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Date: November 1, 2013 Form Approved

OMB No. 0960-0432
EMPLOYER QUESTIONNAffiE
DISCREPANCY BETWEEN ffiS AND SSA RECORDS
The IRS records show that, for the year below, you paid Social Security
and/or Medicare taxes on more employee wages than SSA processed. We base
our wage amount on your Forms W-2 and W-3 reports. The total wages on
your Forms W-2 and W-3 for a year should equal the sum of the amounts that
you report quarterly or annually to the IRS on your Forms 941, 943, 944 or on
Schedule H (Form 1040).

' IRS/SSA Data For Tax Year: 2012 ~ ~ EIN: 43-1219365 - ~.

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Employer Name: BARBARA HALE ~

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Soc. Security Wages Medicare i

Wages/Tips .
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Amount Reported on W-3: $7,017.00 $7,017. 00 ~
Amount Processed by IRS: $7,017.00 $7,017. 00 ~
Amou)'l't~)'ot~ss~abY ~~A ~
(from Forms W-2): $5,251.00 $5,251. 00 ~
Difference Between IRS ;
and SSA Processed ~
Amounts: $1,766. 00 ~
~
Soc.
Amount Reported on W-3: $0.00 ~$e.. ~-+keuJ~4.s'
Amount Processed by IRS: $0. 00 CiC;~
Ved &-1\J~.cier-r-
Amount Processed by SSA 1 U-'h.r~ I. ~6'-~ 0 r'\
.(fromFormsW-2): :-~.:$_~.laW". $0.00 'JJz~\Jf3..J:h~ "::'.

00\0' .JsItA
DIfference Between IRS ,,~.,. ':" 2.m~dt ,. ~ t..I ~ y--c.
[(~.~
and SSA Processed ~;o.~-r~ ~. t\o t 0 ~ Q.-' -., ~
'""" Amounts: ~~" $0. 00 r&-Dr~.(" "5h4>-..Ja..., ~r
dl :5c.('~rp.-l\c.u ' -
CHECK AND COMPLETE ~ - Yl. ~

Check and complete any items that apply to your wage report for the tax year
shown above.
1. () I did not file Forms W -2 with SSA. I am now taking the following
action (check one):

( ) Enclosing the original Copy A of paper Forms W -2 and W -3, or

SSA-97-SM (04-11)

IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
431219365-12-110113

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Page 4 of 6

( ) Sending SSA an electronic file.

Caution: You must identify this as a reconciliation file
when you submit it! Enclose the electronic receipt showing
the Wage File ID (WFID) as proof of filing. \"::""t

2. () I filed Forms W -2 under the EIN for the TY shown above. I am a

now taking the following action for the wages I previously
reported (check one):
( ) Enclosing legible copies of paper Forms W-2 and W-3, or"
" i
( ) Sending SSA an electronic file. if:.c,"" "

~c
, "

.~-- Caution: You must identify this as a reconciliation file -'-~~~

when you submit it! Enclose the electronic receipt showing ~~,f~(f~"'"
the Wage File ID (WFID) as proof of filing. "",c,

3. () The Form W-2 amounts I reported earlier are incorrect. (Enclose

Copy A of paper Forms W -2c and W -3c and attach legible paper
copies of the corrected tax report if filed with the IRS.)
4. () The Form W-2 amounts I reported earlier are correct. I incorrectly
reported wage totals to the IRS. (Attach legible paper copies of the
corrected tax report filed with the IRS.)
5. () The difference is due to sick pay from a third party. (Attach an
explanation that shows the name and EIN of the third party and
the dollar amounts involved.)
6.:P<I: I cannot explain the difference between SSA and the IRS records.
(Attach legible copies of paper Forms W-2 and W-3 and the tax
reports filed with the IRS.) 1\1~C4.-VY\a<..>V")-t-.f
:I' (e;.f6~O-Vc ,.co'(\(ect.

7. () I reported the same correct wage amounts to the IRS that I

reported to SSA. However, the IRS amounts shown above are
- - incorrect. (Attach legible paper copies of the tax reports filed with
the IRS.)
8. () Other

~~ IJ, ~le... ( t;;1'?» J-"/ofp5" -Lf :?Jl.?4

Your Name and Title Daytime Phone, with area code

SSA-97-SM (04-11)

IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
431219365-12-110113

-
 111111
Form W -2 Wage and Tax Statement 2012 OMB No. 1545-0008 De artment of the Treasu -- InternalRevenueService
a Employee's social security No. Cop~ 8-To Be Filed with Employee's FEDERAL Tax Return. 1 Wages, tips, other Compo 2 Federal income tax withheld
497-52 -1085 This InformationISbeing furnished to the Internal RevenueService $1,865.78 $0.00
c Employer'sname, address, and ZIP code b Employer 1.0.number 3 Social securitywages 4 Social securitytax withheld
BARBARA N. HALE
821 OAK KNOLL RD.
43-1219365 $1 766.00
,.
$74 17
ROLLA, MO 65401 d Control number 5 Medicare wages and tips 6 Medicaretaxwithheld
$1,766.00 $25.61
7 Social security tips 8 Allocated tips 9
$0.00 $0.00
. Employee's
first,initial, and last names, and suffix 10 Dependentcare benefits 11 Nonqualifiedplans 13 Stat Retirement 3rd-party
VEDA J. NEIDERT $0.00 $0.00 EOI Rian slc[jay
33240 CO. RD. 6330 0
LICKING, MO 65542 12a Code See Inst. for box 12 2b Code 14 Other
$0.00 $0.00 $0.00
12c Code 2d Code
f Employee's address and ZIP code I $0.00 I $0.00
15 Slate Employer'sstateIDNo. 19 Localincometax
MO 8873190161881 $0.00
$0.00

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Form W -2 Wage and Tax Statement 2012 OMB No. 1545-0008 Departmentof the Treasury --Internal RevenueService
a Employee's social security No. Copy C For EMPLOYEE'SRecords (See Noticeto Employeeon the back of Copy B.) 1 Wages, tips, other Compo 2 Federal income tax withheld
497-52-1085 This informationis being furnished to the Internal RevenueService. $1,865.78 $0.00
c Emptoyer'sname, address, and ZIP code b Employer 1.0.number 3 Social securitywages 4 Social securitytax withheld
BARBARA N. HALE 43-1219365 $1,766.00 $74.17 .
821 OAK KNOLL RD. d Control number 5 Medicarewages and tips 6 Medicaretax withheld
ROLLA, MO 65401 $1,766.00 $25.61
7 Social securitytips 8 Allocatedtips 9
$0.00 $0.00
. Employee'sfirst, initial, and last names, and suffix 10 Dependentcare benefits 11 Nonqualifiedplans 13 t;i Ret~I..~ent l\~~'r1::
VEDA J. NEIDERT $0.00 $0.00 u 0 U
33240 CO. RD. 6330 12a Code Seelnst.forbox12 14 Other
LICKING, MO 65542 $0.00 $0.00 $0.00

12c Code $0.00

f Employee'saddress and ZIP code I I $0.00
Employer's slate ID No.
8873190161881 .
ired to file e tax return, a negligence

.
t:. :. -

~ a Controlnumber For official use only

OMB No. 1545-0008

b Kind of payer Kind of employer Third-party 1 Wages, tips, other compensation 2 Federal income lax withheld
Household Employer None apply sick PE $7,413.46 $0.00
U 3 Social securitywages 4 Social security tax withheld
$7,017.00 $294.71
c Total numberof FormsW-2 d Establishmentnumber 5 Medicarewages and tips 6 Medicarelax withheld
2 $7,017.00 $101.75
e Employer identificationnumber 7 Social security tips 8 Allocatedtips
43-1219365 $0.00 $0.00
f Employer'sname 9 10 Dependentcare benefits
..~~~.~~.~~ $0.00
821 OAK KNOLL RD. 11 Nonqualified plans 2a Deferred compensation
ROLLA, MO 65401 $0.00
13 For third-partysick pay use only 12b

14 Incomelax withheld by payer of third-partysick pay

9 Employer'saddress and ZIP code
h OtherEINusedthis year

$0.00
18 Local wages, tips, etc.
$0.00
Telephone number For official use only
BARBARA HALE 573-341-4795
E-mail address Fax number
BHALE@MST.EDU 573-341-4715
Underpenaltiesof perjury,I declarethat I haveexaminedthis returnandaccompanying
documents,and,to the bestof my knowledgeandbelief,theyaretrue,correct,andcomplete.

YOUR COpy
Signature Title Date

Form
W -3 .
Transmittal of Wage and Tax Statements 2012 Department of the Treasury
Internal Revenue Service

Purpose
A of Form
Form W-3 Transmittal is completed only when 11111111
. ' I

paper Copy A of Form(s) W-2, Wage and Tax . ..'.',

Statement, are being filed. Do not file Form W-3

alone. Do not file Form W-3 for Form(s) W-2 that .'
~
.
~
. ~
were submitted electronically to the Social Security
Administration (see below).

For employer records only!

Do not send this form to the Social Security Administration.

he information contained on this form was not submitted to the Social Security Administration.

For Privacy Act and Paperwork Reduction Act Notice, see the 2012 Instructions for Forms W-2 and W-3.