PSb 6-7 Complete Form W-3

Complete the W-3 Form for Gameroom Associates Corp. (employer identification #55-5555555), based on the employee information listed below. The company is located at 87 Rose Way, Lexington, KY 40361, and its Kentucky State ID number is the same as its federal identification number. The form is signed by the CFO of the company, Rachel Flowers (telephone #859-555-2766), and is submitted on the due date for e-filing. The company files Form 941 during the year and selects 'none apply' in the Kind of Employer section.

• Employee #1: Rachel Flowers is an employee of Gameroom Associates Corp. Gross earnings for federal income tax withholding, Social Security tax, and Medicare tax were $101,470 for the year, while these taxes were $9,250, $6,291.14, and $1,471.32, respectively. The annual charitable contribution was $260. Kentucky income tax withholding was $6,088.20 (based on the same gross earnings amount as above), with no local taxes withheld. The employer's Kentucky State ID number is the same as the federal identification number.
• Employee #2: Adrian Pitts, is an employee of Gameroom Associates Corp. Gross earnings for federal income tax withholding were $136,960 for the year, while gross earnings for Social Security tax and Medicare tax were $141,460 for the year. The federal income tax, Social Security tax, and Medicare tax were $16,350, $8,537.40, and $2,051.17, respectively. The annual charitable contribution was $675, and the 401(k) retirement plan contribution was $4,500. Kentucky income tax withholding was $10,382.73 (based on the above gross earnings for federal income tax), with no local taxes withheld. The employer's Kentucky State ID number is the same as the federal identification number.

Notes:

• For simplicity, all calculations throughout this exercise, both intermediate and final, should be rounded to two decimal places at each calculation.

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a Control number

For Official Use Only OMB No. 1545-0008

b

Kind of Payer (Check one)

941CT-1

MilitaryHshld. emp.

943Medicare govt. emp.

944

Kind of Employer (Check one)

None applyState/local non-501c

501c non-govt.State/local 501c

Federal govt.

Third-party sick pay (Check if applicable)

c Total number of Forms W-2

d Establishment number

1 Wages, tips, other compensation

2 Federal income tax withheld

e Employer identification number (EIN)

3 Social security wages

4 Social security tax withheld

f Employer's name

5 Medicare wages and tips

6 Medicare tax withheld

g Employer's address and ZIP code

7 Social security tips

8 Allocated tips

9

10 Dependent care benefits

11 Nonqualified plans

12a Deferred compensation

h Other EIN used this year

13 For third-party sick pay use only

12b

15State	Employer's state ID number

14 Income tax withheld by payer of third-party sick pay

16State wages, tips, etc.

17State income tax

18Local wages, tips, etc.

19Local income tax

Employer's contact person

Employer's telephone number

For Official Use Only

Employer's fax number

Employer's email address

Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and belief, they are true, correct, and complete.

Signature

Title

Date

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