2023 W-2 and EARNINGS SUMMARY
Employee Reference Copy W-2 SUMMARY: FEDERAL (BOX 01) SOCSEC (BOX 03) MEDICARE(BOX 05)
************ --------------- --------------- ----------------
Wage and Tax
W-2 Statement
Copy C for employee’s records.
2023
OMB No. 1545-0008
TOTAL GROSS YTD $25,225.10 $25,225.10 $25,225.10
d Control number Dept. Corp. Employer use only LESS PRE-TAX DEDUCTIONS
0000004152 VVN 033100 ATC0 51668
REPORTED ON W-2 $25,225.10
c Employer’s name, address, and ZIP code $25,225.10 $25,225.10
AMPAC TRI-STATE CDC, INC. 215
3110 B, INLAND EMPIRE BLVD,
ONTARIO, CA 91764
e/f Employee’s name, address, and ZIP code
RAFAEL GONZALEZ
183 Myrtle Ave,
Staten Island, NY
10310
b Employer’s FED ID number a Employee’s SSA number
04-8915223 XXX-XX-4846
1 Wages, tips, other comp. 2 Federal income tax withheld
25225.10 1255.19
3 Social security wages 4 Social security tax withheld
25225.10 1317.00
5 Medicare wages and tips 6 Medicare tax withheld
25225.10 325.12
7 Social security tips 8 Allocated tips
9 10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12
14 Other 46.26 FLI 12b RAFAEL Social Security Number: XXX-XX-4846
46.26 NJ SDI
140.42 UI/HC/WD
12c GONZALEZ
183 Myrtle Ave,
12d
13 Stat emp. Ret. plan 3rd party sick pay
Staten Island, NY
15 State Employer’s state ID no. 16 State wages, tips, etc.
10310
NY 042-103-460/000 25225.10
17 State income tax 18 Local wages, tips, etc.
597.30
19 Local income tax 20 Locality name ¤ 2023 ADP, Inc.
PAGE 01 OF 01
1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld
25225.10 1255.19 25225.10 1255.19 25225.10 1255.19
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
25225.10 1317.00 25225.10 1317.00 25225.10 1317.00
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
25225.10 325.12 25225.10 325.12 25225.10 325.12
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
0000004152 VVN 033100 ATC0 51668 0000004152 VVN 033100 ATC0 51668 0000004152 VVN 033100 ATC0 51668
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
AMPAC TRI-STATE CDC, INC. 215 AMPAC TRI-STATE CDC, INC. 215 AMPAC TRI-STATE CDC, INC. 215
3110 B, INLAND EMPIRE BLVD, 3110 B, INLAND EMPIRE BLVD, 3110 B, INLAND EMPIRE BLVD,
ONTARIO, CA 91764 ONTARIO, CA 91764 ONTARIO, CA 91764
b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA Number
04-8915223 XXX-XX-4846 04-8915223 XXX-XX-4846 04-8915223 XXX-XX-4846
7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips
9 10 Dependent care benefits 9 10 Dependent care benefits 9 10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12 11 Nonqualified plans 12a
12 11 Nonqualified plans 12a
14 Other 46.26 FLI 12b 14 Other 46.26 FLI 12b 14 Other 46.26 FLI 12b
46.26 NJ SDI 46.26 NJ SDI 46.26 NJ SDI
140.42 UI/HC/WD 12c 140.42 UI/HC/WD 12c 140.42 UI/HC/WD 12c
12d 12d 12d
13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay 13 Stat emp. Ret. plan 3rd party sick pay
e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code
RAFAEL RAFAEL RAFAEL
GONZALEZ GONZALEZ GONZALEZ
183 Myrtle Ave, 183 Myrtle Ave, 183 Myrtle Ave,
Staten Island, NY Staten Island, NY Staten Island, NY
10310 10310 10310
15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc.
NY 042-103-460/000 25225.10 NY 042-103-460/000 25225.10 NY 042-103-460/000 25225.10
17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.
597.30 597.30 597.30
19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name
Federal Filing Copy NJ. State Filing Copy City or Local Filing Copy
Wage and Tax Wage and Tax Wage and Tax
W-2 Statement 2023
OMB No. 1545-0008
Copy B to be filed with employee’s Federal Income Tax Return.
W-2 Statement 2023
OMB No. 1545-0008
Copy 2 to be filed with employee’s State Income Tax Return.
W-2 Statement OMB
2023 No. 1545-0008
Copy 2 to be filed with employee’s City or Local Income Tax Return.
