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Employee Reference Copy This blue Earnings Summary section is included with your W-2 to help describe portions in more detail.
Wage and Tax
W-2 Statement
Copy C for employee’s records.
2017
OMB No. 1545-0008
The reverse side includes general information that you may also find helpful.
1. The following information reflects your final 2017 pay stub plus any adjustments submitted by your employer.
d Control number Dept. Corp. Employer use only Gross Pay Social Security OR. State Income Tax
6076.20 352.74 174.18
014085 SEAT/AU0 000480 T 125 Tax Withheld Box 17 of W-2
c Employer’s name, address, and ZIP code Box 4 of W-2 SUI/SDI
APORT LLC Box 14 of W-2
Fed. Income 266.87 Medicare Tax 82.50
6233 NE 78TH COURT Tax Withheld Withheld
PORTLAND OR 97218 Box 2 of W-2 Box 6 of W-2
2. Your Gross Pay was adjusted as follows to produce your W-2 Statement.
Batch #01145
Wages, Tips, other Social Security Medicare OR. State Wages,
e/f Employee’s name, address, and ZIP code Compensation Wages Wages Tips, Etc.
Box 1 of W-2 Box 3 of W-2 Box 5 of W-2 Box 16 of W-2
SCOTT R SWAYZE
814 SE 178TH AVENUE Gross Pay 6,076.20 6,076.20 6,076.20 6,076.20
PORTLAND OR 97233 Less Other Cafe 125 386.88 386.88 386.88 386.88
Reported W-2 Wages 5,689.32 5,689.32 5,689.32 5,689.32
b Employer’s FED ID number a Employee’s SSA number
93-1157983 541-94-6949
1 Wages, tips, other comp. 2 Federal income tax withheld
5689.32 266.87
3 Social security wages 4 Social security tax withheld
5689.32 352.74
5 Medicare wages and tips 6 Medicare tax withheld
5689.32 82.50
7 Social security tips 8 Allocated tips
9 Verification Code 10 Dependent care benefits 3. Employee W-4 Profile. To change your Employee W-4 Profile Information, file a new W-4 with your payroll dept.
1568-5113-0af9-6f62
11 Nonqualified plans 12a See instructions for box 12
12b
DD 1240.20 SCOTT R SWAYZE Social Security Number:541-94-6949
14 Other 814 SE 178TH AVENUE Taxable Marital Status: SINGLE
12c
12d PORTLAND OR 97233 Exemptions/Allowances:
____________________
13 Stat emp. Ret. plan 3rd party sick pay FEDERAL: 3
STATE: 3
15 State Employer’s state ID no. 16 State wages, tips, etc.
OR 00818975-6 5689.32
17 State income tax 18 Local wages, tips, etc.
174.18
19 Local income tax 20 Locality name ¤ 2017 ADP, LLC
1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld
5689.32 266.87 5689.32 266.87 5689.32 266.87
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
5689.32 352.74 5689.32 352.74 5689.32 352.74
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
5689.32 82.50 5689.32 82.50 5689.32 82.50
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
014085 SEAT/AU0 000480 T 125 014085 SEAT/AU0 000480 T 125 014085 SEAT/AU0 000480 T 125
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
APORT LLC APORT LLC APORT LLC
6233 NE 78TH COURT 6233 NE 78TH COURT 6233 NE 78TH COURT
PORTLAND OR 97218 PORTLAND OR 97218 PORTLAND OR 97218
b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number
93-1157983 541-94-6949 93-1157983 541-94-6949 93-1157983 541-94-6949
7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips
9 Verification Code 10 Dependent care benefits 9 Verification Code 10 Dependent care benefits 9 Verification Code 10 Dependent care benefits
1568-5113-0af9-6f62
11 Nonqualified plans 12a See instructions for box 12 11 Nonqualified plans 12a
12 11 Nonqualified plans 12a
DD 1240.20 DD 1240.20 DD 1240.20
14 Other 12b 14 Other 12b 14 Other 12b
12c 12c 12c
12d 12d 12d
13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay
e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code
SCOTT R SWAYZE SCOTT R SWAYZE SCOTT R SWAYZE
814 SE 178TH AVENUE 814 SE 178TH AVENUE 814 SE 178TH AVENUE
PORTLAND OR 97233 PORTLAND OR 97233 PORTLAND OR 97233
15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc.
OR 00818975-6 5689.32 OR 00818975-6 5689.32 OR 00818975-6 5689.32
17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.
174.18 174.18 174.18
19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name
NOTE: THESE ARE SUBSTITUTE WAGE AND TAX STATEMENTS AND ARE ACCEPTABLE FOR FILING WITH YOUR FEDERAL, STATE AND LOCAL/CITY INCOME TAX RETURNS.
Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service