2009 Page 3

	Note: This page is used only if did not have enough space on the first income page!									2009
W-2 Income & Withholding Taxes (Income where taxes have been withheld) - BRING FORMS!!!
Employer	Wages	Fed	S.S.	Med	NYS	NYC	Other	Other St	Other	City
Name	Box 1	Box 2	Box 4	Box 6	Box 17	Box 19	St. Tax	Name	City Tax	Name





















Total Add. Income

Unemployment Income			Fed WT			State WT			St. Name
Unemployment Income			Fed WT			State WT			St. Name

Distribution of Retirement Funds - This is reported on Forms 1099R - Bring Forms!!!
Total Distribution #3		Fed Tax			St. WT		St. Name		Dist. Code
Employee Contribution		Total Dist.?		No	Taxable amount
Total Distribution #4		Fed Tax			St. WT		St. Name		Dist. Code
Employee Contribution		Total Dist.?		No	Taxable amount

Form 1099 Misc & other Self-Employment Income INCLUDING CASH - Bring Forms!!!





















Total

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