a Employee’s social security number This information is being furnished to the Internal Revenue Service.

If you
are required to file a tax return, a negligence penalty or other sanction
***-**-5077 OMB No. 1545-0008 may be imposed on you if this income is taxable and you fail to report it.
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
99-1941513 15249.81 0.00
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
Blooming Oaks Wellness & Rehabilitation LLC 15249.81 945.49
4525 Wilshire Blvd 5 Medicare wages and tips 6 Medicare tax withheld
Ste 210 15249.81 221.12
Los Angeles, CA 90010 7 Social security tips 8 Allocated tips
0.00
d Control number 9 10 Dependent care benefits
40399 40399192
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
Sabrena Wortham d
e

13 Statutory Retirement Third-party 12b

623 Scenic Dr employee plan sick pay C
o
Saint Louis, MO 63137-3358 d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
MO Applied 15249.81 418.00

Form W-2 Wage and Tax Statement

Copy C—For EMPLOYEE’S RECORDS
2024 Department of the Treasury—Internal Revenue Service
Safe, accurate,
FAST! Use
(See Notice to Employee on the back of Copy B.)
Notice to Em ployee y ears bef ore y ou reach retirement age. Contact y our plan administrator f or more
inf ormation. Amounts in excess of the ov erall electiv e def erral limit must be included
in income. See the Form 1040 instructions. Note: If a y ear f ollows code D through H,
Do you have to file? Ref er to the Form 1040 instructions to determine if y ou are S, Y , AA, BB, or EE, y ou made a make-up pension contribution f or a prior y ear(s)
required to f ile a tax return. Ev en if y ou don’t hav e to f ile a tax return, y ou may be when y ou were in military serv ice. To f igure whether y ou made excess def errals,
eligible f or a ref und if box 2 shows an amount or if y ou are eligible f or any credit. consider these amounts f or the y ear shown, not the current y ear. If no y ear is shown,
Earned income credit (EIC). Y ou may be able to take the EIC f or 2024 if y our the contributions are f or the current y ear.
adjusted gross income (AGI) is less than a certain amount. The amount of the credit A—Uncollected social security or RRTA tax on tips. Include this tax on Form 1040 or
is based on income and f amily size. Workers without children could qualif y f or a 1040-SR. See the Form 1040 instructions.
smaller credit. Y ou and any qualif y ing children must hav e v alid
B—Uncollected Medicare tax on tips. Include this tax on Form 1040 or 1040-SR.
social security numbers (SSNs). Y ou can’t take the EIC if y our inv estment income is See the Form 1040 instructions.
more than the specif ied amount f or 2024 or if income is earned f or serv ices prov ided
while y ou were an inmate at a penal institution. For 2024 income limits and more C—Taxable cost of group-term lif e insurance ov er $50,000 (included in boxes 1, 3
inf ormation, v isit www.irs.gov /EITC. See also Pub. 596. Any EIC that is more than (up to the social security wage base), and 5)
your tax liability is refunded to you, but only if you file a tax return. D—Electiv e def errals to a section 401(k) cash or def erred arrangement. Also
Employ ee’s social security number (SSN). For y our protection, this f orm may show includes def errals under a SIMPLE retirement account that is part of a section 401(k)
only the last f our digits of y our SSN. Howev er, y our employ er has reported y our arrangement.
complete SSN to the IRS and the Social Security Administration (SSA). E—Electiv e def errals under a section 403(b) salary reduction agreement (continued
Clergy and religious workers. If you aren’t subject to social security and Medicare on back of Copy 2) Instructions f or Employ ee (continued f rom back of Copy C)
taxes, see Pub. 517. F—Electiv e def errals under a section 408(k)(6) salary reduction SEP
Corrections. If your name, SSN, or address is incorrect, correct Copies B, C, and 2 G—Electiv e def errals and employ er contributions (including nonelectiv e def errals) to
and ask y our employ er to correct y our employ ment record. Be sure to ask the a section 457(b) def erred compensation plan
employ er to f ile Form W-2c, Corrected Wage and Tax Statement, with the SSA to H—Electiv e def errals to a section 501(c)(18)(D) tax-exempt organization plan. See
correct any name, SSN, or money amount error reported to the the Form 1040 instructions f or how to deduct.
SSA on Form W-2. Be sure to get y our copies of Form W-2c f rom y our employ er f or J—Nontaxable sick pay (inf ormation only , not included in box 1, 3, or 5)
all corrections made so y ou may f ile them with y our tax return. If y our name and K—20% excise tax on excess golden parachute pay ments. See the Form 1040
SSN are correct but aren’t the same as shown on y our social security card, y ou instructions.
should ask f or a new card that display s y our correct name at
L—Substantiated employ ee business expense reimbursements (nontaxable)
any SSA of f ice or by calling 800-772-1213. Y ou may also v isit the SSA website at
www.SSA.gov . M—Uncollected social security or RRTA tax on taxable cost of group term lif e
insurance ov er $50,000 (f ormer employ ees only ). See the Form 1040 instructions.
Cost of employer-sponsored health coverage (if such cost is provided by the
employer). The reporting in box 12, using code DD, of the cost of employ er- N—Uncollected Medicare tax on taxable cost of group-term lif e insurance ov er
sponsored health cov erage is f or y our inf ormation only . The amount reported with $50,000 (f ormer employ ees only ). See the Form 1040 instructions.
code DD is not taxable. P—Excludable mov ing expense reimbursements paid directly to a member of the
Credit for excess taxes. If y ou had more than one employ er in 2024 and more than U.S. Armed Forces (not included in box 1, 3, or 5)
$9,932.40 in social security and/or Tier 1 railroad retirement (RRTA) taxes were Q—Nontaxable combat pay . See the Form 1040 instructions f or details on reporting
withheld, y ou may be able to claim a credit f or the excess against y our f ederal this amount.
