For Official Use Only > security number 22222 Void O OMB No. 1545-0008 000-00-6839 b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld 00-0000972 65,262.75 4,264 3 Social security wages 4 Social security tax withheld c Employer's name, address, and ZIP code 4,368.69 5 Medicare wages and tips 6 Medicare tax withheld Quigley Corporation X 1,021.97 4800 River Road Philadelphia, PA 19113-5548 7 Social security tips B Allocated tips O V O V d Control number 9 10 Dependent care benefits O V e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12 Kenneth T. Ford O V Code 262.75 V 13 Retirement plan V 12b 338 North Side Avenue Code 5,200 V 14 Other Philadelphia, PA 19130-6638 12c Code O V f Employee's address and ZIP code PA SUI 42.12 12d Code O V 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 PA 00-0-1066 70,200 2,155.40 $ 70,200 2,695.68 Phila. Form W-2 Wage and Tax Statement 20- Department of the Treasury-Internal Revenue Service For Privacy Act and Paperwork Reduction Copy A For Social Security Administration - Send this entire page with Act Notice, see the separate instructions. Form W-3 to the Social Security Administration: photocopies are not acceptable