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2011 W-2 and EARNINGS SUMMARY
Employee
Reference
Wage and Tax
Statement

W-2

Copy C for employee’s records.

Dept.

d Control number
0000090794 WTE
c

0318

Copy

2011

OMB No. 1545-0008

Corp.

ML90

Employer use only

A

34041

Employer’s name, address, and ZIP code

BLAZIN WINGS INC
5500 WAYZATA BLVD SUITE 1600
MINNEAPOLIS, MN 55416

e/f Employee’s name, address, and ZIP code

MATTHEW E WHEELER
60 SOUTH 25TH STREET
PITTSBURGH, PA 15203
b

Employer’s FED ID number

a Employee’s SSA number

41-1957107

608-24-2969

1

Wages, tips, other comp.

3

Social security wages

5

Medicare wages and tips

7

Social security tips

2 Federal income tax withheld

6702.85

771.97
4 Social security tax withheld

2028.74

281.52
6 Medicare tax withheld

6702.85

97.19
8 Allocated tips

4674.11
9

10 Dependent care benefits
12a See instructions for box 12

11 Nonqualified plans
5.37 PA SUI

14 Other

Social Security Number: 608-24-2969
Taxable Marital Status:
SINGLE
Exemptions/Allowances:
Federal: 0
State:
0
Local:
0

MATTHEW E WHEELER
60 SOUTH 25TH STREET
PITTSBURGH, PA 15203

12b
12c
12d
13 Stat emp. Ret. plan 3rd party sick pay

15 State Employer’s state ID no. 16 State wages, tips, etc.

9079 2064
PA
17 State income tax

6702.85
18 Local wages, tips, etc.

205.76
19 Local income tax

6702.85
20 Locality name

33.51
1

Wages, tips, other comp.

¤

Social security wages

5

Medicare wages and tips

c

3

Social security wages
Medicare wages and tips

281.52
6 Medicare tax withheld

ML90

Employer use only

A

34041

c

Employer’s name, address, and ZIP code

a Employee’s SSA number

b

Social security tips

8 Allocated tips

7

9

10 Dependent care benefits

11 Nonqualified plans
14 Other

7

Social security wages
Medicare wages and tips

ML90

Employer use only

A

34041

771.97
4 Social security tax withheld

2028.74

97.19
Corp.

281.52
6 Medicare tax withheld

6702.85
d Control number
0000090794 WTE
c

Employer’s name, address, and ZIP code

Dept.
0318

97.19
Corp.

Employer use only

ML90

A

34041

Employer’s name, address, and ZIP code

BLAZIN WINGS INC
5500 WAYZATA BLVD SUITE 1600
MINNEAPOLIS, MN 55416

Employer’s FED ID number

a Employee’s SSA number

b

Social security tips

8 Allocated tips

7

9

10 Dependent care benefits

9

10 Dependent care benefits

12a See instructions for box 12

11 Nonqualified plans

12a
12

11 Nonqualified plans

12a

12b

14 Other

12b

14 Other

608-24-2969

41-1957107

4674.11

5.37 PA SUI

3

281.52
6 Medicare tax withheld

2 Federal income tax withheld

6702.85

BLAZIN WINGS INC
5500 WAYZATA BLVD SUITE 1600
MINNEAPOLIS, MN 55416

Employer’s FED ID number

41-1957107

Dept.
0318

Wages, tips, other comp.

5

4 Social security tax withheld

6702.85
d Control number
0000090794 WTE

1

771.97

2028.74

97.19
Corp.

2 Federal income tax withheld

6702.85

BLAZIN WINGS INC
5500 WAYZATA BLVD SUITE 1600
MINNEAPOLIS, MN 55416

b

Wages, tips, other comp.

5

4 Social security tax withheld

6702.85
Dept.
0318

1

771.97

2028.74

d Control number
0000090794 WTE
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