income tax. See the Form 1040 instructions. If y ou had more than one railroad R—Employ er contributions to y our Archer MSA. Report on Form 8853.
employ er and more than $5,821.20 in Tier 2 RRTA tax was withheld, y ou may be S—Employ ee salary reduction contributions under a section 408(p) SIMPLE plan
able to claim a ref und on Form 843. See the Instructions f or Form 843. (not included in box 1)
T—Adoption benef its (not included in box 1). Complete Form 8839 to f igure any
Instructions for Em ployee taxable and nontaxable amounts.
V—Income f rom exercise of nonstatutory stock option(s) (included in boxes 1, 3 (up
Box 1. Enter this amount on the wages line of y our tax return. to the social security wage base), and 5). See Pub. 525 f or reporting requirements.
Box 2. Enter this amount on the f ederal income tax withheld line of y our tax return. W—Employ er contributions (including amounts the employ ee elected to contribute
using a section 125 (caf eteria) plan) to y our health sav ings account. Report on Form
Box 5. Y ou may be required to report this amount on Form 8959. See the Form
8889.
1040 instructions to determine if y ou are required to complete Form 8959.
Y—Def errals under a section 409A nonqualif ied def erred compensation plan
Box 6. This amount includes the 1.45% Medicare tax withheld on all Medicare
wages and tips shown in box 5, as well as the 0.9% Additional Medicare Tax on any Z—Income under a nonqualif ied def erred compensation plan that f ails to satisf y
of those Medicare wages and tips abov e $200,000. section 409A. This amount is also included in box 1. It is subject to an additional
20% tax plus interest. See the Form 1040 instructions.
Box 8. This amount is not included in box 1, 3, 5, or 7. For inf ormation on how to
report tips on y our tax return, see the Form 1040 instructions. Y ou must f ile Form AA—Designated Roth contributions under a section 401(k) plan
4137 with y our income tax return to report at least the allocated tip amount unless BB—Designated Roth contributions under a section 403(b) plan
y ou can prov e with adequate records that y ou receiv ed a smaller amount. If y ou DD—Cost of employ er-sponsored health cov erage. The amount reported with
hav e records that show the actual amount of tips y ou receiv ed, report that amount code DD is not taxable.
ev en if it is more or less than the allocated tips. EE—Designated Roth contributions under a gov ernmental section 457(b) plan. This
Use Form 4137 to f igure the social security and Medicare tax owed on tips y ou didn’t amount does not apply to contributions under a tax-exempt organization section
report to y our employ er. Enter this amount on the wages line of y our tax return. By 457(b) plan.
f iling Form 4137, y our social security tips will be credited to y our social security
FF—Permitted benef its under a qualif ied small employ er health reimbursement
record (used to f igure y our benef its).
arrangement
Box 10. This amount includes the total dependent care benef its that y our employ er
GG—Income f rom qualif ied equity grants under section 83(i)
paid to y ou or incurred on y our behalf (including amounts
HH—Aggregate def errals under section 83(i) elections as of the close of the
f rom a section 125 (caf eteria) plan). Any amount ov er y our employ er’s plan limit is
calendar y ear
also included in box 1. See Form 2441.
Box 13. If the “Retirement plan” box is checked, special limits may apply to the
Box 11. This amount is (a) reported in box 1 if it is a distribution made to y ou f rom a
amount of traditional IRA contributions y ou may deduct. See Pub. 590-A.
nonqualif ied def erred compensation or nongov ernmental section 457(b) plan, or (b)
included in box 3 and/or box 5 if it is a prior y ear def erral under a nonqualif ied or Box 14. Employ ers may use this box to report inf ormation such as state disability
section 457(b) plan that became taxable f or social security and Medicare taxes this insurance taxes withheld, union dues, unif orm pay ments, health insurance premiums
y ear because there is no longer a substantial risk of f orfeiture of your right to the deducted, nontaxable income, educational assistance pay ments, or a member of the
def erred amount. This box shouldn’t be used if y ou had a def erral and a distribution clergy ’s parsonage allowance and utilities. Railroad employ ers use this box to report
in the same calendar y ear. If y ou made a def erral and receiv ed a distribution in the railroad retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax, and
same calendar y ear, and y ou are or will be age 62 by the end of the calendar y ear, Additional Medicare Tax. Include tips reported by the employ ee to the employ er in
y our employ er should f ile Form SSA-131, Employ er Report of Special Wage railroad retirement (RRTA) compensation.
Pay ments, with the Social Security Administration and giv e y ou a copy . Note: Keep Copy C of Form W-2 f or at least 3 y ears af ter the due date f or f iling y our
Box 12. The f ollowing list explains the codes shown in box 12. Y ou may need this income tax return. Howev er, to help protect your social security benefits, keep
inf ormation to complete y our tax return. Electiv e def errals (codes D, E, F, and S) and Copy C until y ou begin receiv ing social security benef its, just in case there is a
designated Roth contributions (codes AA, BB, and EE) under all plans are generally question about y our work record and/or earnings in a particular y ear.
limited to a total of $22,500 ($15,500 if y ou only hav e SIMPLE plans; $25,500 f or
section 403(b) plans if y ou qualif y for the 15-y ear rule explained in Pub. 571).
Def errals under code G are limited to $22,500. Def errals under code H are limited to
$7,000.
Howev er, if y ou were at least age 50 in 2024, y our employ er may hav e allowed an
additional def erral of up to $7,500 ($3,500 f or section 401(k)(11) and 408(p) SIMPLE
plans). This additional def erral amount is not subject to the ov erall limit on electiv e
def errals. For code G, the limit on electiv e def errals may be higher f or the last 3