a Employee’s social security number For Official Use Only ▶

22222 VOID
35333333-72-9623
-72-9623
353-72-9623 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
36-2835724 164,436 32,537.64
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

BALLY TOTAL FITNESS 164,436 10,194.96

45 E 55TH ST 5 Medicare wages and tips 6 Medicare tax withheld

NEW YORK, NY 10022 164,436 2,384.32

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
RICK J SUERO d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay
311 LATHAM RD C
o
d
e
MINEOLA, NY 11501 14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

NY 164,436 10293.62

Form W-2 Wage and Tax Statement

Copy A—For Social Security Administration. Send this entire page with
2020 Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see the separate instructions.
Form W-3 to the Social Security Administration; photocopies are not acceptable. Cat. No. 10134D

Do Not Cut, Fold, or Staple Forms on This Page

 a Employee’s social security number
22222 353-72-9623 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
36-2835724 164,436 32,537.64
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
BALLY TOTAL FITNESS 164,436 10,194.96
45 E 55TH ST 5 Medicare wages and tips 6 Medicare tax withheld
NEW YORK, NY 10022 164,436 2,384.32
7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
RICK J SUERO d
e

13 Statutory Retirement Third-party 12b

311 LATHAM RD employee plan sick pay C
o
d
MINEOLA, NY 11501 e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

NY 164,436 10293.62

Form W-2 Wage and Tax Statement

Copy 1—For State, City, or Local Tax Department
2020 Department of the Treasury—Internal Revenue Service
 a Employee’s social security number Safe, accurate, Visit the IRS website at
OMB No. 1545-0008 FAST! Use www.irs.gov/efile

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

Form W-2 Wage and Tax Statement

Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
2020 Department of the Treasury—Internal Revenue Service

This information is being furnished to the Internal Revenue Service.

Notice to Employee W-2c, Corrected Wage and Tax Statement, with the Social
Security Administration (SSA) to correct any name, SSN, or money
Do you have to file? Refer to the Instructions for Forms 1040 amount error reported to the SSA on Form W-2. Be sure to get
and 1040-SR to determine if you are required to file a tax return. your copies of Form W-2c from your employer for all corrections
Even if you don’t have to file a tax return, you may be eligible for made so you may file them with your tax return. If your name and
a refund if box 2 shows an amount or if you are eligible for any SSN are correct but aren’t the same as shown on your social
credit. security card, you should ask for a new card that displays your
Earned income credit (EIC). You may be able to take the EIC correct name at any SSA office or by calling 800-772-1213. You
for 2020 if your adjusted gross income (AGI) is less than a may also visit the SSA website at www.SSA.gov.
certain amount. The amount of the credit is based on income Cost of employer-sponsored health coverage (if such cost is
and family size. Workers without children could qualify for a provided by the employer). The reporting in box 12, using
smaller credit. You and any qualifying children must have valid code DD, of the cost of employer-sponsored health coverage is
social security numbers (SSNs). You can’t take the EIC if your for your information only. The amount reported with code DD
investment income is more than the specified amount for 2020 is not taxable.
or if income is earned for services provided while you were an
inmate at a penal institution. For 2020 income limits and more Credit for excess taxes. If you had more than one employer in
information, visit www.irs.gov/EITC. See also Pub. 596, Earned 2020 and more than $8,537.40 in social security and/or Tier 1
Income Credit. Any EIC that is more than your tax liability is railroad retirement (RRTA) taxes were withheld, you may be able
refunded to you, but only if you file a tax return. to claim a credit for the excess against your federal income tax.
If you had more than one railroad employer and more than
Clergy and religious workers. If you aren’t subject to social $5,012.70 in Tier 2 RRTA tax was withheld, you may also be
security and Medicare taxes, see Pub. 517, Social Security and able to claim a credit. See the Instructions for Forms 1040 and
Other Information for Members of the Clergy and Religious 1040-SR and Pub. 505, Tax Withholding and Estimated Tax.
Workers.
(See also Instructions for Employee on the back of Copy C.)
Corrections. If your name, SSN, or address is incorrect, correct
Copies B, C, and 2 and ask your employer to correct your
employment record. Be sure to ask the employer to file Form
 a Employee’s social security number This information is being furnished to the Internal Revenue Service. If you
are required to file a tax return, a negligence penalty or other sanction
OMB No. 1545-0008 may be imposed on you if this income is taxable and you fail to report it.
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

