Attachment W-2

This document pretains to FCN-NEW-INTR2011-01770 for New Application on a Foreign Carrier Notification filing.

IBFS_FCNNEWINTR201101770_894261

Form W-2 Wage and Tax Statement 2010 OMB No. 1545-0008 Department of the Treasury -- Internal Revenue Service a Employee's social security No. Copy 1 For State, City, or Local Tax Department. 1 Wages, tips, other Comp. 2 Federal income tax withheld 339-66-4416 $0.01 $0.00 c Employer's name, address, and ZIP code b Employer I.D. number 3 Social security wages 4 Social security tax withheld UNITED STATES PATENT 1781100 38-3751164 $0.00 $0.00 CHICAGO, IL 60643 d Control number 5 Medicare wages and tips 6 Medicare tax withheld $0.00 $0.00 7 Social security tips 8 Allocated tips 9 Advance EIC payment $0.00 $0.00 $0.00 e Employee's first, initial, and last names, and suffix 10 Dependent care benefits 11 Nonqualified plans Stat. 13 Empl. Retirement 3rd-party plan sick pay BRAIN GAYLORD $0.00 $0.00 49 W 118TH ST 12a Code See Inst. for box 12 12b Code 14 Other CHICAGO, IL 60628-6142 $0.00 $0.00 12c Code 12d Code $0.00 f Employee's address and ZIP code $0.00 $0.00 $0.00 15 State Employer's state ID No. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ------------------------------------------------------------------------------ Form W-2 Wage and Tax Statement 2010 OMB No. 1545-0008 Department of the Treasury -- Internal Revenue Service a Employee's social security No. Copy 2 To Be Filed With Employee's State, City, or Local Income Tax Return 1 Wages, tips, other Comp. 2 Federal income tax withheld 339-66-4416 $0.01 $0.00 c Employer's name, address, and ZIP code b Employer I.D. number 3 Social security wages 4 Social security tax withheld UNITED STATES PATENT 1781100 38-3751164 $0.00 $0.00 CHICAGO, IL 60643 d Control number 5 Medicare wages and tips 6 Medicare tax withheld $0.00 $0.00 7 Social security tips 8 Allocated tips 9 Advance EIC payment $0.00 $0.00 $0.00 e Employee's first, initial, and last names, and suffix 10 Dependent care benefits 11 Nonqualified plans Stat. 13 Empl. Retirement 3rd-party plan sick pay BRAIN GAYLORD $0.00 $0.00 49 W 118TH ST 12a Code See Inst. for box 12 12b Code 14 Other CHICAGO, IL 60628-6142 $0.00 $0.00 12c Code 12d Code $0.00 f Employee's address and ZIP code $0.00 $0.00 $0.00 15 State Employer's state ID No. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ------------------------------------------------------------------------------ Form W-2 Wage and Tax Statement 2010 OMB No. 1545-0008 Department of the Treasury -- Internal Revenue Service a Employee's social security No. Copy C For EMPLOYEE'S Records (See Notice to Employee on back of Copy B.) 1 Wages, tips, other Comp. 2 Federal income tax withheld This information is being furnished to the Internal Revenue Service. 339-66-4416 $0.01 $0.00 c Employer's name, address, and ZIP code b Employer I.D. number 3 Social security wages 4 Social security tax withheld UNITED STATES PATENT 1781100 38-3751164 $0.00 $0.00 CHICAGO, IL 60643 d Control number 5 Medicare wages and tips 6 Medicare tax withheld $0.00 $0.00 7 Social security tips 8 Allocated tips 9 Advance EIC payment $0.00 $0.00 $0.00 e Employee's first, initial, and last names, and suffix 10 Dependent care benefits 11 Nonqualified plans Stat. 13 Empl. Retirement 3rd-party plan sick pay BRAIN GAYLORD $0.00 $0.00 49 W 118TH ST 12a Code See Inst. for box 12 12b Code 14 Other CHICAGO, IL 60628-6142 $0.00 $0.00 12c Code 12d Code $0.00 f Employee's address and ZIP code $0.00 $0.00 $0.00 15 State Employer's state ID No. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 If you are required to file a tax return, a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it. ------------------------------------------------------------------------------ Form W-2 Wage and Tax Statement 2010 OMB No. 1545-0008 Department of the Treasury -- Internal Revenue Service a Employee's social security No. Copy B To Be Filed with Employee's FEDERAL Tax Return. 1 Wages, tips, other Comp. 2 Federal income tax withheld This information is being furnished to the Internal Revenue Service. 339-66-4416 $0.01 $0.00 c Employer's name, address, and ZIP code b Employer I.D. number 3 Social security wages 4 Social security tax withheld UNITED STATES PATENT 1781100 38-3751164 $0.00 $0.00 CHICAGO, IL 60643 d Control number 5 Medicare wages and tips 6 Medicare tax withheld $0.00 $0.00 7 Social security tips 8 Allocated tips 9 Advance EIC payment $0.00 $0.00 $0.00 e Employee's first, initial, and last names, and suffix 10 Dependent care benefits 11 Nonqualified plans Stat. 13 Empl. Retirement 3rd-party plan sick pay BRAIN GAYLORD $0.00 $0.00 49 W 118TH ST 12a Code See Inst. for box 12 12b Code 14 Other CHICAGO, IL 60628-6142 $0.00 $0.00 12c Code 12d Code $0.00 f Employee's address and ZIP code $0.00 $0.00 $0.00 15 State Employer's state ID No. