Complete the W-3 Form for Belt Buckle Industries (employer identification #88-8888888). The company (located at 435 Georgia Lane, Clifton, NJ 07011) does not use control numbers. Total employee compensation (gross pay) for the year was $527,000, and annual retirement plan contributions totaled $15,200. Federal income tax withholding totaled $73,100 for the year, Of the companys four employees, only one had earnings subject to Social Security tax that did not exceed $137,700 (this employee earned $18,200). New Jersey state earnings subject to income tax withholding were the same as that subject to federal income tax withholding. State income tax withholding totaled $53,000, with no local taxes withheld. The employers New Jersey State ID number is the same as its federal identification number. The form is signed by the CEO of the company, Paul Goldstein (telephone #862-555-0052), and is submitted on the due date for e-filing. The company files Form 941 during the year, and selects none apply in the Kind of Employer section.

Notes:

• There are no rounding differences for Social Security tax or Medicare tax between withheld amounts and those that can be calculated by using the total taxable earnings for the year, and no employee was subject to Additional Medicare Tax during the year.

33333 a Control number b 941 Military 943 | DO NOT STAPLE For Official Use Only OMB No. 1545-0008 944 Kind of Employer (Check one) None apply Kind of Payer (Check ono) 501c non-govt. Third-party sick pay (Check applicable) CT-1 Hshid emp Medicare govt emp State/local non-5010 State/local 5010 Federal govt C Total number of Forms W-2 d Establishment number e Employer identification number (EIN) 1 Wages, tips, other compensation $ 3 Social Security wages $ 5 Medicare wages and tips $ 7 Social Security tips S Employer's name 2 Federal income tax withheld s 4 Social Security tax withheld $ Medicare tax withheld $ 8 Alocated tips $ 10 Dependent care benefits S 12a Deferred compensation $ 12b 9 11 Nonqualified plans Employer's address and ZIP code n Other EIN used this year 13 For third-party sick pay use only 15 State Employer's state ID number 14 Income tax withheld by payer of third-party sick pay 16 State wages, tips, etc $ Employer's contact person 17 State income tax S 18 Local wages, tips, etc S Employer's telephone number 19 Local income tax $ For Ocial Use Only Employer's fax number Employer's email address 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 Title Date 01/31/2021 Signature Paul Goldstein Form W-3 Transmittal of Wage and Tax Statements 20XX Department of the Treasury Internal Revenue Service Departmer Form W-3 Transmittal of Wage and Tax Statements 20XX Internal Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration (SSA). Photocopies are not acceptable. Do not send Form W-3 if you filed electronically with the SSA. Do not send any payment (cashchecks, money orders, etc.) with Forms W-2 and W-3. Reminder Separate instructions See the 20XX General Instructions for Forms W-2 and W-3 for information on completing this form. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the SSA Purpose of Form Complete a Form W-3 Transmittal only when filing paper Copy A of Form(s) W-2, Wage and Tax Statement. Don't file Form W-3 alone. All paper forms must comply with IRS standards and be machine readable. Photocoples are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and When To File Paper Forms Form(s) W-2 show the correct tax year and Employer identification Number (EIN). Make a copy of this form and keep it with Copy D (For Mail Form W-3 with Copy A of Form(s) W-2 by January 31, 20XX. Employer) of Form(s) W-2 for your records. The IRS recommends retaining copies of these forms for four years. Where To File Paper Forms E-Filing Send this entire page with the entire Copy A page of Form(s) W-2 to: The SSA strongly suggests employers report Form W-3 and Forms W-2 Social Security Administration Copy A electronically instead of on paper. The SSA provides two free e-filing options on its Business Services Online (BSO) website: Data Operations Center W-2 Online. Use fill-in Forms to create, save, print, and submit up to Wilkes-Barre, PA 18769-0001 50 Forms W-2 at a time to the SSA Note: If you use "Certified Mail to file, change the ZIP code to File Upload Upload wage files to the SSA you have created using "18769-0002." If you