a Employee’s social security number Safe, accurate, Visit the IRS website at

FAST! Use www.irs.gov/efile

XXX-XX-8715 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
82-4031209 42443.76 3483.88
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CARING SMILES LLC 42487.75 2634.24
5 Medicare wages and tips 6 Medicare tax withheld
30 AMES AVE 42487.75 616.07
7 Social security tips 8 Allocated tips
RUTHERFORD NJ 07070
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
SILVIA P LECAROS JIMENEZ d
e D 43.99
257 HIGH STREET, 2ND FLOOR 13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
C
o
d
e

NORTH ARLINGTON NJ 07031 14 Other 12c

C
o
NJ SDI 59.49 d
e

NJ SUI 169.14 12d

C

NJ FLI 59.49 o
d
e

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

NJ 824-031-209/000 42443.76 741.24

Form W-2 Wage and Tax Statement

Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
2022 Department of the Treasury—Internal Revenue Service

This information is being furnished to the Internal Revenue Service.

Notice to Employee Corrections. If your name, SSN, or address is incorrect, correct
Copies B, C, and 2 and ask your employer to correct your
Do you have to file? Refer to the Form 1040 instructions to employment record. Be sure to ask the employer to file Form
determine if you are required to file a tax return. Even if you W-2c, Corrected Wage and Tax Statement, with the SSA to
don’t have to file a tax return, you may be eligible for a refund if correct any name, SSN, or money amount error reported to the
box 2 shows an amount or if you are eligible for any credit. SSA on Form W-2. Be sure to get your copies of Form W-2c
Earned income credit (EIC). You may be able to take the EIC from your employer for all corrections made so you may file
for 2022 if your adjusted gross income (AGI) is less than a them with your tax return. If your name and SSN are correct but
certain amount. The amount of the credit is based on income aren’t the same as shown on your social security card, you
and family size. Workers without children could qualify for a should ask for a new card that displays your correct name at
smaller credit. You and any qualifying children must have valid any SSA office or by calling 800-772-1213. You may also visit
social security numbers (SSNs). You can’t take the EIC if your the SSA website at www.SSA.gov.
investment income is more than the specified amount for 2022 Cost of employer-sponsored health coverage (if such cost is
or if income is earned for services provided while you were an provided by the employer). The reporting in box 12, using
inmate at a penal institution. For 2022 income limits and more code DD, of the cost of employer-sponsored health coverage is
information, visit www.irs.gov/EITC. See also Pub. 596, Earned for your information only. The amount reported with code DD
Income Credit. Any EIC that is more than your tax liability is is not taxable.
refunded to you, but only if you file a tax return.
Credit for excess taxes. If you had more than one employer in
Employee’s social security number (SSN). For your 2022 and more than $9,114 in social security and/or Tier 1
protection, this form may show only the last four digits of your railroad retirement (RRTA) taxes were withheld, you may be able
SSN. However, your employer has reported your complete SSN to claim a credit for the excess against your federal income tax.
to the IRS and the Social Security Administration (SSA). See the Form 1040 instructions. If you had more than one
Clergy and religious workers. If you aren’t subject to social railroad employer and more than $5,350.80 in Tier 2 RRTA tax
security and Medicare taxes, see Pub. 517, Social Security and was withheld, you may be able to claim a refund on Form 843.
Other Information for Members of the Clergy and Religious See the Instructions for Form 843.
Workers. (See also Instructions for Employee on the back of Copy C.)
 a Employee’s social security number This information is being furnished to the Internal Revenue Service. If you
are required to file a tax return, a negligence penalty or other sanction
XXX-XX-8715 OMB No. 1545-0008 may be imposed on you if this income is taxable and you fail to report it.
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
82-4031209 42443.76 3483.88
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CARING SMILES LLC 42487.75 2634.24
5 Medicare wages and tips 6 Medicare tax withheld
30 AMES AVE 42487.75 616.07
7 Social security tips 8 Allocated tips
RUTHERFORD NJ 07070
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
SILVIA P LECAROS JIMENEZ d
e D 43.99
Statutory Retirement Third-party
257 HIGH STREET, 2ND FLOOR 13 employee plan sick pay
12b
C
o
d
e

