Fom 1040 (2021) Page 2 SCHEDULE 1 Additional Income and Adiustments to Income OMBNo.1545-0074 Part II Adjustments to Income Part II Other Taxes For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 3 (Form 1040) 2021 Page 2 c. Employer's name, address and ZIP code Carter's Restaurant 1449 Country View Road Your City, Your State - Your ZIP \begin{tabular}{|l|l|} \hline b Employer's FED ID number 633305332 \\ \hline 7 Social security tips \\ \hline 9 \\ \hline 11 Nonqualified plans \\ \hline 14 Other \\ \hline \end{tabular} Marsha Brown 100 Muncie Blvd. Your City, Your State - Your ZIP \begin{tabular}{|c|l|l|} \hline 15 State YS & Employer's state ID no 633305332 & 16 State wages, tips, etc. \\ \hline 17 State & 451.01 & 18 Local Wages, tips, etc. \\ \hline 19 Local income tax & 20273.12 \\ \hline \end{tabular} Federal Filing Copy N=2 Wage and Tax OMB No. 1545-0008 CORRECTED (if checked) Form 1099-G (keep for your records) WWw.irs.goviform 1099g Department of the Treasury - Internal Revenue Service Fom 1040 (2021) Page 2 SCHEDULE 1 Additional Income and Adiustments to Income OMBNo.1545-0074 Part II Adjustments to Income Part II Other Taxes For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 3 (Form 1040) 2021 Page 2 c. Employer's name, address and ZIP code Carter's Restaurant 1449 Country View Road Your City, Your State - Your ZIP \begin{tabular}{|l|l|} \hline b Employer's FED ID number 633305332 \\ \hline 7 Social security tips \\ \hline 9 \\ \hline 11 Nonqualified plans \\ \hline 14 Other \\ \hline \end{tabular} Marsha Brown 100 Muncie Blvd. Your City, Your State - Your ZIP \begin{tabular}{|c|l|l|} \hline 15 State YS & Employer's state ID no 633305332 & 16 State wages, tips, etc. \\ \hline 17 State & 451.01 & 18 Local Wages, tips, etc. \\ \hline 19 Local income tax & 20273.12 \\ \hline \end{tabular} Federal Filing Copy N=2 Wage and Tax OMB No. 1545-0008 CORRECTED (if checked) Form 1099-G (keep for your records) WWw.irs.goviform 1099g Department of the Treasury - Internal Revenue Service