Beruflich Dokumente
Kultur Dokumente
000-00-4310
Void
00-0000972
34,580.00
37,180.00
Omni Corporation
4800 River Road
Philadelphia, PA
Last name
Nonqualified plans
Allocated tips
2,305.16
539.24
12a
Code
13 Statutory
employee
54 Gradison Place
Philadelphia, PA 19113-4054
$
11
Suff.
Kellison
3,172.00
10
Randy A.
$
9
$
d Control number
37,180.00
19113-5548
Retirement
plan
Third-party
sick pay
$ 2,600.00
12b
Code
X
14
12c
Other
Code
12d
f
Employees address and ZIP code
15 State
Employers state ID number
16
PA
00-0-1066
W-2
$
$
17
$
$
37,180.00
18
Code
$
19
Local income tax
1,141.40 $ 37,180.00 $
$
20
Locality name
PHILA
1,457.56
201-
(b)
22222
000-00-8804
Void
00-0000972
c Employers name, address, and ZIP code
Omni Corporation
4800 River Road
Philadelphia, PA
19113-5548
47,580.00
51,220.00
51,220.00
Vince T.
Last name
Roper
Nonqualified plans
Allocated tips
3,120.00
3,175.64
742.56
Dependent care benefits
950.00
Code
13 Statutory
employee
Retirement
plan
Third-party
sick pay
$ 3,648.00
12b
Code
X
14
12a
$
11
Suff.
10
$
e Employees first name and initial
$
9
d Control number
12c
Other
Code
12d
f
Employees address and ZIP code
15 State
Employers state ID number
16
PA
00-0-1066
W-2
$
$
51,220.00
17
$ 1,572.48
$
201-
18
$
$
Code
$
19
Local income tax
51,220.00 $ 2,007.72
20
Locality name
PHILA
413B. (Continued)
(c)
22222
000-00-3316
Void
00-0000972
39,780.00
19113-5548
Last name
Murray T.
Rodson
Nonqualified plans
Third-party
sick pay
W-2
$
$
Code
12c
14
Other
39,780.00
17
18
$ 1,221.48
$
Code
12d
1 0 2
State wages, tips, etc.
$
$
12b
UNION DUES
00-0-1066
576.68
12a
Retirement
plan
employee
PA
Allocated tips
Code
13 Statutory
f
Employees address and ZIP code
15 State
Employers state ID number
16
2,466.36
10
$
11
Suff.
5,148.00
$
e Employees first name and initial
$
d Control number
39,780.00
39,780.00
Omni Corporation
4800 River Road
Philadelphia, PA
$ 39,780.00
$
Code
$
19
Local income tax
20
Locality name
PHILA
$ 1,559.48
$
201-
(d)
22222
000-00-6839
Void
00-0000972
92,562.75
97,762.75
Omni Corporation
4800 River Road
Philadelphia, PA
Frank A.
Last name
Kent
Allocated tips
6,061.29
1,417.69
10
Nonqualified plans
Code
13 Statutory
employee
Retirement
plan
Third-party
sick pay
12b
Code D
X
14
12a
5,501.60
$
11
Suff.
$
e Employees first name and initial
$
d Control number
97,762.75
19113-5548
$ 262.75
$ 5,200.00
12c
Other
Code
12d
f
Employees address and ZIP code
15 State
Employers state ID number
16
PA
00-0-1066
W-2
$
$
97,500.00
17
18
$ 2,993.12 $ 97,500.00
$
$
201-
Code
$
19
Local income tax
$ 3,822.00
$
20
Locality name
PHILA
*Including cost of C, Group-Term Life Insurance, reported and included in Boxes 1, 3, and 5.
413B. (Continued)
(e)
22222
000-00-5771
Void
00-0000972
40,560.00
Last name
Carlie C.
Nonqualified plans
Third-party
sick pay
W-2
$
$
Code
12c
14
Other
40,560.00
17
Code
12d
102 . 0 0
State wages, tips, etc.
$
$
12b
UNION DUES
00-0-1066
588.12
12a
Retirement
plan
employee
PA
Allocated tips
Code
13 Statutory
f
Employees address and ZIP code
15 State
Employers state ID number
16
2,514.72
10
$
11
Suff.
Christian
1,248.00
$
e Employees first name and initial
$
d Control number
40,560.00
19113-5548
40,560.00
Omni Corporation
4800 River Road
Philadelphia, PA
18
Code
$
19
Local income tax
20
Locality name
PHILA
201-
(f)
22222
000-00-8703
Void
00-0000972
3
5
Zana W.
Last name
Amelia
10
PA
00-0-1066
W-2
$
$
Nonqualified plans
Code
Retirement
plan
Third-party
sick pay
17
$
$
Code
Code
1261.00
201-
$ 2600.00
$
12c
Other
12b
X
14
12a
EDUC. ASSIST
675.00
41080.00
employee
Allocated tips
13 Statutory
f
Employees address and ZIP code
15 State
Employers state ID number
16
595.92
8
11
Suff.
2546.96
6
$
e Employees first name and initial
$
d Control number
4420.00
4
41080.00
19113-5548
41080.00
Omni Corporation
4800 River Road
Philadelphia, PA
38480.00
18
$
$
41080.00
12d
Code
$
19
Local income tax
$
$
1612.00
20
Locality name
PHILA
413B. (Concluded)
DO NOT STAPLE OR FOLD
941
Kind
Of
Payer
c
a Control number
33333
CT-1
Military
943
944
$
Hshld. Medicare
emp. govt. emp.
Third-party
sick pay
d Establishment number
307,582.75
7 Social security tips
$
10 Dependent care benefits
OMNI CORPORATION
4800 RIVER ROAD
PHILADELPHIA, PA
19113-5548
4,460.21
8 Allocated tips
Employers name
19,070.13
307,582.75
22,609.60
4 Social security tax withheld
00-0000972
f
6
e
293,543.75
950.00
11 Nonqualified plans
12 Deferred compensation
14,048.00
15 State
PA
00-0-1066
16
17
307,320.00
9,434.88
307,320.00
$
Contact person
Telephone number
VINCENT T. ROPER
E-mail address
12,048.92
For Official Use Only
(215) 555-0017
Fax number
N/A
(215) 555-0010
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 4
Form
W-3
Frank A. Kent
Title 4
President
Date 4
201--
11/13/16
Department of the Treasury
Internal Revenue Service