Tax Statement

City or Local Filing Copy
5 Medicare wages and tips 6 Medicare tax withheld
Description Amount Box b Employer's identification number d Control Number 17148.69 248.67
Health ER Premium 3294.51 12 31-0955124 22317-7799 7 Social security tips 8 Allocated tips

Copy 2 for Employee's City/Local Income Tax Return.

Health 125 Deduction 1206.38 12 e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
Section 125 Benefit Plan 1299.46 ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST DD 4500.89
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick
W 673.91
14 Other
HEASAVE 673.91

W2
15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
OH 51-534602 17148.69 236.45 13791.11 137.91 MilfrdJD

a Employee's social security number

OMB No. 1545-0008
2017

291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
JUNGLE JIMS INTERNATIONAL MARKET, INC 17148.69 674.88
3 Social security wages 4 Social security tax
5440 DIXIE HWY
17148.69 1063.21
Employee Reference Copy

FAIRFIELD, OH 45014
Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld

b Employer's identification number 248.67
d Control Number 17148.69
31-0955124 22317-7799 7 Social security tips 8 Allocated tips

e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST DD 4500.89
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick
W 673.91
Copy C for Employee's records.

14 Other
HEASAVE 673.91
W2

15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
OH 51-534602 17148.69 236.45 13791.11 137.91 MilfrdJD
 2017
a Employee's social security number

OMB No. 1545-0008

2017
W2 & EARNINGS 291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
SUMMARY JUNGLE JIMS INTERNATIONAL MARKET, INC
3 Social security wages 4 Social security tax
5440 DIXIE HWY
FAIRFIELD, OH 45014

Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld

Copy B to be filed with Employee's Federal Income Tax Return.

b Employer's identification number d Control Number

Federal Filing Copy

JUNGLE JIMS INTERNATIONAL MARKET, I
5440 DIXIE HWY
FAIRFIELD, OH 45014
31-0955124 22317-7799 7 Social security tips 8 Allocated tips
e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick

14 Other

ROBERT S SMITH

W2
15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
3357.58 33.58 MlfrdJD2

a Employee's social security number

OMB No. 1545-0008

2017
291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
JUNGLE JIMS INTERNATIONAL MARKET, INC
3 Social security wages 4 Social security tax
5440 DIXIE HWY
FAIRFIELD, OH 45014

Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld
b Employer's identification number d Control Number

Copy 2 to be filed with Employee's State Income Tax Return.

State Filing Copy
31-0955124 22317-7799 7 Social security tips 8 Allocated tips

e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick

14 Other

W2
15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
3357.58 33.58 MlfrdJD2

a Employee's social security number

OMB No. 1545-0008

2017
291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
JUNGLE JIMS INTERNATIONAL MARKET, INC
3 Social security wages 4 Social security tax
5440 DIXIE HWY
FAIRFIELD, OH 45014

Wage and Tax Statement

City or Local Filing Copy
5 Medicare wages and tips 6 Medicare tax withheld
b Employer's identification number d Control Number
31-0955124 22317-7799 7 Social security tips 8 Allocated tips

Copy 2 for Employee's City/Local Income Tax Return.

e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick

14 Other

W2
15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
3357.58 33.58 MlfrdJD2

a Employee's social security number

OMB No. 1545-0008
2017

291-60-5185
c Employer's name, address, and ZIP code 1 Wages,tips,other compensation 2 Federal income tax
JUNGLE JIMS INTERNATIONAL MARKET, INC
3 Social security wages 4 Social security tax
5440 DIXIE HWY
Employee Reference Copy

FAIRFIELD, OH 45014
Wage and Tax Statement

5 Medicare wages and tips 6 Medicare tax withheld

b Employer's identification number d Control Number
31-0955124 22317-7799 7 Social security tips 8 Allocated tips

e Employee's name and address 9 Advanced EIC payment 10 Dependent care benefits
ROBERT S SMITH
11 Nonqualified plans 12 See instrs. for box 12
98 SOUTH EAST ST
FAYETTEVILLE, OH 45118 13 Stat emp. Ret. Plan 3 Party Sick
Copy C for Employee's records.

14 Other
W2

15 State & Employer's state ID 16 State wages,tips,etc 17 State income tax 18 Local wages,tips,etc. 19 Local income tax 20 Locality name
3357.58 33.58 MlfrdJD2