Department of the Treasury — Internal Revenue Service

Form W-2

Wage and Tax Statement

OMB No. 1545-0008

Tax Year

This form reports wages paid to employees and taxes withheld. Complete all applicable boxes. Contact your payroll administrator if you have questions about specific box amounts.

Employer Information

bEmployer identification number (EIN)

Employer name

Employer address

Employer city, state, ZIP

Employee Information

aEmployee's social security number

eEmployee's first name, middle initial, last name

fEmployee's address and ZIP code

City, state, ZIP

Wages & Tax Withholding

1Wages, tips, other compensation

2Federal income tax withheld

3Social security wages

4Social security tax withheld

5Medicare wages and tips

6Medicare tax withheld

7Social security tips

8Allocated tips

10Dependent care benefits

11Nonqualified plans

Box 12 — Deferred Compensation & Benefits

12a Code

12a Amount

12b Code

12b Amount

Box 13

Retirement planThird-party sick pay

14Other (describe)

State & Local Tax Information

15State

15Employer's state ID number

16State wages, tips, etc.

17State income tax

18Local wages, tips, etc.

19Local income tax

20Locality name

Certification & Signature

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that providing false information may result in penalties under applicable law.

Employee Signature *

Draw your signature here

Sign above using mouse or touch

Date

Complete required fields and add your signature to submit.