33333
DO NOT STAPLE
For Official Use Onlyâ–º
OMB No. 1545-0008
a Control number
b Kind of Payer (Check one)
941
Military
943
944
Kind of Employer (Check one)
None apply 501c non-govt.
Third-party sick pay (Check if applicable)
CT-1
Hshld. emp.
Medicare govt. emp.
State/local non-501c
State/local 501c Federal govt.
c Total number of Forms W-2
d Establishment number
1 Wages, tips, other compensation
2 Federal income tax withheld
$122,300.00
e Employer identification number (EIN)
33-3333333
3 Social security wages
4 Social security tax withheld
f Employer's name
Shipbuilders of New England
5 Medicare wages and tips
6 Medicare tax withheld
7 Social security tips
8 Allocated tips
9
10 Dependent care benefits
2 Hickory Trail, Pawtucket, RI 02
g Employer's address and ZIP code
11 Nonqualified plans
12a Deferred compensation
$27,500.00
h Other EIN used this year
13 For third-party sick pay use only
12b
15 State
RI
Employer's state ID number
33-3333333
14 Income tax withheld by payer of third-party sick pay
16 State wages, tips, etc.
17 State income tax
18 Local wages, tips, etc.
19 Local income tax
Employer's contact person
Employer's telephone number
For Official Use Only
Molly Richmond
401-555-9929
