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I a Employee's social security number This information is being fumished to the Internal Revenue Service.

II yoU{
are required to file a tax retum, a negligence penalty or other sanction I
091743286 OMB No. 1545-0008 may be imposed on you if this income is taxable and you fail to report it. ,;
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
26-4223118 $67,089.56 $9112.09
e Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
BROOKLYN HIT FACTORM LLC $65700.62 $5491.80
183 LEFFERTS AVENUE 5 Medicare wages and tips 6 Medicare tax withheld
BROOKLYN, NY 11225 $3675.44
7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits


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e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
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AHMED JEROME
105 LEFFERTS PLACE 13 Statutory Retirement ThIrd-party
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12b
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ernplcyee plan sick pay
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BROOKLYN, NY 11238
14 Other
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12c
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d
e
12d
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f Employee's address and ZIP code ,"' F",,;;' " •.
15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages. tips, etc. 19 Local income tax 20 Localityname

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$67,089.56 $4462.90 $1900.89 $1900.89
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NYC
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I
Department of the Treasury-Intemal Revenue Service
Wage and Tax
Form W2 - Statement 2011 Safe, accurate
FASTIUse
6~
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Copy C-For EMPLOYEE'S RECORDS (See Notice to
Employee on the back of Copy B.)