uoDv It I o tte h rled wrtn FEbERAL Tax Return,

a Employee's SSN

Emolovee's 15882.04

zu

lz

r vvages, I ps, olner comp. 5 )Octat secunly wages

I oH,re No. 1545.0008 Feoera rncome lax wrlnne o

I o Ee i rled wrln Emolovee's CitV; or Local lncome Tax

uopv

817.00
4 Socral secuflty tax wlthhe
6 Medrcare tax w thheld
d

a Emp oyee's SSN

'l Wages, tips, other comp.

3 Socral secur ty wages

5tate, Retur-n,
L5BB2 . A4

i orr,re No, 545-0008 2 Fede.al income tax withheld

zulz

817.00
4 Social security tax withheld

31 b

A-96-8293

Employer lD no. (ElN)

1s882.04
5 l\4edrcare wages and trps

667.05

3t a-96-8293
b
Emp oyer lD no.

(ElN)

15882.04
5 lvledrcare wages and t ps

661 .05
6 IMedLcare tax wrlhheld

45-5517576

15882.04

230.29

45-5511516

75882 .04
LLC

230.29

c Emp oyer's name, address, and ZIP code

RIDI

c Employer's name, address, and ZIP code

STONE OAK LLC

RID] STONE OAK 9140 ANGOLA RD

9140 ANGOLA RD

HOLLAND
d Control number
e Employee's name, address, and Z P

OH
code
.

43528

HOLLAND
d Control number
e Employee's name, address, and ZIP

OH code MI
SAllocated tlps

43528

DUSTIN PERKINS

^ MI
48144

Suff,

Sufi.

8039 MCCLAIN AVE LAMBERTVILLE

7 Soc

DUSTTN PERKINS 8039 MCCLAIN AVE

LAMBERTVILLE
7

48L44

security

lips
bene'rts

Allocated t os

Soclal security tips ljependent care benettts

q :t I ::t:t: l
1. :| : :..
::',
) 1

:1

:.1ii|::i.1\

Depe-dent ca'e

1
|l

NolqJa i' ed

o ans

lZaCode See
I ZbCode
1

Lnst,

tor

box

I Nonqualified plans

2a Code See ins'i. for box I

13
;tatutory employee

'l4Other

IJ
Statutory employee Retirement Plan

l4Other

2b Code 2c Code

2c Code

iet rement Plan

'l2d Code
hird-party sick
pay

'l2d Code
Th rd-oartv sick oav

M]

15882 04

668 . A2
l7 State income tax

Mr
l5

145-5517576
I

15882.04
l6 State waqes, tips, etc

668 . A2
State income tax

145-5517576
l5 State Emolover's state iD number
16 State waqes, tips, etc

State

Employei's state D number

l8

Local wages, tips, etc.

'19

ocal income tax

Locality name

Local wages, tips, etc

9 Locai income tax

Local ty name

Eorm W-2 Waqe and lax

Th.s '1'0r mat

0r

5 be'ng rur nrsheo t0

Slatement
tre Internal

RevenJe Servrce.

ljept. of lhe lreasury -

IRS

orm W"2 Waoe and lax Stat ment

reasury-lRS

Thsinformationisbeingfurnishedtothelnterna RevenueServrce.lfyouarereqlrrediofieataxreturn,anegligence
perdhy 0r other sanction mav be imoosed 0i you r'thrs income s taxable and you 0ther sancuor aay rmposed 0n vou if this 4c0me raiable ard yoL oenaltv

Copy C For EMPLOYEE'S (See Notice to I Wages, t ps, other comp.

a Employee's SSN

RECORDS. Emplovees).
1s882.04
3 Socral secunty wages

lar fai i0

reDort it.

QBI\4822C

10t10/12

1545-0008 2 ledeta) rncome tax wrthheld

120'12 loMB No.

Copy 2 To Be Filed With Employee's Citv. or Local lncome Tax Return.

a Employee's SSN waqes, t ps, other comp.

