413B.

Wage and Tax Statement

(a)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-4310

Void

b Employer identification number (EIN)

00-0000972

Wages, tips, other compensation

34,580.00

c Employers name, address, and ZIP code

Social security wages

Medicare wages and tips

Social security tips

37,180.00

Omni Corporation
4800 River Road
Philadelphia, PA

Last name

Nonqualified plans

Allocated tips

2,305.16
539.24

Dependent care benefits

See instructions for box 12

12a

Code
13 Statutory
employee

54 Gradison Place
Philadelphia, PA 19113-4054

Medicare tax withheld

$
11

Suff.

Kellison

3,172.00

10

Randy A.

Social security tax withheld

$
9

e Employees first name and initial

$
d Control number

Federal income tax withheld

37,180.00

19113-5548

Retirement
plan

Third-party
sick pay

$ 2,600.00

12b

Code

X
14

12c

Other

Code
12d

f
Employees address and ZIP code
15 State
Employers state ID number
16

PA

00-0-1066

W-2

$
$

State wages, tips, etc.

17

$
$

37,180.00

Wage and Tax

Statement

State income tax

18

Local wages, tips, etc.

Code
$
19
Local income tax

1,141.40 $ 37,180.00 $
$

20

Locality name

PHILA

1,457.56

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

201-

(b)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-8804

Void

b Employer identification number (EIN)

00-0000972
c Employers name, address, and ZIP code

Social security wages

Medicare wages and tips

Social security tips

Omni Corporation
4800 River Road
Philadelphia, PA

19113-5548

Wages, tips, other compensation

47,580.00

51,220.00

51,220.00

Vince T.

Last name

Roper

Nonqualified plans

Medicare tax withheld

Allocated tips

3,120.00
3,175.64
742.56
Dependent care benefits

950.00

Code
13 Statutory
employee

Retirement
plan

Third-party
sick pay

$ 3,648.00

12b
Code

X
14

See instructions for box 12

12a

56 Andrews Court, Apt. 7

Philadelphia, PA 19103-3356

Social security tax withheld

$
11

Suff.

10

$
e Employees first name and initial

Federal income tax withheld

$
9

d Control number

12c

Other

Code

12d
f
Employees address and ZIP code
15 State
Employers state ID number
16

PA

00-0-1066

W-2

$
$

State wages, tips, etc.

51,220.00

Wage and Tax

Statement

17

State income tax

$ 1,572.48
$

201-

18

$
$

Local wages, tips, etc.

Code
$
19
Local income tax

51,220.00 $ 2,007.72

20

Locality name

PHILA

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

413B. (Continued)
(c)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-3316

Void

b Employer identification number (EIN)

00-0000972

Wages, tips, other compensation

Social security wages

Medicare wages and tips

Social security tips

Advance EIC payment

c Employers name, address, and ZIP code

39,780.00

19113-5548

Last name

Murray T.

Rodson

Nonqualified plans

Third-party
sick pay

W-2

See instructions for box 12

$
$

Code
12c

14

Other

39,780.00

17

State income tax

18

$ 1,221.48
$

Wage and Tax

Statement

Code
12d

1 0 2
State wages, tips, etc.

$
$

Dependent care benefits

12b

UNION DUES

00-0-1066

576.68

12a

Retirement
plan

employee

PA

Allocated tips

Code
13 Statutory

f
Employees address and ZIP code
15 State
Employers state ID number
16

2,466.36

10

770 Carnac Street

Philadelphia, PA 19101-3770

Medicare tax withheld

$
11

Suff.

5,148.00

$
e Employees first name and initial

Social security tax withheld

$
d Control number

39,780.00

Federal income tax withheld

39,780.00

Omni Corporation
4800 River Road
Philadelphia, PA

Local wages, tips, etc.

$ 39,780.00
$

Code
$
19
Local income tax

20

Locality name

PHILA

$ 1,559.48
$

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

201-

(d)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-6839

Void

b Employer identification number (EIN)

00-0000972

Wages, tips, other compensation

92,562.75

c Employers name, address, and ZIP code

Social security wages

Medicare wages and tips

Social security tips

Advance EIC payment

97,762.75

Omni Corporation
4800 River Road
Philadelphia, PA

Frank A.

Last name

Kent

Medicare tax withheld

Allocated tips

6,061.29

1,417.69

10

Nonqualified plans

Dependent care benefits

Code
13 Statutory
employee

Retirement
plan

Third-party
sick pay

12b
Code D

X
14

See instructions for box 12

12a

338 North Side Avenue

Philadelphia, PA 19130-6638

5,501.60

$
11

Suff.

Social security tax withheld

$
e Employees first name and initial

$
d Control number

Federal income tax withheld

97,762.75

19113-5548

$ 262.75
$ 5,200.00

12c

Other

Code

12d
f
Employees address and ZIP code
15 State
Employers state ID number
16

PA

00-0-1066

W-2

$
$

State wages, tips, etc.

