Copy B - To Be Filed With Employee's Copy 2 - To Be Filed With Employee's State

FEDERAL Tax Return. 2021 OMB No

1545-0008 City, or Local Income Tax Return. 2021 OMB No
1545-0008
a Employee's social 1 Wages, tips, other comp 2 Federal income tax withheld a Employee's social 1 Wages, tips, other comp 2 Federal income tax withheld
security number 125115.09 16679.11 security number 16679.11
125115.09
120-74-1676 3 Social security wages 4 Social security tax withheld 120-74-1676 3 Social security wages 4 Social security tax withheld
b Employer ID number 135515.09 8401.95 b Employer ID number 135515.09 8401.95
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
11-6002971 135515.09 1964.95 11-6002971 135515.09 1964.95
c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code

HALF HOLLOW HILLS CSD HALF HOLLOW HILLS CSD

525 HALF HOLLOW ROAD 525 HALF HOLLOW ROAD
DIX HILLS, NY 11746 DIX HILLS, NY 11746

d Control number d Control number

6003 OTSEGO ELEM SCHOOL/024 6003 OTSEGO ELEM SCHOOL/024
e Employee's name, address, and ZIP code e Employee's name, address, and ZIP code

CARRIE MC CABE CARRIE MC CABE

1 PENSDALE COURT 1 PENSDALE COURT
STONEYBROOK, NY 11790 STONEYBROOK, NY 11790

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code See inst for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code See inst for box 12
C 387.90 C 387.90
13 Stat employee 14 Other 12b Code 13 Stat employee 14 Other 12b Code
FLEX 464.24 E 10400.00 FLEX 464.24 E 10400.00
Retirement Plan 12c Code Retirement Plan 12c Code
X X
Third-party sick pay 12d Code Third-party sick pay 12d Code

NY 116002971 125115.09 7195.85 NY 116002971 125115.09 7195.85

15 State Employer's state ID no 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID no 16 State wages, tips, etc. 17 State income tax
18 Local wages, tips, ect. 19 Local income tax 20 Locality name 18 Local wages, tips, ect. 19 Local income tax 20 Locality name

Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS
Copy C - For EMPLOYEE'S RECORDS Copy 2 - To Be Filed With Employee's State
(See Notice To Employee.) 2021 OMB No
1545-0008 City, or Local Income Tax Return. 2021 OMB No
1545-0008
a Employee's social 1 Wages, tips, other comp 2 Federal income tax withheld a Employee's social 1 Wages, tips, other comp 2 Federal income tax withheld
security number
125115.09 16679.11 security number 125115.09 16679.11
120-74-1676 3 Social security wages 4 Social security tax withheld 120-74-1676 3 Social security wages 4 Social security tax withheld
b Employer ID number 135515.09 8401.95 b Employer ID number 135515.09 8401.95
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
11-6002971 135515.09 1964.95 11-6002971 135515.09 1964.95
c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code
HALF HOLLOW HILLS CSD HALF HOLLOW HILLS CSD
525 HALF HOLLOW ROAD 525 HALF HOLLOW ROAD
DIX HILLS, NY 11746 DIX HILLS, NY 11746

d Control number d Control number

6003 OTSEGO ELEM SCHOOL/024 6003 OTSEGO ELEM SCHOOL/024
e Employee's name, address, and ZIP code e Employee's name, address, and ZIP code
CARRIE MC CABE CARRIE MC CABE
1 PENSDALE COURT 1 PENSDALE COURT
STONEYBROOK, NY 11790 STONEYBROOK, NY 11790

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code See inst for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code See inst for box 12
C 387.90 C 387.90
13 Stat employee 14 Other 12b Code 13 Stat employee 14 Other 12b Code
E 10400.00 FLEX 464.24 E 10400.00
FLEX 464.24
Retirement Plan 12c Code Retirement Plan 12c Code
X X
Third-party sick pay 12d Code Third-party sick pay 12d Code

NY 116002971 125115.09 7195.85 NY 116002971 125115.09 7195.85

15 State Employer's state ID no 16 State wages, tips, etc. 17 State income tax 15 State Employer's state ID no 16 State wages, tips, etc. 17 State income tax
18 Local wages, tips, ect. 19 Local income tax 20 Locality name 18 Local wages, tips, ect. 19 Local income tax 20 Locality name

Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS Form W-2 Wage and Tax Statement Dept. of the Treasury -- IRS
ATU
HALF HOLLOW HILLS CSD
525 HALF HOLLOW ROAD
DIX HILLS, NY 11746

OTSEGO ELEM SCHOOL/024

CARRIE MC CABE
1 PENSDALE COURT
STONEYBROOK, NY 11790