Copy B, To Be Filed with Employee’s Copy C, For EMPLOYEE’S RECORDS.

OMB No. 1545-0008 OMB No. 1545-0008

FEDERAL Tax Return. (See Notice to Employee on back.)
a Employee’s SSN 1 Wages, tips, other compensation 2 Federal income tax withheld a Employee’s SSN 1 Wages, tips, other compensation 2 Federal income tax withheld
3864.80 30.99 3864.80 30.99
596-78-6892 596-78-6892
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
b Employer ID no. (EIN) 3864.80 239.62 b Employer ID no. (EIN) 3864.80 239.62
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
46-1524142 46-1524142
3864.80 56.04 3864.80 56.04
c Employer’s name, address and ZIP code c Employer’s name, address and ZIP code
NORTHEAST FOODS LLC NORTHEAST FOODS LLC
1400 OPUS PLACE 1400 OPUS PLACE
SUITE 900 SUITE 900
DOWNERS GROVE, IL 60515 DOWNERS GROVE, IL 60515
(630) 598-3330 (630) 598-3330

d Control Number d Control Number

e Employee’s first name and initial Last name Suff. e Employee’s first name and initial Last name Suff.

AMBERLYS RIOS AMBERLYS RIOS

184 BEACON ST 184 BEACON ST
LOWELL, MA 01851 LOWELL, MA 01851

f Employee’s address and ZIP code f Employee’s address and ZIP code
7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12 10 Dependent care benefits 11 Nonqualified plans 12a Code See inst. for box 12

13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code
MAPFML 13.53 MAPFML 13.53
Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax
MA WTH-10989101-046 3864.80 178.45 MA WTH-10989101-046 3864.80 178.45

18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

VBA Form W-2 Wage and Tax Statement 2021 Department of the Treasury -- VBA Form W-2 Wage and Tax Statement 2021 Department of the Treasury --
This information is being furnished to the Internal Revenue Service. Internal Revenue Service This information is being furnished to the Internal Revenue Service. If you are required to Internal Revenue Service
file a tax return, a negligence penalty or other sanction may be imposed on you if this
income is taxable and you fail to report it.

Copy 2, To Be Filed with Employee’s Copy 2, To Be Filed with Employee’s

State, City, or Local Income Tax Return OMB No. 1545-0008 OMB No. 1545-0008
State, City, or Local Income Tax Return.
a Employee’s SSN 1 Wages, tips, other compensation 2 Federal income tax withheld a Employee’s SSN 1 Wages, tips, other compensation 2 Federal income tax withheld
3864.80 30.99 3864.80 30.99
596-78-6892 596-78-6892
3 Social security wages 4 Social security tax withheld 3 Social security wages 4 Social security tax withheld
b Employer ID no. (EIN) 3864.80 239.62 b Employer ID no. (EIN) 3864.80 239.62
5 Medicare wages and tips 6 Medicare tax withheld 5 Medicare wages and tips 6 Medicare tax withheld
46-1524142 46-1524142
3864.80 56.04 3864.80 56.04
c Employer’s name, address and ZIP code c Employer’s name, address and ZIP code
NORTHEAST FOODS LLC NORTHEAST FOODS LLC
1400 OPUS PLACE 1400 OPUS PLACE
SUITE 900 SUITE 900
DOWNERS GROVE, IL 60515 DOWNERS GROVE, IL 60515
(630) 598-3330 (630) 598-3330

d Control Number d Control Number

e Employee’s first name and initial Last name Suff. e Employee’s first name and initial Last name Suff.

AMBERLYS RIOS AMBERLYS RIOS

184 BEACON ST 184 BEACON ST
LOWELL, MA 01851 LOWELL, MA 01851

f Employee’s address and ZIP code f Employee’s address and ZIP code
7 Social security tips 8 Allocated tips 9 7 Social security tips 8 Allocated tips 9

10 Dependent care benefits 11 Nonqualified plans 12a Code 10 Dependent care benefits 11 Nonqualified plans 12a Code

13 Statutory employee 14 Other 12b Code 13 Statutory employee 14 Other 12b Code
MAPFML 13.53 MAPFML 13.53
Retirement plan 12c Code Retirement plan 12c Code

Third-party sick pay 12d Code Third-party sick pay 12d Code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax
MA WTH-10989101-046 3864.80 178.45 MA WTH-10989101-046 3864.80 178.45

18 Local wages, tips, etc. 19 Local income tax 20 Locality name 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

VBA Form W-2 Wage and Tax Statement 2021 VBA Form W-2 Wage and Tax Statement Department of the Treasury --
Department of the Treasury -- 2021
Internal Revenue Service Internal Revenue Service
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