a Employee's social security number 791-51-4335 b Employer identification number (EN) 12-3456789 Employer's name, address, and ZIP code Ivy Technologies, Inc. 436 E. 35 Avenue Gary, IN 46409 d Control number Employee's first name and initial Eric Hayes 555 E. 81st Street Merrillville, IN 46410 Last name Safe, accurate, OMB No. 1545-0008 FAST! Use Visit the IRS website at se file www.irs.gov/efile 1 Wages, tips, other compensation 131,080.00 3 Social security wages 137,700.00 5 Medicare wages and tips 138,380.00 7 Social security tips Suff. 11 Nonqualified plans 13 y 14 Other 2 Federal income tax withheld 15,190.00 4 Social security tax withheld 8,537.40 6 Medicare tax withheld 2,006.51 8 Alocated tips 10 Dependent care benefits 5,000.00 12a See instructions for box 12 DDI 11,567.00 Tadpay 12b C 130.00 120 D| 7,300.00 12d f Employee's address and ZIP code 15 State Employer's state ID number IN 00122231001 16 State wages, tips, etc. 17 State income tax 131,080.00 4,900.00 Form W-2 Wage and Tax Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. 18 Local wages, tips, etc. 19 Local income tax 131,080.00 20 Locally name 927.00 LAKE 2020 Department of the Treasury-Internal Revenue Service