Form W-2 Wage and Tax Statement

Copy C—For EMPLOYEE’S RECORDS
2020 Department of the Treasury—Internal Revenue Service
Safe, accurate,
FAST! Use
(See Notice to Employee on the back of Copy B.)
Instructions for Employee distribution in the same calendar year. If you made a deferral and
received a distribution in the same calendar year, and you are or will be
(See also Notice to Employee on the back of Copy B.) age 62 by the end of the calendar year, your employer should file Form
Box 1. Enter this amount on the wages line of your tax return. SSA-131, Employer Report of Special Wage Payments, with the Social
Security Administration and give you a copy.
Box 2. Enter this amount on the federal income tax withheld line of your
tax return. Box 12. The following list explains the codes shown in box 12. You may
need this information to complete your tax return. Elective deferrals (codes
Box 5. You may be required to report this amount on Form 8959,
D, E, F, and S) and designated Roth contributions (codes AA, BB, and EE)
Additional Medicare Tax. See the Instructions for Forms 1040 and
under all plans are generally limited to a total of $19,500 ($13,500 if you
1040-SR to determine if you are required to complete Form 8959.
only have SIMPLE plans; $22,500 for section 403(b) plans if you qualify for
Box 6. This amount includes the 1.45% Medicare Tax withheld on all the 15-year rule explained in Pub. 571). Deferrals under code G are limited
Medicare wages and tips shown in box 5, as well as the 0.9% Additional to $19,500. Deferrals under code H are limited to $7,000.
Medicare Tax on any of those Medicare wages and tips above $200,000.
However, if you were at least age 50 in 2020, your employer may have
Box 8. This amount is not included in box 1, 3, 5, or 7. For information allowed an additional deferral of up to $6,500 ($3,000 for section
on how to report tips on your tax return, see the Instructions for Forms 401(k)(11) and 408(p) SIMPLE plans). This additional deferral amount is
1040 and 1040-SR. not subject to the overall limit on elective deferrals. For code G, the limit
You must file Form 4137, Social Security and Medicare Tax on on elective deferrals may be higher for the last 3 years before you reach
Unreported Tip Income, with your income tax return to report at least retirement age. Contact your plan administrator for more information.
the allocated tip amount unless you can prove with adequate records Amounts in excess of the overall elective deferral limit must be included
that you received a smaller amount. If you have records that show the in income. See the Instructions for Forms 1040 and 1040-SR.
actual amount of tips you received, report that amount even if it is more Note: If a year follows code D through H, S, Y, AA, BB, or EE, you made
or less than the allocated tips. Use Form 4137 to figure the social a make-up pension contribution for a prior year(s) when you were in
security and Medicare tax owed on tips you didn’t report to your military service. To figure whether you made excess deferrals, consider
employer. Enter this amount on the wages line of your tax return. By these amounts for the year shown, not the current year. If no year is
filing Form 4137, your social security tips will be credited to your social shown, the contributions are for the current year.
security record (used to figure your benefits).
A—Uncollected social security or RRTA tax on tips. Include this tax on
Box 10. This amount includes the total dependent care benefits that Form 1040 or 1040-SR. See the Instructions for Forms 1040 and 1040-SR.
your employer paid to you or incurred on your behalf (including amounts
B—Uncollected Medicare tax on tips. Include this tax on Form 1040 or
from a section 125 (cafeteria) plan). Any amount over $5,000 is also
1040-SR. See the Instructions for Forms 1040 and 1040-SR.
included in box 1. Complete Form 2441, Child and Dependent Care
Expenses, to compute any taxable and nontaxable amounts. C—Taxable cost of group-term life insurance over $50,000 (included in
boxes 1, 3 (up to social security wage base), and 5)
Box 11. This amount is (a) reported in box 1 if it is a distribution made to
you from a nonqualified deferred compensation or nongovernmental D—Elective deferrals to a section 401(k) cash or deferred arrangement.
section 457(b) plan, or (b) included in box 3 and/or 5 if it is a prior year Also includes deferrals under a SIMPLE retirement account that is part
deferral under a nonqualified or section 457(b) plan that became taxable of a section 401(k) arrangement.
for social security and Medicare taxes this year because there is no E—Elective deferrals under a section 403(b) salary reduction agreement
longer a substantial risk of forfeiture of your right to the deferred
(continued on back of Copy 2)
amount. This box shouldn’t be used if you had a deferral and a
 a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

Form W-2 Wage and Tax Statement

Copy 2—To Be Filed With Employee’s State, City, or Local
2020 Department of the Treasury—Internal Revenue Service

