'. 1 Wages, lips, other canpense5on 60000.00 2 Federal Income tax withheld 6065.04 o Employers name, address, and ZIP code EPSTEIN INTERESTS 3 Sodel security wages 60000.00 4 Social security lax wIthhard 3720.00 457 MADISON AVENUE NEW YORK, NY 10022 6 Medicare wages Ind Upe 60000.00 6 M00k

l. Nola. IF the account Is In more than ono nano. sea the Instructions for lino I and the chart on page 4 for guidelines on whose number to enter. Sodel number -1 or I EMI woe !decilitre/aeon numbs' Certification Undo, penalties al perjury. I certify that 1. The number shown on this form Is my