97,500.00

Wage and Tax

Statement

17

State income tax

18

Local wages, tips, etc.

$ 2,993.12 $ 97,500.00
$
$

201-

Code
$
19
Local income tax

$ 3,822.00
$

20

Locality name

PHILA

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

*Including cost of C, Group-Term Life Insurance, reported and included in Boxes 1, 3, and 5.

413B. (Continued)
(e)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-5771

Void

b Employer identification number (EIN)

00-0000972

Wages, tips, other compensation

Social security wages

Medicare wages and tips

Social security tips

Advance EIC payment

40,560.00

c Employers name, address, and ZIP code

Last name

Carlie C.

Nonqualified plans

Third-party
sick pay

W-2

See instructions for box 12

$
$

Code
12c

14

Other

40,560.00

17

Code
12d

102 . 0 0
State wages, tips, etc.

$
$

Dependent care benefits

12b

UNION DUES

00-0-1066

588.12

12a

Retirement
plan

employee

PA

Allocated tips

Code
13 Statutory

f
Employees address and ZIP code
15 State
Employers state ID number
16

2,514.72

10

4900 Gladwynne Terrace

Philadelphia, PA 19127-0049

Medicare tax withheld

$
11

Suff.

Christian

1,248.00

$
e Employees first name and initial

Social security tax withheld

$
d Control number

40,560.00

19113-5548

Federal income tax withheld

40,560.00

Omni Corporation
4800 River Road
Philadelphia, PA

State income tax

18

Local wages, tips, etc.

Code
$
19
Local income tax

$ 1,245.40 $ 40,560.00 $ 1,590.16

$
$
$

Wage and Tax

Statement

20

Locality name

PHILA

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

201-

(f)
22222

For Official Use Only

OMB No. 1 545-0008

a Employees social security number

000-00-8703

Void

b Employer identification number (EIN)

00-0000972

3
5

Medicare wages and tips

Zana W.

Last name

Amelia

Social security tips

Advance EIC payment

10

PA

00-0-1066

W-2

$
$

Nonqualified plans

Code
Retirement
plan

Wage and Tax

Statement

Third-party
sick pay

17

$
$

Code

Code

1261.00

201-

$ 2600.00
$

12c

Other

State income tax

12b

X
14

See instructions for box 12

12a

EDUC. ASSIST
675.00

41080.00

Dependent care benefits

employee

State wages, tips, etc.

Allocated tips

13 Statutory

f
Employees address and ZIP code
15 State
Employers state ID number
16

595.92
8

480-A Hopkinson Tower

Philadelphia, PA 19101-3301

Medicare tax withheld

11

Suff.

2546.96
6

$
e Employees first name and initial

Social security tax withheld

$
d Control number

4420.00
4

41080.00

19113-5548

Federal income tax withheld

Social security wages

41080.00

Omni Corporation
4800 River Road
Philadelphia, PA

38480.00

c Employers name, address, and ZIP code

Wages, tips, other compensation

18

$
$

Local wages, tips, etc.

41080.00

12d
Code
$
19
Local income tax

$
$

1612.00

20

Locality name

PHILA

Department of the TreasuryInternal Revenue Service

For Privacy Act and Paperwork
Reduction Act Notice, see back of Copy D.

413B. (Concluded)
DO NOT STAPLE OR FOLD

941

Kind
Of
Payer
c

For Official Use Only 4

OMB No. 1545-0008

a Control number

33333

CT-1

Military

943

944

1 Wages, tips, other compensation

$
Hshld. Medicare
emp. govt. emp.

Total number of Forms W-2

Third-party
sick pay

d Establishment number

6 Medicare tax withheld

307,582.75
7 Social security tips

Employer identification number (EIN)

$
10 Dependent care benefits

OMNI CORPORATION
4800 RIVER ROAD
PHILADELPHIA, PA
19113-5548

4,460.21
8 Allocated tips

9 Advance EIC payments

Employers name

19,070.13

307,582.75

22,609.60
4 Social security tax withheld

5 Medicare wages and tips

00-0000972
f

2 Federal income tax withheld

3 Social security wages

6
e

293,543.75

950.00

11 Nonqualified plans

12 Deferred compensation

14,048.00

13 For third-party sick pay use only

14 Income tax withheld by payer of third-party sick pay

g

Employers address and ZIP code

Other EIN used this year

15 State

Employers state I.D. number

PA

00-0-1066

16

17

State income tax

307,320.00

9,434.88

307,320.00

State wages, tips, etc.

18 Local wages, tips, etc.

$
Contact person

19 Local income tax

Telephone number

VINCENT T. ROPER
E-mail address

12,048.92
For Official Use Only

(215) 555-0017
Fax number

N/A

(215) 555-0010

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.
Signature 4

Form

W-3

Frank A. Kent

Title 4

President

Transmittal of Wage and Tax Statements

Date 4

201--

11/13/16
Department of the Treasury
Internal Revenue Service