EIN Name Control Business Name 1 Business Name 2 Address 1 Address 2 City State Zip Code Agent Name Agent Title Contact Name Contact Title Phone Number e-Mail Address Signature Name Signature Date Account Type Routing Number Account Number Online PIN ( For Indirect Filers Only) Year Total Wages Total Tax Withheld Wages not Subject to SS/Medicare Taxable SS Wages Taxable SS Tips Taxable Medicare Wages Blank Blank Current Year's Adjustment COBRA Premium Assistance Payments Number of Individuals provided CORBA Assistance Advanced Earned Income Credit Payments to Employees Total Deposits Deposit State Date of Final Return Refund or Apply to Next Return ( for Overpayment Only ) January Liability February Liability March Liability April Liability May Liability June Liability July Liability August Liability September Liability October Liability November Liability December Liability 666666666 ELEC Electric Corporation Test International 242 Elm St. Suite Z Annapolis Junction MD 20701 Tim Welch Accountant Tina Welch Bookeeper 3015551212 tw@lswonline.com Tim Welsh 4/1/2008 2009 "$1,000.00 " "$1,000.00 " 0 "$1,000.00 " "$1,000.00 " "$1,000.00 " $0.00 $30.00 3 0 $200.00 MD R $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 $107.66 888888888 HENN Henning Systems 393 Florida Ave Silver Spring MD 20601 Cynthia Henning Owner Sandra Bullock Bookeeper 3018393209 sb@lswonline.com Cynthia Henning 4/12/2008 2009 "$10,000.00 " "$10,000.00 " 0 "$10,000.00 " "$10,000.00 " "$10,000.00 " $0.00 $20.00 2 $0.00 "$14,000.00 " MD A "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,061.25 " "$1,096.25 " 555555555 JOHN Johnson Plumbing Roto Rooter 21 History Road Springdale MD 20774 James Johnson Owner Jenny Wilson Bookeeper 3013244929 jj@lswonline.com James Johnson 3/15/2008 2009 "$50,000.00 " "$50,000.00 " 1 "$5,000.00 " "$5,000.00 " "$5,000.00 " $0.00 $10.00 1 $0.00 "$49,000.00 " NJ A "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,282.75 " "$4,274.75 " 777777777 TEST Testing Corporation Storage Solutions 223 Misdemeanor Ave Suite B Rockville MD 20654 Kenneth Sims President Brenda Willis Financial Secretary 2402224544 bw@lswonline.com Brenda Willis 3/1/2008 Checking 255071981 333333333 2009 "$100,000.00 " "$25,000.00 " 0 "$100,000.00 " "$100,000.00 " "$100,000.00 " $0.00 $0.00 0 $250.00 "$54,000.00 " AR 3/30/2008 R "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.83 " "$4,370.87 "