use an IRS-approved private delivery service, add payroll or tax software that formats the files according to the SSA'S Specifications for Filing Forms W-2 Electronically (EFW2) "ATTN: W-2 Process 1150 E. Mountain Dr" to the address and change W-2 Online fill-in forms or file uploads will be on time if submitted by the ZIP code to "18702-7997." See Publication 15 (Circular E). January 31, 20XX. For more information, go to www.SSA gow/bso. First time Employer's Tax Guide, for a list of IRS-approved private delivery filers, select "Register, returning filers select Log In." services For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 10159 33333 a Control number b 941 Military 943 | DO NOT STAPLE For Official Use Only OMB No. 1545-0008 944 Kind of Employer (Check one) None apply Kind of Payer (Check ono) 501c non-govt. Third-party sick pay (Check applicable) CT-1 Hshid emp Medicare govt emp State/local non-5010 State/local 5010 Federal govt C Total number of Forms W-2 d Establishment number e Employer identification number (EIN) 1 Wages, tips, other compensation $ 3 Social Security wages $ 5 Medicare wages and tips $ 7 Social Security tips S Employer's name 2 Federal income tax withheld s 4 Social Security tax withheld $ Medicare tax withheld $ 8 Alocated tips $ 10 Dependent care benefits S 12a Deferred compensation $ 12b 9 11 Nonqualified plans Employer's address and ZIP code n Other EIN used this year 13 For third-party sick pay use only 15 State Employer's state ID number 14 Income tax withheld by payer of third-party sick pay 16 State wages, tips, etc $ Employer's contact person 17 State income tax S 18 Local wages, tips, etc S Employer's telephone number 19 Local income tax $ For Ocial Use Only Employer's fax number Employer's email address 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 Title Date 01/31/2021 Signature Paul Goldstein Form W-3 Transmittal of Wage and Tax Statements 20XX Department of the Treasury Internal Revenue Service Departmer Form W-3 Transmittal of Wage and Tax Statements 20XX Internal Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration (SSA). Photocopies are not acceptable. Do not send Form W-3 if you filed electronically with the SSA. Do not send any payment (cashchecks, money orders, etc.) with Forms W-2 and W-3. Reminder Separate instructions See the 20XX General Instructions for Forms W-2 and W-3 for information on completing this form. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the SSA Purpose of Form Complete a Form W-3 Transmittal only when filing paper Copy A of Form(s) W-2, Wage and Tax Statement. Don't file Form W-3 alone. All paper forms must comply with IRS standards and be machine readable. Photocoples are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and When To File Paper Forms Form(s) W-2 show the correct tax year and Employer identification Number (EIN). Make a copy of this form and keep it with Copy D (For Mail Form W-3 with Copy A of Form(s) W-2 by January 31, 20XX. Employer) of Form(s) W-2 for your records. The IRS recommends retaining copies of these forms for four years. Where To File Paper Forms E-Filing Send this entire page with the entire Copy A page of Form(s) W-2 to: The SSA strongly suggests employers report Form W-3 and Forms W-2 Social Security Administration Copy A electronically instead of on paper. The SSA provides two free e-filing options on its Business Services Online (BSO) website: Data Operations Center W-2 Online. Use fill-in Forms to create, save, print, and submit up to Wilkes-Barre, PA 18769-0001 50 Forms W-2 at a time to the SSA Note: If you use "Certified Mail to file, change the ZIP code to File Upload Upload wage files to the SSA you have created using "18769-0002." If you use an IRS-approved private delivery service, add payroll or tax software that formats the files according to the SSA'S Specifications for Filing Forms W-2 Electronically (EFW2) "ATTN: W-2 Process 1150 E. Mountain Dr" to the address and change W-2 Online fill-in forms or file uploads will be on time if submitted by the ZIP code to "18702-7997." See Publication 15 (Circular E). January 31, 20XX. For more information, go to www.SSA gow/bso. First time Employer's Tax Guide, for a list of IRS-approved private delivery filers, select "Register, returning filers select Log In." services For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 10159