a Employee's SSN 571-04-1983 b Employer identification number (EIN) 93-1257467 OMB No.

1545-0008
3
C Employer's name, address, and ZIP code TA L LY- H O
ENTERPRISES, I N C JACK'S
1 Wgs, tips, other compn
85 24 . 4 0
2 Fed inc tax withheld
110.00
Social security wages
8156.40 Form W-2
TALLY-HO P. O . BOX 567 4 S3 tax withheld 5 2 8 . 5 Medicare wages & tips 6 Medicare tax withheld Wage and Tax
TALENT OR 97540 51 8524.40
8 Allocated tips 91
123 . 6 0
Advance EIC payment
Statement
7 Social security tips

d Control number
368.00
1 0 Depdnt care benefits 11 Nonqualified plans
2009
r Copy B To Be Filed with
Employee's FEDERAL Tax
Return
6 Employee's name, address, and ZIP code Suff. 13 14 Other 12 D This information is being
furnished to the Internal
LAVONNE D MAITLAND 5411 1 Revenue Service.
HIGHGATE #11 MEDFORD OR Statutory employee [ 12
97501 c
Retirement plan . . |_ 12
c
Third-party sick pay | 18 Local wages, tips, etc 1 9 Local income tax 20 Locality name
15 State Employer's state ID number 16 State wages, tips, etc 17 State income tax OR
11035779-4 8524. 4o|_ 302.00
I T T "
QBMW2B2C 08/19/09 Department of the Treasury — IRS

a Employee's SSN 571-04-1983 b Employer identification number (EIN) 93-1257467 OMB No. 1545-0008

C Employer's name, address, and ZIP code TA L LY- H O 1 Wgs, tips, other compn 2 Fed inc tax withheld 1 1 0 3 Social security wages For.W-2
ENTERPRISES, INC 8524.40 . 00 8156.40 Wage and Tax
97540 4 SS tax withheld
JACK'S TALLY-HO P. O .
528.51
5 Medicare wages & tips 6 Medicare tax withheld Statement
BOX 567 8524 .40 123.60
TALENT OR 7 Social security tips 8 Allocated tips 9 Advance EIC payment 2009
368 . 00 Copy 2 To Be Filed
d Control number 1 0 Depdnt care benefits 11 Nonqualified plans 12a With Employee's
State, City, or Local
Income Tax Return.
e Employee's name, address, and ZIP code Suff. 13 14 Other 12b
LAVONNE D MAITLAND 5411 HIGHGATE
#11 MEDFORD OR 97501 Statutory employee [ 12c

Retirement plan . . [_ 12d

15 State Employer's state ID No. OR 16 State wages, tips, etc 17 StateThird-party

income taxsick pay |
8524.40 18 Local wages, tips, etc 19 Local income tax 20 Locality name
11035779-4 302.00
1
QBMW2B2C 08/19/09

QBMW2B2C 08/19/09
3 Employee's SSN 571-04-1983 b Employer identification number (EIN) 93-1257467 OMB No. 1545-0008
This information is being furnished to the IRS. If you are required to file a tax return, a negligence penalty or other sanction
C Employer's name, address, and ZIP cc de , may be imposed on you if this income is taxable and you fail to report i .
TALLY-HO ENTERPRISES INC 1 Wgs, tips, other compn 2 Fed inc tax withheld 3 Social security wages For.W-2
JACK'S TALLY-HO P.O. 97540
8524.40 110.00 8156.40 Wage and
6 Medicare tax withheld
BOX 567 4 SS tax withheld 5 Medicare wages & tips
123.60 Tax
TALENT OR 528.51 8524.40
7 Social security tips 8 Allocated tips 9 Advance EIC payment Statement
d Control No. 368 . 00
1 0 Depdnt care benefits 11 Nonqualified plans 12a 2009
Copy C For
EMPLOYEE'S
6 Employee's name, address, and ZIP code Suff. 13 14 Other 12b RECORDS. (See
LAVONNE D MAITLAND 5411 Notice to
HIGHGATE #11 MEDFORD OR 97501 Statutory employee [ Employee.)
12c

Retirement plan • • • 1
12d

15 State Employer's state ID No. OR Third-party sick pay | 18 Local wages, tips, etc 19 Local income tax 20 Locality name
16 State wages, tips, etc 17 State income tax 8524.40
J1035779-4 302.00

:r