OMB No. 1545-0008 REISSUED STATEMENT OMB No.

1545-0008 REISSUED STATEMENT

d Control Number 1 Wages, tips, other compensation 2 Federal income tax withheld d Control Number 1 Wages, tips, other compensation 2 Federal income tax withheld

6086.94 292.10 6086.94 292.10

b Employer identification number (EIN) 3 Social security wages 4 Social security tax withheld b Employer identification number (EIN) 3 Social security wages 4 Social security tax withheld

93-0994537 6086.94 377.39 93-0994537 6086.94 377.39

a Employee’s social security number 5 Medicare wages and tips 6 Medicare tax withheld a Employee’s social security number 5 Medicare wages and tips 6 Medicare tax withheld

624-42-0553 6086.94 88.26 624-42-0553 6086.94 88.26

c Employer’s name, address and ZIP code c Employer’s name, address and ZIP code
KOOSHAREM, LLC AS AGENT FOR KOOSHAREM, LLC AS AGENT FOR
3820 STATE STREET 3820 STATE STREET
REAL TIME STAFFING SERVICES REAL TIME STAFFING SERVICES
SANTA BARBARA CA 93105 SANTA BARBARA CA 93105

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a 10 Dependent care benefits 11 Nonqualified plans 12a

Code

Code
12b 12c 12d 12b 12c 12d
Code

Code
Code

Code
Code

Code
13 Statutory Retirement Third-party 14 Other 13 Statutory Retirement Third-party 14 Other
employee plan sick pay employee plan sick pay
CASDI 60.87 CASDI 60.87

e Employee’s name, address and ZIP code e Employee’s name, address and ZIP code
JONATHAN A LUGO JONATHAN A LUGO
APT P APT P
14354 AMAR RD 14354 AMAR RD
LA PUENTE CA 91744 LA PUENTE CA 91744

2014 2014
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 15 State Employer’s state I.D. no. 16 State wages, tips, etc.

CA 45664323 6086.94 CA 45664323 6086.94

W-2 W-2
Form

Form
Wage and Tax Statement 17 State income tax 18 Local wages, tips, etc. Wage and Tax Statement 17 State income tax 18 Local wages, tips, etc.

Copy C For EMPLOYEE’S 34.91 Copy B To Be Filed With 34.91

RECORDS (See Notice to Employee’s FEDERAL Tax
Employee on back of Copy B.) Return.
This information is being furnished to the This information is being furnished to the
Internal Revenue Service. If you are required 19 Local income tax 20 Locality name Internal Revenue Service. 19 Local income tax 20 Locality name
to file a tax return, a negligence penalty or
other sanction may be imposed on you if this
income is taxable and you fail to report it.

Department of the Treasury – Department of the Treasury –

Internal Revenue Service Internal Revenue Service

OMB No. 1545-0008 REISSUED STATEMENT OMB No. 1545-0008 REISSUED STATEMENT
d Control Number 1 Wages, tips, other compensation 2 Federal income tax withheld d Control Number 1 Wages, tips, other compensation 2 Federal income tax withheld

6086.94 292.10 6086.94 292.10

b Employer identification number (EIN) 3 Social security wages 4 Social security tax withheld b Employer identification number (EIN) 3 Social security wages 4 Social security tax withheld

93-0994537 6086.94 377.39 93-0994537 6086.94 377.39

a Employee’s social security number 5 Medicare wages and tips 6 Medicare tax withheld a Employee’s social security number 5 Medicare wages and tips 6 Medicare tax withheld

624-42-0553 6086.94 88.26 624-42-0553 6086.94 88.26

c Employer’s name, address and ZIP code c Employer’s name, address and ZIP code
KOOSHAREM, LLC AS AGENT FOR KOOSHAREM, LLC AS AGENT FOR
3820 STATE STREET 3820 STATE STREET
REAL TIME STAFFING SERVICES REAL TIME STAFFING SERVICES
SANTA BARBARA CA 93105 SANTA BARBARA CA 93105

7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a 10 Dependent care benefits 11 Nonqualified plans 12a
Code

Code

12b 12c 12d 12b 12c 12d

Code

Code
Code

Code
Code

Code

13 Statutory Retirement Third-party 14 Other 13 Statutory Retirement Third-party 14 Other

employee plan sick pay employee plan sick pay
CASDI 60.87 CASDI 60.87

e Employee’s name, address and ZIP code e Employee’s name, address and ZIP code
JONATHAN A LUGO JONATHAN A LUGO
APT P APT P
14354 AMAR RD 14354 AMAR RD
LA PUENTE CA 91744 LA PUENTE CA 91744

2014 2014
15 State Employer’s state I.D. no. 16 State wages, tips, etc. 15 State Employer’s state I.D. no. 16 State wages, tips, etc.

CA 45664323 6086.94 CA 45664323 6086.94

Form

W-2
Form

W-2
Wage and Tax Statement 17 State income tax 18 Local wages, tips, etc. Wage and Tax Statement 17 State income tax 18 Local wages, tips, etc.

