22222

b c

a Void

Employees social security number

234-19-4571

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation

2 4 6 8 10

Federal income tax withheld

54-2097669
Employers name, address, and ZIP code

1825.64
3 5 7
Social security wages

152.00
Social security tax withheld

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name

1825.64
Medicare wages and tips Medicare tax withheld

84.13 26.47
Allocated tips Dependent care benefits

1825.64
Social security tips

WV 25213
9
Suff.

11 13

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

JEREMY A

DALEY
Statutory employee Other Retirement plan

12 b 12 c 12 d

3228 KANAWHA TERR. APT. 5

14

ST. ALBANS
f
Employees address and ZIP code 15 State Employers state ID number

WV 25177
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc

19 Local income tax

20

Locality name

WV 1033-8239

1825.64

67.00

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11

Do Not Cut, Fold, or Staple Forms on This Page

22222
b c

a Void

Employees social security number

234-33-3221

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation

2 4 6 8 10

Federal income tax withheld

54-2097669
Employers name, address, and ZIP code

1838.25
3 5 7
Social security wages

164.00
Social security tax withheld

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name

1838.25
Medicare wages and tips Medicare tax withheld

77.21 26.65
Allocated tips Dependent care benefits

1838.25
Social security tips

WV 25213
9
Suff.

11 13

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

JOSH

FULKS
Statutory employee Other Retirement plan

12 b 12 c 12 d

2539 KANAWHA FOREST DR.

14

CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number

WV 25314
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc

19 Local income tax

20

Locality name

WV 1033-8239

1838.25

64.00

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

22222
b c

a Void

Employees social security number

235-35-6343

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation

2 4 6 8 10

Federal income tax withheld

54-2097669
Employers name, address, and ZIP code

575.00
3 5 7
Social security wages

26.00
Social security tax withheld

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name

575.00
Medicare wages and tips Medicare tax withheld

24.15 8.34
Allocated tips Dependent care benefits

575.00
Social security tips

WV 25213
9
Suff.

11 13

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

CHRISTOPHER 7028 HICKORY DR.

HARRISON
Statutory employee Other Retirement plan

12 b 12 c 12 d

14

SISSONVILLE
f
Employees address and ZIP code 15 State Employers state ID number

WV 25320
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc

19 Local income tax

20

Locality name

WV 1033-8239

575.00

19.00

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11

Do Not Cut, Fold, or Staple Forms on This Page

22222
b c

a Void

Employees social security number

235-35-5053

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation

2 4 6 8 10

Federal income tax withheld

54-2097669
Employers name, address, and ZIP code

211.50
3 5 7
Social security wages

17.00
Social security tax withheld

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name

211.50
Medicare wages and tips Medicare tax withheld

8.88 3.07
Allocated tips Dependent care benefits

211.50
Social security tips

WV 25213
9
Suff.

11 13

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

CODY B

JARRETT
Statutory employee Other Retirement plan

12 b 12 c 12 d

1918 B. PINEWOOD DR.

14

CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number

WY 25320
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc

19 Local income tax

20

Locality name

WV 1033-8239

211.50

7.00

211.50

0.00 City Ta

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

22222
b c

a Void

Employees social security number

234-31-0230

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation

2 4 6 8 10

Federal income tax withheld

54-2097669
Employers name, address, and ZIP code

7242.75
3 5 7
Social security wages

757.00
Social security tax withheld

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
d e
Control number Employees first name and initial Last name

7242.75
Medicare wages and tips

304.20
Medicare tax withheld

7242.75
Social security tips Allocated tips

105.02
Dependent care benefits

WV 25213
9
Suff.

11 13

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

CARLTON A

TAYLOR
Statutory employee Other Retirement plan

12 b 12 c 12 d

5010 KENTUCKY ST.

14

SO. CHARLESTON
f
Employees address and ZIP code 15 State Employers state ID number

WV 25309
16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc

19 Local income tax

20

Locality name

WV 1033-8239

7242.75

273.00

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. FDWA0101 09/09/11

Do Not Cut, Fold, or Staple Forms on This Page

22222
b c

a Void

Employees social security number

Employer identification number (EIN)

For Official Use Only G OMB No. 1545-0008 1 Wages, tips, other compensation 3 5 7
Social security wages

