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Employer:
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| Employer Identification Number (EIN):626001445 |
| STATE OF TENNESSEE | |
| 312 ROSA L PARKS AVE21ST FLOOR WILLIAM S | |
| NASHVILLE, TN 37243-0000 | |
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Employee:
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| Employee's Social Security Number:
415-89-3060 |
| VIDYAVATHI BHUPATHIRAJU | |
| 1506 BRADEN CIRCLE | |
| FRANKLIN, TN 37067-8595 | |
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| Submission Type: | Original document |
| Wages, Tips and Other Compensation: | $33,846.00 |
| Federal Income Tax Withheld: | $2,324.00 |
| Social Security Wages: | $45,846.00 |
| Social Security Tax Withheld: | $2,842.00 |
| Medicare Wages and Tips: | $45,846.00 |
| Medicare Tax Withheld: | $664.00 |
| Social Security Tips: | $0.00 |
| Allocated Tips: | $0.00 |
| Dependent Care Benefits: | $0.00 |
| Deferred Compensation: | $12,000.00 |
| 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: | $11,928.00 |
| Code "EE" Designated ROTH Contributions Under a Governmental Section 457(b) Plan: | $0.00 |
| Third Party Sick Pay Indicator: | Unanswered |
| Retirement Plan Indicator: | Yes - retirement plan |
| Statutory Employee: | Not Statutory Employee |
