Philcon Corporation (P.O. Box 4563, Anchorage, AK 99508; EIN 12-3456789) paid Louise Chugach, an employee who lives at 5471 East Tudor Road, Anchorage, AK 99508, wages of $124,554 in 2016. The income tax withholding for the year amounted to $16,050.40, and the FICA tax withheld was based on 2016 rates. There is no difference between Louise's FICA wages and those reported in Box 1 of the W-2. Her Social Security number is 545-64-7745.

Enter all amounts as positive numbers. If required, round your answers to two decimal places.

a. Complete Form W-2 for Louise Chugach from Philcon Corporation. If required, round your answers to two decimal places.