Devin J Simon 2004 MOHAWK RD APT. 321 Pueblo, Co 81001: Employer Use Only Corp. Dept
Devin J Simon 2004 MOHAWK RD APT. 321 Pueblo, Co 81001: Employer Use Only Corp. Dept
Devin J Simon 2004 MOHAWK RD APT. 321 Pueblo, Co 81001: Employer Use Only Corp. Dept
1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld 1 Wages, tips, other comp. 2 Federal income tax withheld
1303.10 62.84 1303.10 62.84 1303.10 62.84
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
1303.10 80.79 1303.10 80.79 1303.10 80.79
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
1303.10 18.89 1303.10 18.89 1303.10 18.89
d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only d Control number Dept. Corp. Employer use only
36752470 RNU XXXX 215897 36752470 RNU XXXX 215897 36752470 RNU XXXX 215897
c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code c Employer’s name, address, and ZIP code
VICTORIA’S SECRET STORES, LLC VICTORIA’S SECRET STORES, LLC VICTORIA’S SECRET STORES, LLC
FOUR LIMITED PARKWAY FOUR LIMITED PARKWAY FOUR LIMITED PARKWAY
REYNOLDSBURG, OH 43068 REYNOLDSBURG, OH 43068 REYNOLDSBURG, OH 43068
b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number b Employer’s FED ID number a Employee’s SSA number
54-2170171 323-90-9685 54-2170171 323-90-9685 54-2170171 323-90-9685
7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips 7 Social security tips 8 Allocated tips
11 Nonqualified plans 12a See instructions for box 12 11 Nonqualified plans 12a
12 11 Nonqualified plans 12a
e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code e/f Employee’s name, address and ZIP code
DEVIN J SIMON DEVIN J SIMON DEVIN J SIMON
2004 MOHAWK RD APT. 321 2004 MOHAWK RD APT. 321 2004 MOHAWK RD APT. 321
PUEBLO, CO 81001 PUEBLO, CO 81001 PUEBLO, CO 81001
15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc. 15 State Employer’s state ID no. 16 State wages, tips, etc.
CO 02841172 1303.10 CO 02841172 1303.10 CO 02841172 1303.10
17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.
30.00 30.00 30.00
19 Local income tax 20 Locality name 19 Local income tax 20 Locality name 19 Local income tax 20 Locality name
Federal Filing Copy CO. State Filing Copy City or Local Filing Copy
Wage and Tax Wage and Tax Wage and Tax
W-2 Statement 2017
OMB No. 1545-0008
Copy B to be filed with employee’s Federal Income Tax Return.
W-2 Statement 2017
OMB No. 1545-0008
Copy 2 to be filed with employee’s State Income Tax Return.
W-2 Statement OMB
2017 No. 1545-0008
Copy 2 to be filed with employee’s City or Local Income Tax Return.
Instructions for Employee Box 12. The following list explains the codes shown in box 12. You P—Excludable moving expense reimbursements paid directly to
may need this information to complete your tax return. Elective employee (not included in boxes 1, 3, or 5)
Box 1. Enter this amount on the wages line of your tax return. deferrals (codes D, E, F, and S) and designated Roth contributions Q—Nontaxable combat pay. See the instructions for Form 1040 or
Box 2. Enter this amount on the federal income tax withheld line of (codes AA, BB, and EE) under all plans are generally limited to a total Form 1040A for details on reporting this amount.
your tax return. of $18,000 ($12,500 if you only have SIMPLE plans; $21,000 for R—Employer contributions to your Archer MSA. Report on Form 8853,
Box 5. You may be required to report this amount on Form 8959, section 403(b) plans if you qualify for the 15-year rule explained in Archer MSAs and Long-Term Care Insurance Contracts.
Additional Medicare Tax. See the Form 1040 instructions to Pub. 571). Deferrals under code G are limited to $18,000. Deferrals
under code H are limited to $7,000. S—Employee salary reduction contributions under a section 408(p)
determine if you are required to complete Form 8959. SIMPLE plan (not included in box 1)
Box 6. This amount includes the 1.45% Medicare Tax withheld on However, if you were at least age 50 in 2017, your employer may
have allowed an additional deferral of up to $6,000 ($3,000 for section T—Adoption benefits (not included in box 1). Complete Form 8839,
all Medicare wages and tips shown in box 5, as well as the 0.9% 401(k)(11) and 408(p) SIMPLE plans). This additional deferral amount is Qualified Adoption Expenses, to compute any taxable and nontaxable
Additional Medicare Tax on any of those Medicare wages and tips not subject to the overall limit on elective deferrals. For code G, the amounts.
above $200,000. limit on elective deferrals may be higher for the last 3 years before you V—Income from exercise of nonstatutory stock option(s) (included in
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For reach retirement age. Contact your plan administrator for more boxes 1, 3 (up to social security wage base), and 5). See Pub. 525,
information on how to report tips on your tax return, see your Form information. Amounts in excess of the overall elective deferral limit Taxable and Nontaxable Income, for reporting requirements.