2 4 6 8 10

Federal income tax withheld

Employers name, address, and ZIP code

Social security tax withheld

Medicare wages and tips

Medicare tax withheld

Social security tips

Allocated tips

d e

Control number

9
Last name Suff.

Dependent care benefits

Employees first name and initial

11 13 14

Nonqualified plans

12 a
Third-party sick pay

See instructions for box 12

Statutory employee Other

Retirement plan

12 b 12 c 12 d

Employees address and ZIP code 16 State wages, tips, etc 17 State income tax 18 Local wages, tips, etc 19 Local income tax 20 Locality name

15 State Employers state ID number

Wage and Tax Statement Form Copy A for Social Security Administration ' Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

W-2

2011
0 0 0 0 / 1 0 3 0D

Department of the Treasury ' Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

33333
b Kind of Payer
(Check one)

Control number

For Official Use Only G OMB No. 1545-0008

943 Medicare govt emp 944 None apply 501c non-govt.

941

Military Household emp

X
CT-1

Kind of Employer
(Check one)

X
State/local non 501c State/local 501c Federal govt.

Third-party sick pay (Check if applicable)

c e f

Total number of Forms W-2

Establishment number

1 3 5 7

Wages, tips, other compensation

2 4

Federal income tax withheld

5
Employer identification number (EIN) Social security wages

11693.14
Social security tax withheld

1116.00 498.57
6
Medicare tax withheld

54-2097669
Employers name Medicare wages and tips

11693.14 11693.14
Social security tips

THE GLASS BLOCK PLACE, INC THE GLASS BLOCK PLACE PO BOX 563 WINFIELD
g h 15 16
Employers address and ZIP code Other EIN used this year

169.55
8 10
Allocated tips Dependent care benefits

9 11 13 14
Nonqualified plans

WV 25213

12 a 12 b

Deferred compensation

For third-party sick pay use only

State

Employers state ID number

Income tax withheld by payer of third-party sick pay

WV
Contact person

1033-8239
17
State income tax

State wages, tips, etc

18

Local wages, tips, etc

19

Local income tax

11693.14
Email address

430.00
Telephone number Fax number

211.50
For Official Use Only

0.00

(877) 230-9544 sharrison@wvglassblock.com (304) 205-0626 0000/1030D

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete.

Signature G Form

Title G

Date G

W-3

Transmittal of Wage and Tax Statements

2011

Department of the Treasury Internal Revenue Service

Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration. Do not send any payment (cash, checks, money orders, etc.) with Forms W-2 and W-3.

Reminder
Separate instructions. See the 2011 Instructions for Forms W-2 and W-3 for information on completing this form.

Purpose of Form
A Form W-3 Transmittal is completed only when paper Copy A of Form(s) W-2, Wage and Tax Statement, is being filed. Do not file Form W-3 alone. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the Social Security Administration (see below). All paper forms must comply with IRS standards and be machine readable. Photocopies are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and Form(s) W-2 show the correct tax year and Employer Identification Number (EIN). Make a copy of this form and keep it with Copy D (For Employer) of Form(s) W-2 for your records.

When to File
Mail any paper Forms W-2 under cover of this Form W-3 Transmittal by February 29, 2012. Electronic fill-in forms or uploads are filed through SSAs Business Services Online (BSO) Internet site and will be on time if submitted by April 2, 2012.

Electronic Filing

Where to File Paper Forms

Send this entire page with the entire Copy A page of Form(s) The Social Security Administration (SSA) strongly suggests W-2 to: employers report Form W-3 and W-2 Copy A electronically instead Social Security Administration of on paper. SSA provides two free options on its Business Services Data Operations Center Online (BSO) website: Wilkes-Barre, PA 18769-0001 ? W-2 Online. Use fill-in forms to create, save, print, and submit up to 20 Forms W-2 to SSA. Note. If you use Certified Mail to file, change the ZIP code ? File Upload. Upload wage files to SSA that you have created to 18769-0002. If you use an IRS-approved private delivery using payroll or tax software that formats the files according to service, add ATTN: W-2 Process, 1150 E Mountain Dr. to the SSAs Specifications for Filing Form W-2 Electronically (EFW2). address and change the ZIP code to 18702-7997. See For more information, go to www.socialsecurity.gov/employer and Publication 15 (Circular E), Employers Tax Guide, for a list select First Time Filers or Returning Filers under BEFORE YOU of IRS-approved private delivery services. FILE. For Privacy Act and Paperwork Reduction Act Notice, see instructions. FDWA0201

09/21/11