L BRILLO WAY PALM BEACH, FL 33480 3 Social security wages 38536.47 4 Social secunty tax witnheld 2389.26 5 Medicare wages end tips 38536.47 6 Medcare tax withheld 558.78 7 Sodal security tips 8 Allocated tips o Advance BC payment 10 Dependent care benefits • f Employee's address and ZIP code

L BRILLO WAY PALM BEACH, FL 33480 3 Social security wages 38536.47 4 Social secunty tax witnheld 2389.26 5 Medicare wages end tips 38536.47 6 Medcare tax withheld 558.78 7 Sodal security tips 8 Allocated tips o Advance BC payment 10 Dependent care benefits • f Employee's address and ZIP code

L BRILLO WAY PALM BEACH, FL 33480 3 Social security wages 38536.47 4 Social secunty tax witnheld 2389.26 5 Medicare wages end tips 38536.47 6 Medcare tax withheld 558.78 7 Sodal security tips 8 Allocated tips o Advance BC payment 10 Dependent care benefits • f Employee's address and ZIP code

ian I see does not participate with my health care plan • MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I re0uest that payment of authorized Medcare benefits be made either to me or on my behalf to all pro-Mews who treat me during my hospital stay or any services furnished to me by those provide

L BRILLO WAY PALM BEACH, FL 33480 3 Social security wages 38536.47 4 Social secunty tax witnheld 2389.26 5 Medicare wages end tips 38536.47 6 Medcare tax withheld 558.78 7 Sodal security tips 8 Allocated tips o Advance BC payment 10 Dependent care benefits • f Employee's address and ZIP code