Bieg 6b-2

4–13B. Wage and Tax Statement

(a)

| 22222 | Void | a Employee’s social security | For Official Use Only |
| | |number |OMB No. 1 545-0008 |
| | |376-72-4310 | |
|b | Employer identification number (EIN) |1 | |Wages, tips, other compensation |2 | |Federal income tax withheld |
| | 13-7490972 | $ | | 29,380.00 | $ | | 2080.00 |
|c | Employer’s name, address, and ZIP code |3 | |Social security wages |4 | |Social security tax withheld |
| | | $ | |31,980.00 | $ | | 1982.76 |
| | Omni Corporation |5 | |Medicare wages and tips |6 | |Medicare tax withheld |
| | 4800 River Road | $ | | 31,980.00 | $ | | 463.84 |
| | Philadelphia, PA 19113-5548 |7 | |Social security tips |8 | |Allocated tips |
| | | $ | | | $ | | |
|d | Control number |9 | | |10 | |Dependent care benefits |
| | | $ | | | $ | |