Copy B - For Employee's Federal Income Tax Return

2021 OMB No.

1545-0008
Copy 2 - For Employee's State Income Tax Return
[FL] 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 13979.28 1056.24 security number 13979.28 1056.24
497-59-6010 3 Social security wages 4 Social security tax withheld 497-59-6010 3 Social security wages 4 Social security tax withheld
b Employer ID number 13979.28 866.72 b Employer ID number 13979.28 866.72
81-4779752 5 Medicare wages and tips 6 Medicare tax withheld 81-4779752 5 Medicare wages and tips 6 Medicare tax withheld
13979.28 202.70 13979.28 202.70
c Employer's name, address, and ZIP code c Employer's name, address, and ZIP code
Lewis Property Services Inc Lewis Property Services Inc
155 Railroad Plz 155 Railroad Plz
Royersford, PA 19468 Royersford, PA 19468

d Control number d Control number

119789 185 119789 185
e Employee's name, address, and ZIP code e Employee's name, address, and ZIP code
Marcos Nolasco Ramirez Marcos Nolasco Ramirez
6505 Precourt Dr 6505 Precourt Dr
Orlando, FL 32809-6444 Orlando, FL 32809-6444

7 Social security tips 8 Allocated tips 9 Advance EIC payment 7 Social security tips 8 Allocated tips 9 Advance EIC payment

10 Dependent care benefits 11 Nonqualified plans 10 Dependent care benefits 11 Nonqualified plans

12a 13 Statutory employee Retirement plan 3rd-party sick pay 12a 13 Statutory employee Retirement plan 3rd-party sick pay

12b 12b
14 Other 14 Other
12c 12c

12d 12d

N/A N/A N/A FL NOT NEEDED 13979.28

15 State Employer's State ID# 16 State wages, tips, etc. 17 State income tax 15 State Employer's State ID# 16 State wages, tips, etc. 17 State income tax
18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

N/A N/A N/A N/A N/A N/A

Form W-2 Wage and Tax Statement Dept. of the Treasury - IRS Form W-2 Wage and Tax Statement Dept. of the Treasury - IRS
This information is being furnished to the Internal Revenue Service

This information is being furnished to the IRS. If you are required to file a tax return, a negligence penalty/other sanction Printed by Paylocity Payroll
may be imposed on you if this income is taxable and you fail to report it. Page 1 of 2
 Copy C - FOR EMPLOYEE'S RECORDS ONLY 2021 OMB No.
1545-0008
a Employee's social 1 Wages, tips, other comp. 2 Federal income tax withheld
security number 13979.28 1056.24
497-59-6010 3 Social security wages 4 Social security tax withheld
b Employer ID number 13979.28 866.72
81-4779752 5 Medicare wages and tips 6 Medicare tax withheld
13979.28 202.70
c Employer's name, address, and ZIP code
Lewis Property Services Inc
155 Railroad Plz
Royersford, PA 19468

d Control number
119789 185
e Employee's name, address, and ZIP code
Marcos Nolasco Ramirez
6505 Precourt Dr
Orlando, FL 32809-6444

7 Social security tips 8 Allocated tips 9 Advance EIC payment

10 Dependent care benefits 11 Nonqualified plans

12a 13 Statutory employee Retirement plan 3rd-party sick pay

12b
14 Other
12c

12d

FL NOT NEEDED 13979.28

15 State Employer's State ID# 16 State wages, tips, etc. 17 State income tax
18 Local wages, tips, etc. 19 Local income tax 20 Locality name

N/A N/A N/A

Form W-2 Wage and Tax Statement Dept. of the Treasury - IRS

This information is being furnished to the IRS. If you are required to file a tax return, a negligence penalty/other sanction Printed by Paylocity Payroll
may be imposed on you if this income is taxable and you fail to report it. Page 2 of 2