State,

|120'12

i oNte No, 1545-0008 2 Federal rncome tax withheld

817.00
4 Soc al securlty tax withheld

15882.04
3 Social security wages

817.00
4 Social security tax withheld

31 b

0-96-8293

31 b

0-96-8293

Employer lD no. (ElN)

15882.04
5lvledicare waoes and tips

661.05
6 Medicare tax withheld

Employer 1D no. (E N)

15882.04
5 Med care wages and tips

661 .05
6 tvledicare tax withneld

45-5517576

L5BB2 . 0 4

,?n

to

45-5517576

15882.04
LLC

)1,n )a

c Employer's name, address, and ZIP code

RIDI

c Employer's name, address, and ZIP code

STONE OAK ILC

RIDT STONE OAK 9I4O ANGOLA RD

9140 ANGOLA RD

HOLLAND
d Oontrol number e Employee's name, address, and ZIP

OH
code

43528

HOLLAND
d Control number
e Employee's name, address, and ZIP
Suff.

OH
code

43528

Suff.

DUSTIN PERKINS

DUSTIN PERKINS BO39 MCCLAIN AVE

8039 MCCLAIN AVE LAMBERTVILLE

7

MI
SAllocated tips o

48L44
,1,.:: i lllri'",
: ll
7

LAI4BERTV]LLE
Social securlty tips Dependent care benef ts

MI
8A located tips
9
'I

48144

Social secur ty t ps Dependent care benefits

l Nonqua ified plans

l2aCode See inst. for box l2

tzo uooe 'l2c Code

Nonquaiitied plans

2a

Code See inst. for box 1 2

'13 itatutory employee letirement Plan

l4Other

l5
;tatutory emp oyee

'l4Other

Zb Uode

'l2c Code
le'iirement Plan
1

12d Code
thrrd-party sick

2d Code

-h

Mr l4s-55L]516
I

oay

rd-oartv sick

oav

1s882.04
6 State waqes, t ps, etc.
9 Local income

668 .02
17 State lncome tax

MT t45-5511516
I

15882.04
16 State waqes, tips, etc.

668 .02
17 State income tax

l5

State

EmDlover's state lD number

15

State

Emp oyer's state D number

8 Local wages, tips, etc.

ta;

Locality name

8 Local wages, tips, etc

9 Local lncome tax

Localrty name

Form W-2 Wage and Tax

orm W-2 Waqe and I ax Wage

Dept. of the Treasury

coDv B To tse l- rlecl wrth

FEDERAL Tax
a Employee's SSN

Emplovee's Return,
I Wages, trps, olner comp.

I I

zutz

Coov

)aqa/

oMe No. 1545'0008 z ledetal rncome tax wLthneld

??

32'/ .04
4 Socral secuflty lax wrlnne
6 Medicare tax withheld

Citvi or Local lncome Tax Relurh. I Wages, t ps, other comp. Employee's SSN
a

To Be Filed wlth Emplovee's state,

O[,48 No. 1545-0008 2 Fedetal income tax withheld

22594.33
aaqaA
??

32'/ -AA
4 Social security tax wrthheld

31 b

0-96-8293

J SOCral SeCUr ry Wages

Employer lD no. (ElN)

2.2594.33
5 lvledicare wages and tiPS

o/ a oe

31 b

A-96-8293

3 Soc al secuflty wages

Employer lD no. (ElN)

948
5 l\4edlcare tax w thhe d

.96

5 lvledicare wages and tlps

26-2623483

22594.33
LLC
B

321.62

26-2623483

22594 .33
LLC
B

321.62

c Employer's name, address, and Z P code

c Employer's name, address, and ZIP code

RIDI OIL

RIDI OIL

1620 WOODVILLE RD SUITE

1620 WOODVILLE RD SUITE

TOLEDO
d Control number
e Employee's name, address, and Z P

oH
code
"