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Notice to Employee Refund. Even if you do not have to file a tax return, you should file Clergy and religious workers. If you are not subject to social to get a refund if box 2 shows federal income tax withheld or if you security and Medicare taxes, see Pub. 517, Social Security and can take the earned income credit. Other Information for Members of the Clergy and Religious Workers. Earned income credit (EIC). You must file a tax return if any Corrections. If your name, SSN, or address is incorrect, correct amount is shown in box 9. Copies B, C, and 2 and ask your employer to correct your employment record. Be sure to ask the employer to file Form W-2c, You may be able to take the EIC for 2010 if (a) you do not have a Corrected Wage and Tax Statement, with the Social Security qualifying child and you earned less than $13,460 ($18,470 if Administration (SSA) to correct any name, SSN, or money amount married filing jointly), (b) you have one qualifying child and you error reported to the SSA on Form W-2. If your name and SSN are earned less than $35,535 ($40,545 if married filing jointly), or (c) you correct but are not the same as shown on your social security card, have two qualifying children and you earned less than $40,363 you should ask for a new card that displays your correct name at ($45,373 if married filing jointly), or (d) you have three or more any SSA office or call 1-800-772-1213. You also may visit the SSA qualifying children and you earned less than $43,352 ($48,362 if at www.socialsecurity.gov. married filling jointly). You and any qualifying children must have valid social security numbers (SSNs). You cannot take the EIC if Credit for excess taxes. If you had more than one employer in your investment income is more than $3,100. Any EIC that is more 2010 and more than $6,621.60 in social security and/or Tier I than your tax liability is refunded to you, but only if you file a railroad retirement (RRTA) taxes were withheld, you may be able to tax return. If you have at least one qualifying child, you may get as claim a credit for the excess against your federal income tax. If you much as $1,830 of the EIC in advance by completing Form W-5, had more than one railroad employer and more than $3,088.80 in Earned Income Credit Advance Payment Certificate, and giving it to Tier II RRTA tax was withheld, you also may be able to claim a your employer. credit. See your Form 1040 or Form 1040A instructions and Pub. 505, Tax Withholding and Estimated Tax. (Also see Instructions for Employee on the back of Copy C.) ------------------------------------------------------------------------------ Instructions Box 1. Enter this amount on the wages line of your tax return. E - Elective deferrals under a section 403(b) salary reduction agreement Box 2. Enter this amount on the Federal income tax withheld line of your tax F - Elective deferrals under a section 408(k)(6) salary reduction SEP return. G - Elective deferrals and employer contributions (including nonelective Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on deferrals) to a section 457(b) deferred compensation plan how to report tips on your tax return, see your Form 1040 instructions. H - Elective deferrals to a section 501(c)(18)(D) tax-exempt organization Box 9. Enter this amount on the advance earned income credit payments plan. See "Adjusted Gross Income" in the Form 1040 instructions for how to line of your Form 1040 or Form 1040A. deduct. Box 10. This amount is the total dependent care benefits that your employer J - Nontaxable sick pay (information only, not included in boxes 1, 3, or 5) paid to you or incurred on your behalf (including amounts from a section 125 K - 20% excise tax on excess golden parachute payments. See "Total Tax" (cafeteria) plan). Any amount over $5,000 also is included in box 1. Complete in the Form 1040 instructions. Form 2441, Child and Dependent Care Expenses, to compute any taxable L - Substantiated employee business expense reimbursements (nontaxable) and nontaxable amounts M - Uncollected social security or RRTA tax on taxable cost of group-term life Box 11. This amount is (a) reported in box 1 if it is a distribution made to you insurance over $50,000 (former employees only). See "Total Tax" in the from a nonqualified deferred compensation or nongovernmental section Form 1040 instructions. 