Tax Year 2016
W-2 Wage and Tax Statement
Department of the Treasury — Internal Revenue Service
b Employer identification number (EIN) d Control number Void
Copy B — To Be Filed With Employee's FEDERAL Tax Return This information is being f2urni0she1d to6 the Internal Revenue Service.
c4 E1m-p2lo8ye4r'7s n5a0me1, address, and ZIP code NLT-W2-AUTO a Employee's social securityT nAuXm bYeErAR
Clearwater Tech, Inc.
1800 Technology Parkway, Minneapolis, MN 55441
XXX-XX-4444
e Employee's first name and initial Last name Suf. f Employee's address and ZIP code
Alex Chen 3215 Lakeview Circle, Wayzata, MN 55391
1 Wages, tips, other compensation 2 Federal income tax withheld
$127,000.00 $25,400.00
3 Social security wages 4 Social security tax withheld
$118,500.00 $7,347.00
5 Medicare wages and tips 6 Medicare tax withheld
$145,000.00 $2,102.50
7 Social security tips 8 Allocated tips
10 Dependent care benefits 11 Nonqualified plans
12 See instructions for box 12 13 / 14 Checkboxes and Other
12a 13 Retirement plan
3
D $18,000.00
1125b State Employer's state ID number 16 State wages, tip1s,4 e tOc.ther 17 State income tax
W $1,200.00
MN MN-412847501 $127,000.00 $8,100.00
18 Local wages, tips, etc. 19 Local income tax 20 Locality name
Form W-2 Wage and Tax Statement 2016 | Employer: Clearwater Tech, Inc. (EIN 41-2847501) | Employee SSN: XXX-XX-4444 | Synthetic demo data only — not for tax filing purposes
