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Employer:
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| Employer Identification Number (EIN):262051970 |
| SIGNAL BUTTE NNY RESTAURANT LLC | |
| 10000 N 31ST AVENUE SUITE 109B | |
| PHOENIX, AZ 85051-0000 | |
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Employee:
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| Employee's Social Security Number:
647-40-0297 |
| CHANDLER KINSEY | |
| 11414 E. SOLINA AVE | |
| MESA, AZ 85212-0000 | |
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| Submission Type: | Original document |
| Wages, Tips and Other Compensation: | $619.00 |
| Federal Income Tax Withheld: | $33.00 |
| Social Security Wages: | $391.00 |
| Social Security Tax Withheld: | $38.00 |
| Medicare Wages and Tips: | $619.00 |
| Medicare Tax Withheld: | $8.00 |
| Social Security Tips: | $228.00 |
| Allocated Tips: | $0.00 |
| Dependent Care Benefits: | $0.00 |
| Deferred Compensation: | $0.00 |
| Code "Q" Nontaxable Combat Pay: | $0.00 |
| Code "W" Employer Contributions to a Health Savings Account: | $0.00 |
| Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan: | $0.00 |
| Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan: | $0.00 |
| Code "R" Employer's Contribution to MSA: | $0.00 |
| Code "S" Employer's Contribution to Simple Account: | $0.00 |
| Code "T" Expenses Incurred for Qualified Adoptions: | $0.00 |
| Code "V" Income from exercise of non-statutory stock options: | $0.00 |
| Code "AA" Designated Roth Contributions under a Section 401(k) Plan: | $0.00 |
| Code "BB" Designated Roth Contributions under a Section 403(b) Plan: | $0.00 |
| Code "DD" Cost of Employer-Sponsored Health Coverage: | $0.00 |
| Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan: | $0.00 |
| Third Party Sick Pay Indicator: | Unanswered |
| Retirement Plan Indicator: | Unanswered |
| Statutory Employee: | Not Statutory Employee |
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Employer:
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| Employer Identification Number (EIN):464196405 |
| ARIZONA RESTAURANT COMPANY LLC | |
| 1515 N ACADEMY BLVD | |
| COLORADO SPGS, CO 80909-0000 | |
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Employee:
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| Employee's Social Security Number:
647-40-0297 |
| CHANDLER S KINSEY | |
| 11414 E SOLINA AVE | |
| MESA, AZ 85212-0000 | |
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| Submission Type: | Original document |
| Wages, Tips and Other Compensation: | $2,896.00 |
| Federal Income Tax Withheld: | $187.00 |
| Social Security Wages: | $2,896.00 |
| Social Security Tax Withheld: | $179.00 |
| Medicare Wages and Tips: | $2,896.00 |
| Medicare Tax Withheld: | $42.00 |
| Social Security Tips: | $0.00 |
| Allocated Tips: | $0.00 |
| Dependent Care Benefits: | $0.00 |
| Deferred Compensation: | $0.00 |
| Code "Q" Nontaxable Combat Pay: | $0.00 |
| Code "W" Employer Contributions to a Health Savings Account: | $0.00 |
| Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan: | $0.00 |
| Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan: | $0.00 |
| Code "R" Employer's Contribution to MSA: | $0.00 |
| Code "S" Employer's Contribution to Simple Account: | $0.00 |
| Code "T" Expenses Incurred for Qualified Adoptions: | $0.00 |
| Code "V" Income from exercise of non-statutory stock options: | $0.00 |
| Code "AA" Designated Roth Contributions under a Section 401(k) Plan: | $0.00 |
| Code "BB" Designated Roth Contributions under a Section 403(b) Plan: | $0.00 |
| Code "DD" Cost of Employer-Sponsored Health Coverage: | $0.00 |
| Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan: | $0.00 |
| Third Party Sick Pay Indicator: | Unanswered |
| Retirement Plan Indicator: | Unanswered |
| Statutory Employee: | Not Statutory Employee |