457(b) plan or (b) included in box 3 and/or 5 if it is a prior year deferral under N - Uncollected Medicare tax on taxable cost of group-term life insurance a nonqualified or section 457(b) plan that became taxable for social security over $50,000 (former employees only). See "Total Tax" in the Form 1040 and Medicare taxes this year because there is no longer a substantial risk of instructions. forfeiture of your right to the deferred amount. P - Excludable moving expense reimbursements paid directly to employee Box 12. The following list explains the codes shown in box 12. You may (not included in boxes 1, 3, or 5) need this information to complete your tax return. Elective deferrals (codes D, Q - Nontaxable combat pay. See the instructions for Form 1040 or Form E, F, and S) and designated Roth contributions (codes AA and BB) under all 1040A for details on reporting this amount. plans are generally limited to a total of $16,500 ($11,500 if you only have R - Employer contributions to your Archer MSA. Report on Form 8853, SIMPLE plans; $19,500 for section 403(b) plans if you qualify for the 15-year Archer MSAs and Long-Term Care Insurance Contracts. rule explained in Pub. 571). Deferrals under code G are limited to $16,500. S - Employee salary reduction contributions under a section 408(p) SIMPLE Deferrals under code H are limited to $7,000. (not included in box 1) However, if you were at least age 50 in 2010, your employer may have T - Adoption benefits (not included in box 1). Complete Form 8839, Qualified allowed an additional deferral of up to $5,500 ($2,500 for section 401(k)(11) Adoption Expenses, to compute any taxable and nontaxable amounts and 408(p) SIMPLE plans). This additional deferral amount is not subject to V - Income from exercise of nonstatutory stock option(s) (included in boxes 1, the overall limit on elective deferrals. For code G, the limit on elective 3 (up to social security wage base), and 5). See Pub. 525 and instructions for deferrals may be higher for the last 3 years before you reach retirement age. Schedule D (Form 1040) for reporting requirements. Contact your plan administrator for more information. Amounts in excess of W - Employer contributions (including amounts the employee elected to the overall elective deferral limit must be included in income. See the contribute using a section 125 (cafeteria) plan) to your health savings "Wages, Salaries, Tips, etc." line instructions for Form 1040. account. Report on Form 8889, Health Savings Accounts (HSAs). Note: If a year follows code D through H, S, Y, AA, or BB, you made a Y - Deferrals under a section 409A nonqualified deferred compensation plan. make-up pension contribution for a prior year(s) when you were in military Z - Income under section 409A on a nonqualified deferred compensation service. To figure whether you made excess deferrals, consider these plan. This amount is also included in box 1. It is subject to an additional 20% amounts for the year shown, not the current year. If no year is shown, the tax plus interest. See "Total Tax" in the Form 1040 instructions. contributions are for the current year. AA - Designated Roth contributions to a section 401(k) plan. A - Uncollected social security or RRTA tax on tips. Include this tax on Form BB - Designated Roth contributions under a section 403(b) plan. 1040. See "Total Tax" in the Form 1040 instructions. CC(For employer use only)-HIRE exempt wages and tips. B - Uncollected Medicare tax on tips. Include this tax on Form 1040. See Box 13. If the "Retirement plan" box is checked, special limits may apply to "Total Tax" in the Form 1040 instructions. the amount of traditional IRA contributions that you may deduct. C - Taxable cost of group-term life insurance over $50,000 (included in boxes Note: Keep Copy C of Form W-2 for at least 3 years after the due date for 1, 3 (up to social security wage base), and 5) filing your income tax return. However, to help protect your social security D - Elective deferrals to a section 401(k) cash or deferred arrangement. Also benefits, keep Copy C until you begin receiving social security benefits, just includes deferrals under a SIMPLE retirement account that is part of a in case there is a question about your work record and/or earnings in a section 401(k) arrangement. particular year. Compare the Social Security wages and the Medicare wages to the information shown on your annual (for workers over 25) Social Security Statement.