Copy 2 To Be Filed With 34.91 Copy 2 To Be Filed With 34.91

Employee’s State, City, or Employee’s State, City, or
Local Income Tax Return. Local Income Tax Return.

19 Local income tax 20 Locality name 19 Local income tax 20 Locality name

Department of the Treasury – Department of the Treasury –

Internal Revenue Service Internal Revenue Service
Notice to Employee Instructions for Employee Instructions for Employee (Continued) term life insurance over $50,000 (former employees
Do you have to file? Refer to the form 1040 Box 1. Enter this amount on the wages line of your tax (Continued from the back of copy B.) only). See “Other Taxes” in the Form 1040 instructions.
Instructions to determine if you are required to file a return. Elective deferrals (codes D, E, F, and S) and P-Excludable moving expense reimbursements paid
tax return. Even if you do not have to file a tax return, Box 2. Enter this amount on the federal income tax designated Roth contributions (codes AA, BB, and EE) directly to employee (not included in boxes 1, 3, or 5)
you may be eligible for a refund if box 2 shows an withheld line of your tax return. under all plans are generally limited to a total of Q-Nontaxable combat pay. See the instructions for
amount or if you are eligible for any credit. Earned Box 5. You may be required to report this amount on $17,500 ($12,000 if you only have SIMPLE plans; Form 1040 or Form 1040A for details on reporting this
income credit (EIC). You may be able to take the $20,500 for section 403(b) plans if you qualify for the amount. R-Employer contributions to your Archer MSA.
Form 8959, Additional Medicare Tax. See Form 1040
15-year rule explained in Pub. 571). Deferrals under Report on form 8853, Archer MSAs and Long-Term
EIC for 2014 if your adjusted gross income (AGI) is instructions to determine if you are required to
code G are limited to $17,500. Deferrals under code H Care Insurance Contracts. S-Employee salary
less than a certain amount. The amount of the credit complete Form 8959.
are limited to $7,000. However, if you were at least age reduction contributions under a section 408(p) SIMPLE
is based on income and family size. Workers without Box 6. This amount includes the 1.45% Medicare Tax
50 in 2014, your employer may have allowed an (not included in box 1) T-Adoption benefits (not
children could qualify for a smaller credit. You and withheld on all Medicare wages and tips shown in Box
additional deferral of up to $5,500 ($2,500 for section included in box 1). Complete Form 8839, Qualified
any qualifying children must have valid social security 5, as well as the 0.9% Additional Medicare Tax on any Adoption Expenses, to compute any taxable and
numbers (SSNs). You cannot take the EIC if your of those Medicare wages and tips above $200,000. 401(k)(11) and 408(p) SIMPLE plans). This additional
deferral amount is not subject to the overall limit on nontaxable amounts. V-Income from exercise of
investment income is more than the specified amount Box 8. This amount is not included in boxes 1, 3, 5, or nonstatutory stock option(s) (included in boxes 1, 3 (up
for 2014 or if income is earned for services provided 7. For information on how to report tips on your tax elective deferrals. For code G, the limit on elective
deferrals may be higher for the last 3 years before you to social security wage base), and 5) See Pub. 525
while you were an inmate at a penal institution. For return, see your Form 1040 instructions. You must and instructions for Schedule D (Form 1040) for
2014 income limits and more information, visit file Form 4137, Social Security and Medicare Tax on reach retirement age. Contact your plan administrator
for more information. Amounts in excess of the overall reporting requirements. W-Employer contributions
www.irs.gov/eitc. Also see Pub. 596, Earned Income Unreported Tip Income, with your income tax return to (including amounts the employee elected to contribute
Credit. Any EIC that is more than your tax liability report at least the allocated tip amount unless you can elective deferral limit must be included in income. See
the “Wages, Salaries, Tips, etc.” line instructions for using a section 125 (cafeteria) plan) to your health
is refunded to you, but only if you file a tax return. prove a smaller amount. If you have records that show savings account. Report on Form 8889, Health
Clergy and religious workers. If you are not subject the actual amount of tips you received, report that Form 1040.
Note: If a year follows code D through H, S, Y, AA, BB, Savings Accounts (HSAs). Y-Deferrals under a section
to social security and Medicare taxes, see Pub. 517, amount even if it is more or less than the allocated 409A nonqualified deferred compensation plan Z-
Social Security and Other Information for Members of tips. On Form 4137 you will calculate the social or EE, you made a make-up pension contribution for a
prior year(s) when you were in military service. To Income under section 409A on a nonqualified deferred
the Clergy and Religious Workers. Corrections. If security and Medicare tax owed on the allocated tips compensation plan. This amount is also included in
your name, SSN, or address is incorrect, correct shown on your Form(s) W-2 that you must report as figure whether you made excess deferrals, consider
these amounts for the year shown, not the current box 1. It is subject to an additional 20% tax plus
Copies B, C, and 2 and ask your employer to correct income and on other tips you did not report to your interest. See “Other Taxes” in the Form 1040
