John Post, age 45, is single and resides at 123 Main Street, West Haven, CT 06516. His social security number is 123-45-6788. John has two children, Alec (age 17) and Grace (age 8), and their social security #s are 049-52-5472 and 045-23-5432 respectively. Johns mother, Donna Post (age 70, social security #048-68-5874) lives at 50 Benton Street, West Haven, CT. Donna receives Social Security income of $11,000 per year and $9,000 in part-time wages. John pays ABC Afterschool Care (EIN: 01-123456) $100 per week to watch Grace after school (40 weeks). John does not want to designate $3 to the Presidential Election Campaign fund.

Due to the loss of his wife, John decided that he should work from home. In December of 2018, he retired from his job as a Waterbury police officer and started his own security company on January 1, 2019. He continued to work part-time for the Police Department in 2019. His W-2 from the Waterbury Police Department (EIN 06-1234567) reported the following: wages $18,000, federal income taxes withheld $4,500, and Connecticut income taxes withheld $2,000. WPD withheld the proper amounts of social security and medicare taxes from Johns pay during the year. John was not a participant in WPDs retirement plan.

22222 Void a Employee's social security number For Official Use Only OMB No. 1545-0008 b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 7 Social security tips 8 Allocated tips d Control number 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12 Statutory Retirement Third-party employee 14 Other f Employee's address and ZIP 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 2019 Department of the Treasury-Internal Revenue Service Wage and Tax Statement Form For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Copy A For Social Security Administration - Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable. Cat. No. 10134D Do Not Cut, Fold, or Staple Forms on This Page