43605

TOLEDO
d Control number
Suff e Employee's name, address, and ZIP

oH
code MI
SAllocated tLps
1 Nonqualrt

43605

DUSTIN PERKINS 8039 MCLAIN AVE

MI
48144

Suff

DUSTIN PERK]NS BO39 MCLAIN AVE

I,AMBERTVT

LAMBERTVILLE
7

LLE

4814

Socral secur ty ttPS Dependent care benefits

8 Al

ocated trps

I
12a Code

Social security tips Dependent care benefits

9:i

'l Nonqualrtred Plans

See inst. lor box I

ed plans

l2aCode See rnst. tor box l2

I

13
itatutory emp
oyee

'l4Other

2b Code

13
Itatutory employee

4 Other

2b Code 2c Code

12c Code
letrrement Plan ietirement Plan

12d Code
lhird-oartv sick
pav

12d Code
hird'oartv sick
pav

MII
I I

22594.33
Employer's stale lD number

)'1'l

MII
5
State

22594.33
Employer's state D number 6 Staie wages, tips, etc.
120

r211 .79
7 State rncome tax

15

Staie

l6 State waqes, iips,

etc

7 State ncome tax

18 Loca wages, lips, etc.

9 Local income tax

l0 Loca ity name

Local wages, t ps, etc.

9 Local income iax

rocatitv name

22594.33
and Tax Statement

508.38 Toledo
of the Treasury

22594.33
'
IRS

508 .3

roredo

Wage

,no h-rn.ned ro rhe lnrernal RevenJe Service

This information is being furnished to the lnternal Revenue Serv ce. lf you are requtred t0 flle a tax return, a oenaltv or Othr sanctiori may be rmposed on you f this income is taxable and you fa I to report lt.

neg ioence

QBN4B22C 1At10112

Copy C For EMPLOYEE'S RECORDS. (See Notice to Emplovees).

a Employees SSN

2012
OMB No. 1545'0008 2 Federal rncome tax wrthheld

Copy 2 To Be Filed With Employee's State, Citv. or Local lncome Tax Return.
a Employee's SSN

2012
OMB No. 1545-0008 2 Federa lncome tax withheld

Wages, trps, otner comp.

Wages, trps, other comp.

2)qqa
3 Social secur ty wages

??

321.04
4 Soctal secuflty tax wlthheld

22594.33
3 Socral secur ty wages

321.00
4 Social securLty tax w thhe d

31 b

0-96-8293

31 b

A-95-8293

Employer lD no. (ElN)

22594.33
5 Medicare wages and tiPS

948.9C
6 Medicare tax withheld

Employer lD no. (ElN)

)r^9a
5 Medicare wages and tips

??

948.96
6 Medicare tax withheld

26-2623483

22594.33
LLC
B

26-2623483

22594.33
LLC
B

321.62

c Employefs name, address, and ZIP code

c Emp oyer's name, address, and ZIP code

RIDI OIL

RIDI OIL

1620 WOODVILLE RD SUITE

1520 WOODVILLE RD SUITE

TOLEDO
d Control number
e Employee's name, address, and ZIP

oH
code

43605

TOLEDO
d Control number
e Employee's name, address, and ZIP Suff

oH
code

43605

Suff'

DUSTIN PERK]NS BO39 MCLAIN AVE

DUSTIN PERKINS 8039 MCLAIN AVE

LAMBERTVILLE
7

MT
8

Social security tlps Dependent care benefits

Allocated tros Nonqualified plans

t'

48744
7

LAMBERTVILLE
Soc

MT
SAllocated tlos
'I Nonqualif ed pLans

48144

security tips

'i
0

l2acode See inst. for box l2

'l2b Code
12c Code

Dependent care benefits

12a Code See lnst. for box I 2

Zb Code

'13
;tatutory empjoyee

l4Other

13
Statutory employee

I 4 (Jther

12c Code
Retirement Plan

ietLrement Plan

12d Code
ih rd-oartv srck
oaY

12d Code
Thrrd'party slck

MI
l5

)2\qa
l6 State waqes, t ps,
Z0

3?
etc.

1aa1
17 State income tax

L9

MII
State

pay

22594.3
1

L2'/1

.I9

I I

Siate

Emoiover's state lD number

I

l5

Emplover's state lD number

6 State wages, tips, etc,

l7 State ncome tax

8 Local wages, tips, etc.

9 Local income tax

Loca ity name

Local wages, t ps, etc.

9 Local lncome tax

22594.33
Wage and ax

s0B.3B Toledo

22594.33
Wage ax

508.3

120

Locat ty name

lroledo
ot the Treasury NTF r4e2

4U$)Pg$tFE *