a Employee's social security number For Official Use Only 22222 Void o OMB No. 1545-0008 b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld $ 3 Social security wages 4 Social security tax withheld Employer's name, address, and ZIP code 5 Medicare wages and tips 6 Medicare tax withheld Quigley Corporation 4800 River Road Philadelphia, PA 19113-5548 7 Social security tips 8 Allocated tips 10 Dependent care benefits d Control number 9 Verification code $ Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See Instructions for box 12 Randi A. Myer 13 None v Code 12b 770 Camac Street Code 14 Other Philadelphia, PA 19101-3770 Code PA SUI 27.56, Union Dues 102.00 Y 12d f Employee's address and ZIP code Code 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 Locality name PAY Phila. v