1040 instructions. must be included in income. See the “Wages, Salaries, Tips, etc.” line W—Employer contributions (including amounts the employee elected
You must file Form 4137, Social Security and Medicare Tax on instructions for Form 1040. to contribute using a section 125 (cafeteria) plan) to your health
Unreported Tip Income, with your income tax return to report at Note: If a year follows code D through H, S, Y, AA, BB, or EE, you savings account. Report on Form 8889, Health Savings Accounts
least the allocated tip amount unless you can prove that you made a make-up pension contribution for a prior year(s) when you (HSAs).
received a smaller amount. If you have records that show the actual were in military service. To figure whether you made excess deferrals, Y—Deferrals under a section 409A nonqualified deferred
amount of tips you received, report that amount even if it is more or consider these amounts for the year shown, not the current year. If no compensation plan
less than the allocated tips. On Form 4137 you will calculate the year is shown, the contributions are for the current year. Z—Income under a nonqualified deferred compensation plan that fails
social security and Medicare tax owed on the allocated tips shown A—Uncollected social security or RRTA tax on tips. Include this tax on to satisfy section 409A. This amount is also included in box 1. It is
on your Form(s) W-2 that you must report as income and on other Form 1040. See “Other Taxes” in the Form 1040 instructions. subject to an additional 20% tax plus interest. See “Other Taxes” in
tips you did not report to your employer. By filing Form 4137, your B—Uncollected Medicare tax on tips. Include this tax on Form 1040. the Form 1040 instructions.
social security tips will be credited to your social security record See “Other Taxes” in the Form 1040 instructions. AA—Designated Roth contributions under a section 401(k) plan
(used to figure your benefits). C—Taxable cost of group-term life insurance over $50,000 (included in BB—Designated Roth contributions under a section 403(b) plan
Box 9. If you are e-filing and if there is a code in this box, enter it boxes 1, 3 (up to social security wage base), and 5) DD—Cost of employer-sponsored health coverage. The amount
when prompted by your software. This code assists the IRS in D—Elective deferrals to a section 401(k) cash or deferred arrangement. reported with Code DD is not taxable.
validating the W-2 data submitted with your return. The code is not Also includes deferrals under a SIMPLE retirement account that is part EE—Designated Roth contributions under a governmental section
entered on paper-filed returns. of a section 401(k) arrangement. 457(b) plan. This amount does not apply to contributions under a tax-
Box 10. This amount includes the total dependent care benefits that E—Elective deferrals under a section 403(b) salary reduction exempt organization section 457(b) plan.
your employer paid to you or incurred on your behalf (including agreement FF—Permitted benefits under a qualified small employer health
amounts from a section 125 (cafeteria) plan). Any amount over F—Elective deferrals under a section 408(k)(6) salary reduction SEP reimbursement arrangement
$5,000 is also included in box 1. Complete Form 2441, Child and G—Elective deferrals and employer contributions (including Box 13. If the “Retirement plan” box is checked, special limits may
Dependent Care Expenses, to compute any taxable and nontaxable nonelective deferrals) to a section 457(b) deferred compensation plan apply to the amount of traditional IRA contributions you may deduct.
amounts. H—Elective deferrals to a section 501(c)(18)(D) tax-exempt See Pub. 590-A, Contributions to Individual Retirement Arrangements
Box 11. This amount is (a) reported in box 1 if it is a distribution organization plan. See “Adjusted Gross Income” in the Form 1040 (IRAs).
made to you from a nonqualified deferred compensation or instructions for how to deduct. Box 14. Employers may use this box to report information such as
nongovernmental section 457(b) plan, or (b) included in box 3 J—Nontaxable sick pay (information only, not included in boxes 1, 3, state disability insurance taxes withheld, union dues, uniform
and/or 5 if it is a prior year deferral under a nonqualified or section or 5) payments, health insurance premiums deducted, nontaxable income,
457(b) plan that became taxable for social security and Medicare K—20% excise tax on excess golden parachute payments. See “Other educational assistance payments, or a member of the clergy's
taxes this year because there is no longer a substantial risk of Taxes” in the Form 1040 instructions. parsonage allowance and utilities. Railroad employers use this box to
forfeiture of your right to the deferred amount. This box shouldn’t report railroad retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax,
L—Substantiated employee business expense reimbursements Medicare tax and Additional Medicare Tax. Include tips reported by the
be used if you had a deferral and a distribution in the same (nontaxable)
calendar year. If you made a deferral and received a distribution employee to the employer in railroad retirement (RRTA) compensation.
in the same calendar year, and you are or will be age 62 by the M—Uncollected social security or RRTA tax on taxable cost of Note: Keep Copy C of Form W-2 for at least 3 years after the due date
end of the calendar year, your employer should file Form group-term life insurance over $50,000 (former employees only). See for filing your income tax return. However, to help protect your social
SSA-131, Employer Report of Special Wage Payments, with the “Other Taxes” in the Form 1040 instructions. security benefits, keep Copy C until you begin receiving social
Social Security Administration and give you a copy. N—Uncollected Medicare tax on taxable cost of group-term life security benefits, just in case there is a question about your work
insurance over $50,000 (former employees only). See “Other Taxes” in record and/or earnings in a particular year.
the Form 1040 instructions. Department of the Treasury - Internal Revenue Service
NOTE: THESE ARE SUBSTITUTE WAGE AND TAX STATEMENTS AND ARE ACCEPTABLE FOR FILING WITH YOUR FEDERAL, STATE AND LOCAL/CITY INCOME TAX RETURNS.
Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service