NORTH ARLINGTON NJ 07031 14 Other 12c

C
o
NJ SDI 59.49 d
e

NJ SUI 169.14 12d

C
o
NJ FLI 59.49 d
e

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

NJ 824-031-209/000 42443.76 741.24

Form W-2 Wage and Tax Statement

Copy C—For EMPLOYEE’S RECORDS
2022 Department of the Treasury—Internal Revenue Service
Safe, accurate,
FAST! Use
(See Notice to Employee on the back of Copy B.)
Instructions for Employee received a distribution in the same calendar year, and you are or will be
age 62 by the end of the calendar year, your employer should file Form
(See also Notice to Employee on the back of Copy B.) SSA-131, Employer Report of Special Wage Payments, with the Social
Box 1. Enter this amount on the wages line of your tax return. Security Administration and give you a copy.
Box 2. Enter this amount on the federal income tax withheld line of your Box 12. The following list explains the codes shown in box 12. You may
tax return. need this information to complete your tax return. Elective deferrals
(codes D, E, F, and S) and designated Roth contributions (codes AA,
Box 5. You may be required to report this amount on Form 8959,
BB, and EE) under all plans are generally limited to a total of $20,500
Additional Medicare Tax. See the Form 1040 instructions to determine if
($14,000 if you only have SIMPLE plans; $23,500 for section 403(b)
you are required to complete Form 8959.
plans if you qualify for the 15-year rule explained in Pub. 571). Deferrals
Box 6. This amount includes the 1.45% Medicare Tax withheld on all under code G are limited to $20,500. Deferrals under code H are limited
Medicare wages and tips shown in box 5, as well as the 0.9% Additional to $7,000.
Medicare Tax on any of those Medicare wages and tips above
However, if you were at least age 50 in 2022, your employer may have
$200,000.
allowed an additional deferral of up to $6,500 ($3,000 for section
Box 8. This amount is not included in box 1, 3, 5, or 7. For information 401(k)(11) and 408(p) SIMPLE plans). This additional deferral amount is
on how to report tips on your tax return, see the Form 1040 instructions. not subject to the overall limit on elective deferrals. For code G, the limit
You must file Form 4137, Social Security and Medicare Tax on on elective deferrals may be higher for the last 3 years before you reach
Unreported Tip Income, with your income tax return to report at least retirement age. Contact your plan administrator for more information.
the allocated tip amount unless you can prove with adequate records Amounts in excess of the overall elective deferral limit must be included
that you received a smaller amount. If you have records that show the in income. See the Form 1040 instructions.
actual amount of tips you received, report that amount even if it is more Note: If a year follows code D through H, S, Y, AA, BB, or EE, you made
or less than the allocated tips. Use Form 4137 to figure the social a make-up pension contribution for a prior year(s) when you were in
security and Medicare tax owed on tips you didn’t report to your military service. To figure whether you made excess deferrals, consider
employer. Enter this amount on the wages line of your tax return. By these amounts for the year shown, not the current year. If no year is
filing Form 4137, your social security tips will be credited to your social shown, the contributions are for the current year.
security record (used to figure your benefits).
A—Uncollected social security or RRTA tax on tips. Include this tax on
Box 10. This amount includes the total dependent care benefits that Form 1040 or 1040-SR. See the Form 1040 instructions.
your employer paid to you or incurred on your behalf (including amounts
B—Uncollected Medicare tax on tips. Include this tax on Form 1040 or
from a section 125 (cafeteria) plan). Any amount over your employer’s
1040-SR. See the Form 1040 instructions.
plan limit is also included in box 1. See Form 2441.
C—Taxable cost of group-term life insurance over $50,000 (included in
Box 11. This amount is (a) reported in box 1 if it is a distribution made to
boxes 1, 3 (up to the social security wage base), and 5)
you from a nonqualified deferred compensation or nongovernmental
section 457(b) plan, or (b) included in box 3 and/or box 5 if it is a prior D—Elective deferrals to a section 401(k) cash or deferred arrangement.
year deferral under a nonqualified or section 457(b) plan that became Also includes deferrals under a SIMPLE retirement account that is part
taxable for social security and Medicare taxes this year because there is of a section 401(k) arrangement.
no longer a substantial risk of forfeiture of your right to the deferred E—Elective deferrals under a section 403(b) salary reduction agreement
amount. This box shouldn’t be used if you had a deferral and a
(continued on back of Copy 2)
distribution in the same calendar year. If you made a deferral and
 a Employee’s social security number
XXX-XX-8715 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
82-4031209 42443.76 3483.88
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
CARING SMILES LLC 42487.75 2634.24
5 Medicare wages and tips 6 Medicare tax withheld
30 AMES AVE 42487.75 616.07
7 Social security tips 8 Allocated tips
RUTHERFORD NJ 07070
d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
SILVIA P LECAROS JIMENEZ d
e D 43.99
257 HIGH STREET, 2ND FLOOR 13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
C
o
d
e