Income Tax Return

Instructions for Employee (continued from back of Y—Deferrals under a section 409A nonqualified deferred compensation
plan
Copy C)
Z—Income under a nonqualified deferred compensation plan that fails
Box 12 (continued) to satisfy section 409A. This amount is also included in box 1. It is
F—Elective deferrals under a section 408(k)(6) salary reduction SEP subject to an additional 20% tax plus interest. See the Instructions for
G—Elective deferrals and employer contributions (including nonelective Forms 1040 and 1040-SR.
deferrals) to a section 457(b) deferred compensation plan AA—Designated Roth contributions under a section 401(k) plan
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization BB—Designated Roth contributions under a section 403(b) plan
plan. See the Instructions for Forms 1040 and 1040-SR for how to deduct. DD—Cost of employer-sponsored health coverage. The amount
J—Nontaxable sick pay (information only, not included in box 1, 3, or 5) reported with code DD is not taxable.
K—20% excise tax on excess golden parachute payments. See the EE—Designated Roth contributions under a governmental section
Instructions for Forms 1040 and 1040-SR. 457(b) plan. This amount does not apply to contributions under a tax-
L—Substantiated employee business expense reimbursements (nontaxable) exempt organization section 457(b) plan.
M—Uncollected social security or RRTA tax on taxable cost of group- FF—Permitted benefits under a qualified small employer health
term life insurance over $50,000 (former employees only). See the reimbursement arrangement
Instructions for Forms 1040 and 1040-SR. GG—Income from qualified equity grants under section 83(i)
N—Uncollected Medicare tax on taxable cost of group-term life HH—Aggregate deferrals under section 83(i) elections as of the close of
insurance over $50,000 (former employees only). See the Instructions for the calendar year
Forms 1040 and 1040-SR. Box 13. If the “Retirement plan” box is checked, special limits may
P—Excludable moving expense reimbursements paid directly to a apply to the amount of traditional IRA contributions you may deduct.
member of the U.S. Armed Forces (not included in box 1, 3, or 5) See Pub. 590-A, Contributions to Individual Retirement Arrangements
Q—Nontaxable combat pay. See the Instructions for Forms 1040 and (IRAs).
1040-SR for details on reporting this amount. Box 14. Employers may use this box to report information such as state
R—Employer contributions to your Archer MSA. Report on Form 8853, disability insurance taxes withheld, union dues, uniform payments,
Archer MSAs and Long-Term Care Insurance Contracts. health insurance premiums deducted, nontaxable income, educational
assistance payments, or a member of the clergy’s parsonage allowance
S—Employee salary reduction contributions under a section 408(p) and utilities. Railroad employers use this box to report railroad
SIMPLE plan (not included in box 1) retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax,
T—Adoption benefits (not included in box 1). Complete Form 8839, Qualified and Additional Medicare Tax. Include tips reported by the employee to
Adoption Expenses, to compute any taxable and nontaxable amounts. the employer in railroad retirement (RRTA) compensation.
V—Income from exercise of nonstatutory stock option(s) (included in Note: Keep Copy C of Form W-2 for at least 3 years after the due date
boxes 1, 3 (up to social security wage base), and 5). See Pub. 525, for filing your income tax return. However, to help protect your social
Taxable and Nontaxable Income, for reporting requirements. security benefits, keep Copy C until you begin receiving social security
W—Employer contributions (including amounts the employee elected to benefits, just in case there is a question about your work record and/or
contribute using a section 125 (cafeteria) plan) to your health savings earnings in a particular year.
account. Report on Form 8889, Health Savings Accounts (HSAs).
 a Employee’s social security number
VOID
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

Form W-2
Copy D—For Employer
Wage and Tax Statement 2020 Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see separate instructions.
Employers, Please Note— equipment for persons who are deaf, hard of hearing, or have a
speech disability, call 304-579-4827 (not toll free).
Specific information needed to complete Form W-2 is available E-filing. See the 2020 General Instructions for Forms W-2 and
in a separate booklet titled the 2020 General Instructions for W-3 for information on when you’re required to file
Forms W-2 and W-3. You can order these instructions and electronically. Even if you aren’t required to file electronically,
additional forms at www.irs.gov/OrderForms. doing so can save you time and effort. Employers may now use
Caution: Do not send the SSA Forms W-2 and W-3 that you have the SSA’s W-2 Online service to create, save, print, and submit
printed from IRS.gov. The SSA is unable to process these forms. up to 50 Form(s) W-2 at a time over the Internet. When you e-file
Instead, you can create and submit them online. See E-filing, later. with the SSA, no separate Form W-3 filing is required. An
Due dates. By February 1, 2021, furnish Copies B, C, and 2 to electronic Form W-3 will be created for you by the W-2 Online
each person who was your employee during 2020. Mail or service. For information, visit the SSA’s Employer W-2 Filing
electronically file Copy A of Form(s) W-2 and W-3 with the SSA Instructions & Information website at www.SSA.gov/employer.
by February 1, 2021. See the separate instructions. Future developments. Information about any future
Need help? If you have questions about reporting on Form W-2, developments affecting Form W-2 and its instructions (such as
call the information reporting customer service site toll free at legislation enacted after we release them) will be posted at
866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD www.irs.gov/FormW2.