◆ SpookStack

+ tt ; he . Peace ieee token treet neantssos - STAREMENT TO SUPPORT 1749 San finncisce, Catterall 107 ~ CLUDABLE SICK PAY Type or pant EMPLOY EUS wWentheation muniber, name, at! addiese above, ony yt ' eo " See “other side for Employer's certification of sick- ness pay exclusion. L328 ew REALE, DF APR KTR EY RA AGT oS Type print EMPLOYEE'S name and addhess ¢iacluding ZIP code} above. EMPLOYEE'S EXTRA COPY en ee ‘os The Pacific Telephone and Telegraph Company ‘ ; - : 666 Folsom Street . 94-0745535 STATEMENT TO SUPPORT 1969 San Francisto, California 94107 . EXCLUDABLE SICK PAY Type or print EMPLOYER'S identification qumber, name, aad address above. £0, RAT c rT ray r RE BA Gt gad? —— g BE Sruakity ; : Saliyiat DWYGSTY EXCLUDABLE SIX PAY See other side for Employer's certification of ; ness pay exclusion. L PERRY EMPLOYEE: File this statement with your Federal Income Tox Return if an amount is shown in the block hec ‘ad “Excludable sick pay,” and you wish to claim ‘he sick pay exclusion. _ ATTACH TO PAGE 2 OF FORM 1040, < PS2R MC RINLE 4, Be HEE KTLEY The Pacific Telephone and Telegraph Company st tot sve areas. WAGE AND TAX STATEMENT 4529 + Son Francisca. California 94107 Type oz print EMPLOYER'S identification number, name. and address above. Copy C - For employee’s re-ords _. FEDERAL INCOME TAX INFORMATION, SOCIAL SECURITY INFORMATION EXCLUDABLE Ti-7 Pade TRar incom : Perey ee 4D eis ‘ e! - Sale te c4a, i reyes EMDPLOVEE’S social sevurity number Dee or sakes tip qiharted by employee. Amount is belore payrell © oy a ¥ exclusion, vo a . Add this item ta w aces_in fixurine the amount to he repartes vopIrs : bins and caleries on yond inverne tax retem, Se * Ane-eighth of this aniount wat w ithheld te finanee the se ale +: ad NL PEERY Tsun, ince lien tits. J i eeledate vite if Lh 4 te fern . 1 emailer is fee cola Re, suten yam. * includes tips teparted by employee, lf your Wares were subject re? | secutity, taxes, but are not shown, these waget ate the came as wa, under “Federal Iovome Vax inturmation,* but not mare than $7, KG * Portion uf ‘Mages! not subject to Federal Income Tox, RPRKELEY CA 14? Erte ap poo EPI OVERS nome and address Cracluadine ZUP cul + ahove, | Cneotlected Employee Tax on Tips Form W- 2 U.8. Treasury Debariment, Interoal Aeyenue Service, ~ : ee es om mw re Poy - oS me Seu . - dm mee eee