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429-43-9484 OMB No. 1545-0008 FAST! Use
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
C 70.38
d
FLOYD DAVIDSON
e
13 Statutory Retirement Third-party
employee plan sick pay
12b
1221 YORK AVE B
C
E 4222.87
o
9 d
HAWTHORNE, CA 90250
e
14 Other 12c
C
DD
o
d
e 6374.82
12d
C
o
d
e