Pearson v. Colt Oilfield Services, LLC et al

Western District of Texas, txwd-5:2018-cv-01029

Exhibit A

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EXHIBIT A 12V WARNA Tur IR Case 5: 18 - CV - 01029 - OLG Docu2 @ 171W - 2 and EARNINGS SUMMARY AP Employee Reference Copy Wage and Tax Statement OMB No. 1546 - 0008 Cory for employee ' arcondan d Control number Dept. Corp. Employer use only R3 / KDM c Employer's name, address, and ZIP code COLT OILFIELD SERVICES LLC 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 A This blue Earnings Summary section is included with your W - 2 to help describe portions in more detail. The reverse side includes general information that you may also find helpful. 1. The following information reflects your final 2017 pay stub plus any adjustments submitted by your employer. Gross Pay 110850. 00 Social Security 6872. 70 State Income Tax Tax Withheld Box 17 of W - 2 Box 4 of W - 2 Local Income Tax Fed. Income Medicare Tax Box 19 of W - 2 12013. 98 1607, 33 Tax Withheld Withheld SUISDI Box 2 of W - 2 Box 6 of W - 2 Box 14 of W - 2 Batch # 99041 2. Your Grass Pay was adjusted as follows to produce your W - 2 Statement. Wages, Tips, other Social Security Medicare Compensation Wages Wages Box 1 of W - 2 Box 3 of W - 2 Box 5 of W - 2 eft Employee's name, address, and ZIP code DOUGLAS B PEARSON LN DOUGLAS LINE 71037 Gross Pay Reported W - 2 Wages 110, 850, 00 110, 850. 00 110, 850. 00 110, 850. 00 110, 850. 00 1 10, 850. 00 6 Employer's FED ID number Ta Employee's SSA number 26 - 3638316 1300 1 Wages, ups, other comp. 2 Federa * Withheld 110850. 00 12013. 98 3 Social security wagas 4 Social security tax withheld 110850. 00 6872. 70 5 Medicare wages and tips 6 Medicare tax withheld 110850. 00 1607. 33 7 Social security tips 8 Allocated tps 8 Verification Code 10 Dependent care benefits 3. Employee W - 4 Profile. To change your Employee W - 4 Profile Information, file a new W - 4 with your payroll dept. 11 Nonqualified plans 128 Seo Instructions for box 12 14 Other DOUGLAS B PEARSON LA 71037 12b 12c 120 13 Stat emp Rat. plangrd party sick pay 331. 54 DENTAL 4097. 28 MEDICA 87. 78 VISION Social Security Number: 300 Taxable Marital Status: MARRIED Exemptions / Allowances: FEDERAL: 2 1. 15 State Employer's state - ID - no. 116 - State - wages, - tips, etc. - - - - - - - - - - - - - - - DEL 17 State Income tax 18 Local wages, tips, ato. 19 Local income tax 20 Locality name © 2017 ADP, uc 6872. 70 1 Wages, tips, other comp. 2 Federal income tax withheld 110850. 00 12013. 98 3 Social security, wages 4 Social security tax with held 110850. 00 6872. 70 15 Medicare wages and dips 6 Medicare tax withheld 110850. 00 1607. 33 d Control number Dept. Corp. Employer use only 000017 R3 / KDM C Employer's name, address, and ZIP code COLT OILFIELD SERVICES LLC 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 11 Wages, tips, other comp. T2 Federal Income tax withheld 110850. 00 12013. 98 13 Social Security wages 4 Social security tax withheld 110850. 00 6872. 70 5 Medicare wages and tips 6 Medicare tax withheld 110850. 00 1607. 33 Id Control number Dept. Corp. Employer use only 1000017 R3 / KDM А C Employer's name, address, and ZIP code COLT OILFIELD SERVICES LLC 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 1 Wages, tips, other comp. Federal income tax withheld 110850. 00 12013. 98 3 social security wages 4 Social security tax withheld 110850. 00 5 Medicare wages and tips, 6 Medicare tax withheld 110850. 00 1607. 33 d Control number Dept. Corp. Employer use only 1000017 R3 / KDM C Employer's name, address, and ZIP code COLT OILFIELD SERVICES LLC 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 D 6 Employer's FED ID number 26 - 3638316 17 Social Security dps a Employee's USA number 1300 8 Alloca Employer's FED ID number Ta Employee's SSA number 26 - 3638316 7300 Social security tips 8 Alloc Employer's FED ID number 26 - 3638316 Social security tips a Employee's SSA number (300 8 Alloce 7 9 Verification Code 10 Dependent care benefits Verification Code 10 Dependent care benefits 9 Verification Code 10 Dependent care benefits 77 Nonqualified plans 12a See Instructions for box 12 11 Nonqualified plans 11 Nonqualified plans 14 Other 14 Other 14 Other 126 12C 120 1120 331. 54 DENTAL 4097. 28 MEDICA 87. 78 VISION 331. 54 DENTAL 4097. 28 MEDICA 87. 78 VISION 120 331. 54 DENTAL 4097. 28 MEDICA 87. 78 VISION 112d 113 Stat emp Ret plan 3rd party sick pay 13 Stat emp Ret plan 3rd party alck pay 13 Stat emp Rot. plan 3rd party sick pay elf Employee's name, address and ZIP code DOUGLAS B PEARSON LN LA 71037 eft Employee's name, address and ZIP code DOUGLAS B PEARSON LN LA 71037 elf Employee's name, address and ZIP code DOUGLAS B PEARSON. . . LN LA 71037 | 15 gr. Employer's state ID no. 116 State wages, tips, etc. 15 State Employer's state ID no. 16 State wages, tips, etc. 16 State Employer's state ID no. 16 State wages, tips, etc. 17 Sezier income tax | 18 Local wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 17 State Income tax 18 Local wages, tips, etc. 19 Local Income tax 20 Locality name 19 Local Income tax 20 Locality name Copy 19 Local income tax 20 Locality name Federal Filing Copy Wage and Tax Statement CopyB to be filed with employee's Federal Income Tax Return State Reference Wage and Tax Statement ity or Local Reference Copy Wage and Tax Statement Copy 2 to be filled with employeo ' sCity or Local Income Tax Rotüm. QMB No. 1545 - 0008 OMB No. 1645 - 0008 Copy 2 to be filled with employee's State Income Tax Retur. OMB No. 1545 - 0008