Wage and Tax Statement for 2023 Box 12

D—Elective deferrals to a section 401(k) cash or deferred

arrangement. Also includes deferrals under a SIMPLE retirement
This Form W-2 shows the total wages you earned from this account that is part of a section 401(k) arrangement.
employer in 2023, along with the total federal, state, or local taxes
withheld from your earnings. Use Form W-2 to file your annual tax E—Elective deferrals under a section 403(b) salary reduction
returns. Attach Copy B to your federal tax return, Copy 2 to your agreement.
state, city, or local tax returns, and keep Copy C for yourself.
G—Elective deferrals and employer contributions (including
nonelective deferrals) to a section 457(b) deferred compensation
Instructions for Employee
plan.
Box 1
W—Employer contributions (including amounts the employee
Enter this amount on the wages line of your tax return.
elected to contribute using a section 125 (cafeteria) plan) to your
Box 2 health savings account.
Enter this amount on the federal income tax withheld line of your
AA—Designated Roth contributions under a section 401(k) plan.
tax return.
BB—Designated Roth contributions under a section 403(b) plan.
Box 5
You may be required to report this amount on Form 8959, DD—Cost of employer-sponsored health coverage. The amount
Additional Medicare Tax. See the Form 1040 instructions to reported with Code DD is not taxable.
determine if you are required to complete Form 8959.
EE—Designated Roth contributions under a governmental
Box 6 section 457(b) plan.
This amount includes the 1.45% Medicare Tax withheld on all
Medicare wages and tips shown in box 5, as well as the 0.9% S—Employee salary reduction contributions under a section 408(p)
Additional Medicare Tax on any of those Medicare wages and tips SIMPLE plan (not included in box 1)
above $200,000.
Box 13
Box 9 If the “Retirement plan” box is checked, special limits may apply
Your W-2 does not have a Verification Code. If you are prompted to to the amount of traditional IRA contributions you may deduct.
enter one, leave this value blank.
Box 14
Box 10 Employers may use this box to report information such as state
This amount includes the total dependent care benefits that your disability insurance taxes withheld or health insurance premiums
employer paid to you or incurred on your behalf (including deducted.
amounts from a section 125 (cafeteria) plan). Any amount over
A note about the earned income credit (EIC)
$5,000 is also included in box 1.
You may be able to take the EIC for 2023 if your adjusted gross
Box 11 income (AGI) is less than a certain amount. The credit amount is
This amount is (a) reported in box 1 if it is a distribution made to based on income and family size. You and any qualifying children
you from a nonqualified deferred compensation or nongovernmen- must have valid social security numbers (SSNs). For 2023 income
tal section 457(b) plan. limits and more information, visit www.irs.gov/eitc or see Pub.
596, Earned Income Credit.
 Employee’s social security number Employer identification number (EIN) 1 Wages, tips, other compensation

W-2 2023 Wage and

Tax Statement
Copy C — For the employee’s records
636-82-1668
2 Federal income tax withheld
0.00
3 Social security wages
81-1208811

50.00
4 Social security tax withheld
68.75

4.26
5 Medicare wages and tips 6 Medicare tax withheld 7 Social security tips
68.75 1.00 18.75
Employee’s name, address, and ZIP code 8 Allocated tips 10 Dependent care benefits 11 Nonqualified plans

Anisa Mars 0.00

12 Code 13 14 Other
10250 Lands End Dr, Apt 106
12a Statutory employee
Houston, TX 77099 12b Retirement plan

12c 3rd party sick pay

Employer’s name, address, and ZIP code
12d
Bean Here LLC
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax
DBA bean here coffee TX 68.75 0.00
4340 Sienna Pkwy Ste 102 18 Local wages, tips, etc 19 Local income tax 20 Locality name

Missouri City, TX 77459

Control number
RHCZuo9e 0eBjSymt
Department of the Treasury—Internal Revenue Service OMB No. 1545-0008 Source XEA

Employee’s social security number Employer identification number (EIN) 1 Wages, tips, other compensation

W-2
2023 Wage and 636-82-1668 81-1208811 68.75
Tax Statement 2 Federal income tax withheld 3 Social security wages 4 Social security tax withheld
0.00 50.00 4.26
Copy 2 — To be filed with employee’s state, city, or local
5 Medicare wages and tips 6 Medicare tax withheld 7 Social security tips
income tax return
68.75 1.00 18.75
8 Allocated tips 10 Dependent care benefits 11 Nonqualified plans
Employee’s name, address, and ZIP code 0.00
Anisa Mars 12 Code 13 14 Other
12a
10250 Lands End Dr, Apt 106 Statutory employee

12b Retirement plan

Houston, TX 77099
12c 3rd party sick pay

12d
Employer’s name, address, and ZIP code
Bean Here LLC 15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax

DBA bean here coffee TX 68.75 0.00

18 Local wages, tips, etc 19 Local income tax 20 Locality name
4340 Sienna Pkwy Ste 102
Missouri City, TX 77459
Control number
RHCZuo9e 0eBjSymt
Department of the Treasury—Internal Revenue Service OMB No. 1545-0008 Source XEA

Employee’s social security number Employer identification number (EIN) 1 Wages, tips, other compensation

W-2 2023 Wage and

Tax Statement
Copy B — To be filed with the employee’s federal
636-82-1668
2 Federal income tax withheld
0.00
3 Social security wages
81-1208811

50.00
4 Social security tax withheld
68.75

4.26
5 Medicare wages and tips 6 Medicare tax withheld 7 Social security tips
tax return
68.75 1.00 18.75
8 Allocated tips 10 Dependent care benefits 11 Nonqualified plans
Employee’s name, address, and ZIP code 0.00
Anisa Mars 12 Code 13 14 Other
12a
10250 Lands End Dr, Apt 106 Statutory employee

12b Retirement plan

Houston, TX 77099
12c 3rd party sick pay

12d
Employer’s name, address, and ZIP code

Bean Here LLC 15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax

DBA bean here coffee TX 68.75 0.00

18 Local wages, tips, etc 19 Local income tax 20 Locality name
4340 Sienna Pkwy Ste 102
Missouri City, TX 77459
Control number
RHCZuo9e 0eBjSymt
Department of the Treasury—Internal Revenue Service OMB No. 1545-0008 Source XEA