Preferred Risk
8 '1 ?rismgle Madical Centar
Lnuisville, KY 40220

RE: Rebecca M. 

 

at. 22, 19%

To whom it may concaru 

Due to an accident injury on Mmsen an empiayee Ham ef Fire
M??stries, was unable to carry out her regular work routine. She was released 1?-22v%
from her primary caregiver Dr. Iglchart. Her salary is a year, $1 153.? wk,

totaling $18,925.60 in loss wages.

  

?milk You,
-..
r- r" . ..- .., 



?Dri'Dmgioln on

because he hath anoimad ma to preach the goapa! to the poor; he hath sent me To hen: the brokenhanrwd. Pra?ch

Luke 4:18 - ?Tho Spirit of (he Lord is upon me. . 
10 set at ilberty them (ha! are bruised.

de?voranoe to the capuvcsi and recovering oi 10 me biind.

 

 

- 

 

4.. .. 
a

 

 

a. Control number

 

Copy 8 To Be
OMB 



 

Employer's Idan??ca?on number

With Empfoyaa?s? FEDERAL Tax Return

 

 

1 Wages, Ups, other comp. 2 Fed. Incometaxuvlmhald

 

5017 Bardstown Rd,
Louisville, KY 40291?

7210;99?29 $50 000100' "m 000.00
_c Employer?s name, address, and ZIP code 3 Social sacunry wages . ,r Social seourity tax withheld
$60?000 0W 
Heart of Fire M1nistries,lnc.

 

5 Medicare Wages and I?ps 6 Medicare tax withheld

$602 000. OD $870. 00

 

 

c3 Ernpzoyae?s social security number

.7 Scale! seounIty up?

a I

 

8. Allocated ups

  

 

[105:077611

9 Advance EIin pIaymentI to Dependant care benefits

 

Emloyee?s name, address, and ZIP code

- Nonqua??ed pISans

12 Bene?ts Included In box 1

3.

 

Rebecca M. 'J?hnson xx
9103 Wendell Court - 
Louisville, KY 4Q299 

 

14 Older .

 

 

.15 Stat. Blamed Pension Lana: 

 

 

 

 

 

 

Subtotal Dntumd
smp.I .. lemI II. rap. amIp.I .companntlon
15 sun sm- LD.N5. 17 at" ?W""Jpg' 18 $211. [acorns but 15 20 :ffiwanu, Ups, 2} Lac-illncoml ax
KY [721029929 $60, 000. 0 $60, 000 0G $1320.,00

 

 

 

 

Copyright Form Soflwun Only.

Wage and Tax
me 2 Statement 1995 
BWZEEB 

?55 Helen. Inc. N95W281

     

 

 

Ilniarna: Revenue Service
1 49?17549:-

 

-.

 

adieu .-.. 

 

. . 

 

 

 

Filigmaunrmm-Wmim ?jig

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


8* Comm: number Void F'o?r Official Use Only-k - 
23333 El OMB Nor1545-00089. '7 I .
Employer?s identification number 1 Wages. tips, other compensation A 2 Federal income tax withheld 
721029929 $60,000.00 . $9,000.00 i
Employer?s name. address. and ZIP code 3 Social Security wages 4 Social Security tax withheld
$601000.00 A $3720.00 i 
. - . 5 Medicare wages and tips 5 Medicare tax withheid I
Heart of Inc. . - 
. 5.7-1: 5 7 Sociai Security tips 7 8 Aiiocated tips -
KY 40291' I 
Empioyea's Sociai Securitynumb?r 9 Advance payment 10 Dependen: care b?hefits i, 
404927611 3 .i
*3 Employee's name (first. middle initial. iasi) . ?i?i plans 1 12 Benefits lnciuded in Box 1 
. . I 
ReBecca M. Jb nson awnmmeamis omw i
i 
i
9103 Wendell Court ?i
Deceased Pension Le ai e42 SubLotai Deferred 
KY 40299 ?Ew? 'i61 49 m. mm . i 
i Employee's address and ZEP code 6 Cf .
15 Empioyer?s KY Wiihhoiding Acct. No. 17 KY wages, iip?. etc. 1 8 KY income tax 19 Locality name 20 Local wages, tips, etc. 21 Local incoma tax. 
[721029929 $60,000.0 
Departme'nt of the Treasury?internal Revenue Service 
Wage and Tax For Paperwork Reduction Act Notice, i . 
lg Statem 8 nt 39.1 050711 see sep?arate instructions. ?1 in
Copy A For Social Security Administration 3 9
i

- . PRINTING COST PAID BY KY REVENUE 
Do NOT Cu: or Separate Forms on This Page .