EFTA01145587.pdf

Acom U.S.Individual it toldl If total? is 310.000 or men, or Mono Horn interns. dive rc: 17,,,'rmI "Ilign Is I-188 Income Tax Retu rn "telio one: our social security number 4. C we, use lust names aad middle initials ol toga . Sing, : .;s1 1 Na i ' .5 0 terniAt."" .:a : 12, ".11,1 mesa s weal la income) 0. eb; Home address Musty shot or foul route) • a Winn. enter her (his) mug ',Hurd O ❑ ._,11,,isz Mint war, I.r . r E ae pj :• •• • S ___2] '7 -7e . ri :td:- AUg number in gem 3 and give 6:3 Cdy, town or post office, Stets ad ZIP rade ib • z • Id S - 1 ri me hear l/r. you,* p. PI Enter total wages, saki His, tips, etc. Enclose your turn .e/ 1 4.(2 Enter below name and a --rest used If none tiled. give reason. If Forms W- 2. Copy 8. I not shown on enclosed (If same as bove. write "Same.")or joint to separate returns. nation. SpouSe's lo changing Is m separate to joint Forms W-2 attach expl enter 1967 ernes and addresses. @Interest Yours * x..1if Spouse's * •• n $ NW le ©Dividends: yours—before exclusio If item 7 A 55.000 or more, compute tax if you omit items 8. 10 & 11 (but tax A surcharge & pay complet IRS will compute item 10 in full with return. If under $5.000. e item 9). (See instr.) Spouse's—before 7 Total income (add items S. exclusion $ 6a. and 6b) Aber P. P. f lip," + b. Surcharge $ c. Total * for tax, see Instructions: pages 5-7 for regular tables, page M 8 8 Tax S -- 6 4 4 IM surcharge, page for $5,000 or mole computatiyn. Total Federal Income tax withheld (from Forms W-2) IP BC/ ..LQ Balance doe le apedy Mond to: r U.S. Savings Bonds, L. & excess refunded; or Refund onl ..9/ 0 If item 8c is larger than item 9, enter Refund 10* ji ;11777 SIDE. II it item 9 is taro than item 8c, enter EXEMPT IONS AND SIGN ON OTHER UST YOUR Re r 65 or over Blind ®EXEMPTIONS FOR YOURSELF —ANC. SPOUSE (only if all her (his) Yourself . • O 0 Ent er number boxes Income Is Included In this return, or she (he) had no income) ey Spouse . ' O O 0 } ofchecked P —.t— oC ck boxes which apply Enter lived with you number * First names of your dependent children who (4) Did (o) Arnow' YOU fur. Hy Amount furnished NY Months lined O DEMENOIJITS OTIO4 THAN RINI (4 NAME (inn to right for each name sob P. Enter figure 1 in the Intlisted ON IbILSCHWhie in your home. II born or died dui ing year also write depomfmt hem income el $600 or i mats for depend. ant's support. II IOC% write "All" by OTHERS Including dependent. See in. striatum le CAMEO (if more spas* Is needed. attach were IN ITEM 13. schedule) * S S * * / 1 12, 13, AND 14 ABOVE 11. TOTAL EXEMPTIONS FROM ITEMS Your present employer and address wj j 9 "FAY e— 0 if appropriate. for "Reimbursed Expenses" and check here charged expenses to your employer, see instructions lf you had an expense allowance or complet e return. is a true, correct, and the best of my knowledge and belief this Under penalties of perjury, i declare that to •— r . Data Sign Yow signature • •- 6ii here s.....Prawn (II Ming We*. !MTN arrir sile arm it Wilt me AM in of Form 1040A is $5,000 or more) Tax Computation Schedule (Use only if total income, item 7 Copy C—For employee's record Fenn W-2 U.S. Treasury Department Internal Revenue Service WAGE AND TAX STATEMENT Keep this copy as part of your tax records. 1968 SOCIAL SECURITY INFORMATION STATE OR MUNICIPAL INFORMATION INCOME TAX INFORMATION New York State New York City Other nimpensation • F.I.C.A. employee Total F.I.C.A. wages TeX Withheld Metal inceme tax Wages I paid subject to with tax withheld • Paid In 1968 • Tax Withheld holding in 1968 paid in 1968 withheld 122.40 2.30 122.40 .20 .20 5.70 • 0 II • 5- and address bel Type or print EMPLOYEE'S social security number, yarns Single No. of M—If OsPee- Am ss -dyne uTarr rry Be Kafka Mar- dents rled 1770 Surf avaoue Brooklyn, New York . Amount is before • Includes tips reported by employee payroll deductions Or sick pay exclusion. • Add this item to wages in figuring the amount to be re- Type or Print tax return. E OYER'S ported as wages and salaries on your income -- —12.4801032 rte tification s the social security (F.I.C.A.) rate of 4.4% Includes .6% nu er, name Old-age, 'RICHTON BEACH "ATMS. IOC. for Hospital Insurance Benefits and 3.8% for arc address survivors. and disability insurance. SUITE 34OO • Includes ties reports by employee. TIDE AU) !Art WILDING W. c'let lee E":(00Yee Tax on TIPS Form W-2 U.S. Treasury Department APP. IRS awes ROCK/PC.1XE CENTER NEts YORK. N.Y. 1OO2O EFTA01145587