your employment record. Be sure to ask the employer employer. By filing Form 4137, your social security tips year. If no year is shown, the contributions are for the
current year. A-Uncollected social security or RRTA instructions. AA- Designated Roth contributions under
to file Form W-2c, Corrected Wage and Tax will be credited to your social security record (used to a section 401(k) plan. BB- Designated Roth
tax on tips. Include this tax on Form 1040. See “Other
Statement, with the Social Security Administration figure your benefits). contributions under a section 403(b) plan DD-Cost of
Taxes” in the Form 1040 instructions. B-Uncollected
(SSA) to correct any name, SSN, or money amount Box 10. This amount includes the total dependent employer-sponsored health coverage. The amount
Medicare tax on tips. Include this tax on Form 1040.
error reported to the SSA on Form W-2. Be sure to care benefits that your employer paid to you or reported with Code DD is not taxable. EE-
See “Other Taxes” in the Form 1040 instructions. C-
get your copies of Form W-2c from your employer for incurred on your behalf (including amounts from a Designated Roth contributions under a governmental
Taxable cost of group-term life insurance over $50,000
all corrections made so you may file them with your section 125 (cafeteria) plan). Any amount over $5,000 (included in boxes 1, 3 (up to social security wage section 457(b) plan. This amount does not apply to
tax return. If your name and SSN are correct but are is also included in box 1. Complete Form 2441, Child base), and 5) D-Elective deferrals to a section 401(k) contributions under a tax-exempt organization section
not the same as shown on your social security card, and Dependent Care Expenses, to compute any cash or deferred arrangement. Also includes deferrals 457(b) plan. Box 13. If the “Retirement plan” box is
you should ask for a new card that displays your taxable and nontaxable amounts. under a SIMPLE retirement account that is part of a checked, special limits may apply to the amount of
correct name at any SSA office or by calling 1-800- Box 11. This amount is (a) reported in box 1 if it is section 401(k) arrangement. E-Elective deferrals under traditional IRA contributions you may deduct. See Pub.
772-1213. You also may visit the SSA at a distribution made to you from a nonqualified deferred a section 403(b) salary reduction agreement F-Elective 590, Individual Retirement Arrangements (IRAs). Box
www.socialsecurity.gov. Cost of employer- compensation or nongovernmental section 457(b) plan deferrals under a section 408(k)(6) salary reduction 14. Employers may use this box to report information
sponsored health coverage (if such cost is or (b) included in box 3 and/or 5 if it is a prior year SEP G-Elective deferrals and employer contributions such as state disability insurance taxes withheld, union
provided by the employer). The reporting in Box 12, deferral under a nonqualified or section 457(b) plan (including nonelective deferrals) to a section 457(b) dues, uniform payments, health insurance premiums
using Code DD, of the cost of employer-sponsored that became taxable for social security and Medicare deferred compensation plan H-Elective deferrals to a deducted, nontaxable income, educational assistance
health coverage is for your information only. The taxes this year because there is no longer a section 501(c)(18)(D) tax-exempt organization plan. payments, or a member of the clergy’s personage
amount reported with Code DD is not taxable. substantial risk of forfeiture of your right to the deferred See “Adjusted Gross Income” in the Form 1040 allowance and utilities. Railroad employers use this
Credit for excess taxes. If you had more than one amount. This box should not be used if you had a instructions for how to deduct. J-Nontaxable sick pay box to report RRTA compensation, Tier 1 tax, Tier II
employer in 2014 and more than $7,254 in social deferral and a distribution in the same calendar year. If (information only, not included in boxes 1, 3 or 5) K- tax, Medicare tax and Additional Medicare Tax. Include
security and/or Tier I railroad retirement (RRTA) taxes this happens and you are or will be age 62 by the end 20% excise tax on excess golden parachute payments. tips reported by the employee to the employer in
were withheld, you may be able to claim a credit for of the calendar year, your employer should file form See “Other Taxes” in the Form 1040 instructions. L- railroad retirement (RRTA) compensation.
the excess against your federal income tax. If you SSA-131 with the Social Security Administration and Substantiated employee business expense Note. Keep Copy C of Form W-2 for at least 3 years
had more than one railroad employer and more than give you a copy. reimbursements (nontaxable) M-Uncollected social after the due date for filing your income tax return.
$3,828 in Tier II RRTA tax was withheld, you also Box 12. The following list explains the codes shown in security or RRTA tax on taxable cost of group-term life However, to help protect your social security
may be able to claim a credit. See your Form 1040 or box 12. You may need this information to complete insurance over $50,000 (former employees only). See benefits, keep Copy C until you begin receiving social
Form 1040A instructions and Pub. 505, Tax your tax return. “Other Taxes” in the Form 1040 instructions. N- security benefits, just in case there is a question about
Withholding and Estimated Tax. (Instructions for Employee continued on the back of copy C.) Uncollected Medicare tax on taxable cost of group- your work record and/or earnings in a particular year.

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