NORTH ARLINGTON NJ 07031 14 Other 12c

C
o
NJ SDI 59.49 d
e

NJ SUI 169.14 12d

C

NJ FLI 59.49 o
d
e

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

NJ 824-031-209/000 42443.76 741.24

Form W-2 Wage and Tax Statement

Copy 2—To Be Filed With Employee’s State, City, or Local
2022 Department of the Treasury—Internal Revenue Service

Income Tax Return

Instructions for Employee (continued from back of W—Employer contributions (including amounts the employee elected to
Copy C) contribute using a section 125 (cafeteria) plan) to your health savings
account. Report on Form 8889, Health Savings Accounts (HSAs).
Box 12 (continued) Y—Deferrals under a section 409A nonqualified deferred compensation plan
F—Elective deferrals under a section 408(k)(6) salary reduction SEP Z—Income under a nonqualified deferred compensation plan that fails to
G—Elective deferrals and employer contributions (including nonelective satisfy section 409A. This amount is also included in box 1. It is subject
deferrals) to a section 457(b) deferred compensation plan to an additional 20% tax plus interest. See the Form 1040 instructions.
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization AA—Designated Roth contributions under a section 401(k) plan
plan. See the Form 1040 instructions for how to deduct. BB—Designated Roth contributions under a section 403(b) plan
J—Nontaxable sick pay (information only, not included in box 1, 3, or 5) DD—Cost of employer-sponsored health coverage. The amount
K—20% excise tax on excess golden parachute payments. See the reported with code DD is not taxable.
Form 1040 instructions. EE—Designated Roth contributions under a governmental section
L—Substantiated employee business expense reimbursements 457(b) plan. This amount does not apply to contributions under a tax-
(nontaxable) exempt organization section 457(b) plan.
M—Uncollected social security or RRTA tax on taxable cost of group- FF—Permitted benefits under a qualified small employer health
term life insurance over $50,000 (former employees only). See the Form reimbursement arrangement
1040 instructions. GG—Income from qualified equity grants under section 83(i)
N—Uncollected Medicare tax on taxable cost of group-term life HH—Aggregate deferrals under section 83(i) elections as of the close of
insurance over $50,000 (former employees only). See the Form 1040 the calendar year
instructions.
Box 13. If the “Retirement plan” box is checked, special limits may apply
P—Excludable moving expense reimbursements paid directly to a to the amount of traditional IRA contributions you may deduct. See Pub.
member of the U.S. Armed Forces (not included in box 1, 3, or 5) 590-A, Contributions to Individual Retirement Arrangements (IRAs).
Q—Nontaxable combat pay. See the Form 1040 instructions for details Box 14. Employers may use this box to report information such as state
on reporting this amount. disability insurance taxes withheld, union dues, uniform payments,
R—Employer contributions to your Archer MSA. Report on Form 8853, health insurance premiums deducted, nontaxable income, educational
Archer MSAs and Long-Term Care Insurance Contracts. assistance payments, or a member of the clergy’s parsonage allowance
S—Employee salary reduction contributions under a section 408(p) and utilities. Railroad employers use this box to report railroad
SIMPLE plan (not included in box 1) retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax,
and Additional Medicare Tax. Include tips reported by the employee to
T—Adoption benefits (not included in box 1). Complete Form 8839, the employer in railroad retirement (RRTA) compensation.
Qualified Adoption Expenses, to figure any taxable and nontaxable
amounts. Note: Keep Copy C of Form W-2 for at least 3 years after the due date
for filing your income tax return. However, to help protect your social
V—Income from exercise of nonstatutory stock option(s) (included in security benefits, keep Copy C until you begin receiving social security
boxes 1, 3 (up to the social security wage base), and 5). See Pub. 525, benefits, just in case there is a question about your work record and/or
Taxable and Nontaxable Income, for reporting requirements. earnings in a particular year.