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

If you
619-03-7222 OMB No. 1545-0008 are required to file a tax return, a negligence penalty or other sanction
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
84-3534276 213302.46 47096.29
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
GIPSOL LLC
3505 CADILLAC AVE 213302.46 9114.00
UNIT O-105 5 Medicare wages and tips 6 Medicare tax withheld
3
COSTA MESA CA 92626 213302.46 212.61
7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
Eric L Gipson Jr C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

f Employee’s address and ZIP code 14 Other 12c

C
o
d
e
14971 Geneva St 12d
Irvine CA 92604 C
o
d
e

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
CA 84-3534276 213302.46 18032.01

W-2
Department of the Treasury—Internal Revenue Service
Wage and Tax
Form Statement
Copy C—For EMPLOYEE’S RECORDS (See Notice to
2022 Safe, accurate,
FAST! Use

Employee on the back of Copy B.)