a Employee's social security No. 339-66-4416 OMB No. 1545-0008 b Employer identification number 1 Wages, tips, other compensation 2 Federal income tax withheld 38-3751164 $0.01 $0.00 c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld UNITED STATES PATENT 1781100 $0.00 $0.00 CHICAGO, IL 60643 5 Medicare wages and tips 6 Medicare tax withheld $0.00 $0.00 7 Social security tips 8 Allocated tips $0.00 $0.00 d Control Number 9 Advance EIC payment 10 Dependent care benefits $0.00 $0.00 C e Employee's first, initial, and last names, and suffix 11 Nonqualified plans o 12a d BRAIN GAYLORD $0.00 e $0.00 49 W 118TH ST 13 Statutory Retirement 3rd-party C 12b employee plan sick pay o CHICAGO, IL 60628-6142 d e $0.00 C 14 Other o 12c d e $0.00 $0.00 C o 12d d $0.00 e $0.00 f Employee's address and ZIP code 15 State Employer's state ID No. 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name $0.00 $0.00 $0.00 $0.00 - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -------------------- -------------------- -------------------- -------------------- ------------------ $0.00 $0.00 $0.00 $0.00 Wage and Tax Department of the Treasury -- Internal Revenue Service Form W-2 Statement 2010 Copy D For Employer. For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Employers, Please Note--- Specific information needed to complete Form W-2 is Need Help? If you have questions about reporting on available in a separate booklet titled 2010 Instructions Form W-2, call the information reporting customer for Forms W-2 and W-3. You can order those service site toll free at 1-866-455-7438 or instructions and additional forms by calling 304-263-8700 (not toll free). For TTY/TDD equipment, 1-800-TAX-FORM (1-800-829-3676). You can also call 304-579-4827 (not toll free). The hours of get forms and instructions from the IRS website at operation are 8:30 a.m. to 4:30 p.m., Eastern time. www.irs.gov. Due dates. Furnish Copies B, C, and 2 to the employee generally by January 31, 2011. For employer records only! Do not send this form to the Social Security Administration. The information contained on this form was submitted to the Social Security Administration on 06/15/2011. The Wage File ID (WFID) assigned to this submission is:NDG157.

a Control number For official use only OMB No. 1545-0008 b 941 Military 943 944 1 Wages, tips, other compensation 2 Federal income tax withheld Kind X $0.01 $0.00 of Hshld. Medicare Third-party CT-1 Emp. Govt. Emp. sick pay 3 Social security wages 4 Social security tax withheld payer $0.00 $0.00 c Total number of Forms W-2 d Establishment number 5 Medicare wages and tips 6 Medicare tax withheld 1 $0.00 $0.00 e Employer identification number 7 Social security tips 8 Allocated tips 38-3751164 $0.00 $0.00 f Employer's name 9 Advance EIC payments 10 Dependent care benefits UNITED STATES PATENT 1781100 $0.00 $0.00 ------------------------------------------------------ CHICAGO, IL 60643 11 Nonqualified plans 12a Deferred compensation $0.00 $0.00 13 For third-party sick pay use only 12b HIRE exempt wages and tips $0.00 14 Income tax withheld by payer of third-party sick pay g Employer's address and ZIP code $0.00 h Other EIN used this year 15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax $0.00 $0.00 18 Local wages, tips, etc. 19 Local income tax $0.00 $0.00 Contact person Telephone number For official use only BRAIN GAYLORD TOSCANA 773-264-4609 E-mail address Fax number msbrain@att.net 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. YOUR COPY Signature Title Date Form W-3 Transmittal of Wage and Tax Statements 2010 Department of the Treasury Internal Revenue Service Purpose of Form A Form W-3 Transmittal is completed only when paper Copy A of Form(s) W-2, Wage and Tax Statement, are 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). For employer records only! Do not send this form to the Social Security Administration. The information contained on this form was submitted to the Social Security Administration on 06/15/2011. The Wage File ID (WFID) assigned to this submission is:NDG157. For Privacy Act and Paperwork Reduction Act Notice, see the 2010 Instructions for Forms W-2 and W-3.


Document Created: 2011-06-15 21:12:41
Document Modified: 2011-06-15 21:12:41
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