10 Yes No No No No No No 95-4678910 CA 445-6789 Sample Company 111 Crooked Lane Suite 10 Fullerton CA 92831 Stella Hartono stellahartono@go.com 714-555-1111 714-555-2222 Wages, Tips, and Other Compensation 100000 Federal Income Tax Witheld 25000 Social Security Wages 100000 Social Security Tax Witheld 7000 Medicare Wages and Tips 100000 Medicare Tax Witheld 2500 State Wages and Tips 100000 State Income Tax Witheld 1000