Pearson v. Colt Oilfield Services, LLC et al

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

Exhibit B

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EXHIBIT WINTE. . . 2017 W - 2 and EARNINGS SUMMARY AP Employee Reference Copy Wage and Tax Statement OMB No. 1646 - 0008 Canvc faremployer ' srecords d Control number Depi. Employor use only 000021 R3 / KDM C Employor's name, address, and ZIP code COLT OILFIELD SERVICES corp This blue Earnings Summary section is included with your W - 2 to help describe portions in more detalt. The reverse side includes general information that you may also find helpful. 1. The following information rallacts your final 2017 pay stub plus any adjustments submitted by your employer. Gross Pay 93025. 00 Soojal Securlty 5767. 55 Stata Income Tax Tax Withheld 8ox 17 of W - 2 Box 4 of W - 2 Local Income Tax Fed. Income Box 19 of W - 2 17670. 46 Medloare Tax 1348. 86 Tax Withheld Withheld SUUSDI Box 2 of W - 2 Box 6 of W - 2 Box 14 of W - 2 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 Batch # 99041 2. Your Gro88 Pay was adjusted as follows to produce your W - 2 Statement. Wages, Tips, other Social Security Medicare Compensation Wages Wagos Box 1 of W - 2 Box 3 of W - 2 Box 5 of W - 2 olf Employoo's name, address, and ZIP codo JAMES ADKINS ca 75633 Gross Pay Reported W - 2 Wages 93, 025. 00 93, 025, 00 93, 025. 00 93, 025. 00 93, 025. 00 9 3, 025. 00 TAM www b Employor ': FED ID number 26 - 3638376 7 Wages, (ips, other comp. 93025. 00 3 Social security wages 93025. 00 5 Modicara wages and tips 93025. 00 17 Soclal security tips 0 Vernication Code Employee's 99A number 437 - 71 - 5074 2 Federal Income tax withheld 17670. 48 4 Social security tax withheld 5767. 55 6 Medlcare tax withheld 1348. 86 8 Allocated tips 110 Dependent care benefits 3. Employee W - 4 Profile. To change your Employee W - 4 Profile Information file a new W4 with your payroll dort. 11 Nonquallflod plans 12a ses instructionslor box 12 074 SINGLE 12b 1120 wwwwwwwwwwwwww 120 JAMES ADKINS TX 75633 w 14 Other 381. 78 DENTAL 2743. 02 MEDICA 76. 14 VISION 13 Statomp Rel. planard party slok pay 15 - State - Employer's atato - D no: 16 State Wagon, tips, etc. w Social Security Number: Taxable Marital Status: Exemptlons / Allowances: FEDERAL: 0 17 State Income tax 18 Local Wages, tips, etc. 18 Local income tax 20 Locality name 2017 ADP, UC 5767. 55 5767. 55 mammas 11 Wagoe, tips, other comp. 12 Federal Income tax withhold 93025. 00 17670. 46 3 Sodlal security wagos 14 Social security tax withheld 93025. 00 6 Medicare wages, 30025. 00 6 Medicare tax withheld 1348. 86 a Control number Dept. Employat We only 000021 R3 / KDM ГА o Employer's name, addrass, and ZIP code COLT OILFIELD SERVICES LLC 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 1 Wages, tips, other comp, 2 Federal Income tax withh 93025. 00 17670. 46 3 Soolel soourlty wagos 4 Social security tax withhold 93025. 00 6 Medicare wagos and tips 8 Medicare tax withhold. . " 93026. 00 1348. 86 • Control number Dopt. Corp. Employer use only 000021 R3 / KDM C Employer's name, addrost, and ZIP codo COLT OILFIELD SERVICES LLC 17116 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 1 Wagas, tips, other comp. Federal Income tax withheld 93025. 00 17670. 48 3 Social security wagas 14 Goolal security tax withheld 93025. 00 5767. 55 6 Medloare wages and dp 6 Medicare tax withheld 93025. 00 1348. 88 d Control number 1 Dept. Corp. Employer use only 000021 R3 / KM C Employer's name, addroos, and ZIP code COLT OILFIELD SERVICES A LA N 17115 SAN PEDRO AVE STE 320 SAN ANTONIO, TX 78232 b D 6 2 Employee's SBA number Employer's FED _ ID number 26 - 3638316 social security tips a EmployRRA number 024 8 Allocal - Employer's FED ID number 28 - 3838316 social security tips a Employeo's 88A number 1074 8 Alloca ! Employer's FED ID number 28 - 3638316 Social security tips 074 7 7 8 Alloch 9 Vorification Codo 10 Depondent care benefits 9 Vorification Code 10 Dependent care benefits o Verification Codo 10 Dopendont care benefits 11 Nonqualified plans (12a Soo Instruotons for box 12 (11 Nonqualified plans 11 Nonqualified plans 14 Olhor 12b 14 Other 14 Other > 2 120 381. 78 DENTAL 2743. 02 MEDICA 78. 14 VISION rad 3B1. 78 DENTAL 2743, 02 MEDICA 78. 14 VISION 12 381. 78 DENTAL 2743, 02 MEDICA 78. 14 VISION 120 13 Stat om tomp Ral plan and party alak pay 13 Stat omplRat. plan 3rd party sick pay 13 Stat amp Ret. plan 3rd party sick pay elf Employee's name, address and ZIP code JAMES ADKINS of Employer's name, address and ZIP code JAMES ADKINS elf Employeo's name, address and ZIP code JAMES ADKINS 633 75633 75633 MW 15 State Employer's state ID no. 18 Stato wages, tips, etc. 16 State Employer ' e stato ID no. 16 Slato wagoy, tips, eto. 16 Slate Employer's atato ID no. 16 Siata wagos, eps, eto. 17 State Income tax 18 Local wager, tips, sto. 17 Slalo Income tex 18 Local wages, upe, eto. 17 State Income tax 18 Local wagos, tips, oto. 119 Local income tax 20 Locality mama 19 Local income tax 20 Locality name Federal Filing Copy Wage and Tax Statement State Reference Copy Wage and Tax Statement Copy 2 to be filed with omployeo ' State incomo Tax Return. " OMS Mo. 1646 - 0008 19 Local Income tax 20 Locallty name City or Local Reference Copy Wage and Tax Statement Copy 2 to bo fled with employee ' sCity or Local Income Tax Return M. 1675. 000 Copy ] QMA No. 1815. 000 Federallncome Tax Return. ' lobe flled with employeo's