n n _ ;12b I 3 I 14 Other 32° I 1 I Employee's address and ZIP coda 28.80 NYDD I N 16 Sine E a date NY J i ID number 16 Male vars. (Pa dc. 60000.00 17 815t8 Income lee 3173.41 16 Isoel alms eld. MC. 19 Local Worn* lax 20 Locefq nerd W 0 Wage and Tax Form IN iL Statement Cop