Attention: 

You may file Forms W-2 and W-3 electronically on the SSA’s Employer 
W-2 Filing Instructions and Information web page, which is also accessible 
at www.socialsecurity.gov/employer.  You can create fill-in versions of 
Forms W-2 and W-3 for filing with SSA. You may also print out copies for 
filing with state or local governments, distribution to your employees, and 
for your records.

Note: Copy A of this form is provided for informational purposes only. Copy A appears in 
red, similar to the official IRS form. The official printed version of this IRS form is scannable, 
but the online version of it, printed from this website, is not. Do not print and file Copy A 
downloaded from this website with the SSA; a penalty may be imposed for filing forms that 
can’t be scanned. See the penalties section in the current General Instructions for Forms 
W-2 and W-3, available at www.irs.gov/w2, for more information.

Please note that Copy B and other copies of this form, which appear in black, may be 
downloaded, filled in, and printed and used to satisfy the requirement to provide the 
information to the recipient.

To order official IRS information returns such as Forms W-2 and W-3, which include a 
scannable Copy A for filing, go to IRS’ Online Ordering for Information Returns and 
Employer Returns page, or visit www.irs.gov/orderforms and click on Employer and 
Information returns. We’ll mail you the scannable forms and any other products you order.

See IRS Publications 1141,1167  , and1179 for more information about printing these tax 
forms.

                                     a  Employee’s social security number
     22222          VOID                                                 For Official Use Only  
                                                                         OMB No. 1545-0008 
b  Employer identification number (EIN)                                               1   Wages, tips, other compensation   2   Samoa income tax withheld

c  Employer’s name, address, and ZIP code                                             3   Social security wages             4   Social security tax withheld

                                                                                      5   Medicare wages and tips           6   Medicare tax withheld

                                                                                      7   Social security tips              8   

d  Control number                                                                     9                                     10   

e  Employee’s first name and initial    Last name                            Suff.    11   Nonqualified plans               12a Cdoe See instructions for box 12
                                                                                      13  Statutory Retirement  Third-party 
                                                                                          employee  plan        sick pay
                                                                                                                            12bCdoe
                                                                                      14  Other
                                                                                                                            12cCdoe
                                                                                                                            12dCo 
f  Employee’s address and ZIP code                                                                                          de

                             American Samoa                                                              Department of the Treasury—Internal Revenue Service
Form  W-2AS                  Wage and Tax Statement                      2024                                   For Privacy Act and Paperwork Reduction Act 
Copy A—For Social Security Administration. Send this entire page with Copy A of                                              Notice, see the separate instructions.
Form W-3SS to the Social Security Administration; photocopies arenot acceptable.                                                         Cat. No. 10140H
                                          Do Not Cut, Fold, or Staple Forms on This Page 

                                     a  Employee’s social security number
     22222          VOID                                                  OMB No. 1545-0008 
b  Employer identification number (EIN)                                         1   Wages, tips, other compensation   2   Samoa income tax withheld

c  Employer’s name, address, and ZIP code                                       3   Social security wages             4   Social security tax withheld

                                                                                5   Medicare wages and tips           6   Medicare tax withheld

                                                                                7   Social security tips              8   

d  Control number                                                               9                                     10   

e  Employee’s first name and initial    Last name                         Suff. 11   Nonqualified plans               12a Cdoe
                                                                                13  Statutory Retirement  Third-party 
                                                                                    employee  plan        sick pay
                                                                                                                      12bCdoe
                                                                                14  Other
                                                                                                                      12cCdoe
                                                                                                                      12dCo 
f  Employee’s address and ZIP code                                                                                    de

                             American Samoa                                                        Department of the Treasury—Internal Revenue Service
Form  W-2AS                  Wage and Tax Statement                      2024
Copy 1—For American Samoa Treasurer

                                     a  Employee’s social security number
                                                                          OMB No. 1545-0008 
b  Employer identification number (EIN)                                         1   Wages, tips, other compensation   2   Samoa income tax withheld

c  Employer’s name, address, and ZIP code                                       3   Social security wages             4   Social security tax withheld

                                                                                5   Medicare wages and tips           6   Medicare tax withheld

                                                                                7   Social security tips              8   

d  Control number                                                               9                                     10   

e  Employee’s first name and initial    Last name                         Suff. 11   Nonqualified plans               12a Cdoe See instructions for box 12  
                                                                                13  Statutory Retirement  Third-party 
                                                                                    employee  plan        sick pay
                                                                                                                      12bCdoe
                                                                                14  Other
                                                                                                                      12cCdoe
                                                                                                                      12dCo 
f  Employee’s address and ZIP code                                                                                    de

                             American Samoa                                                        Department of the Treasury—Internal Revenue Service
Form  W-2AS                  Wage and Tax Statement                      2024                                         This information is being furnished to 
Copy B—To Be Filed With Employee’s American Samoa Tax Return                                                            the American Samoa Tax Office, 
                                                                                                                        Government of American Samoa. 

Future developments. For the latest information about developments related to          filers, see the instructions for Form 1040-SS, Part I, line 6.) By filing this form, your 
Form W-2AS, such as legislation enacted after it was published, go to                  social security tips will be credited to your social security record (used to figure 
www.irs.gov/FormW2AS.                                                                  your benefits).
                                                                                       (See also Instructions for Employee on this page and the back of Copy C.)
Notice to Employee
Do you have to file? Refer to the Form 1040 instructions to determine if you are       Instructions for Employee
required to file a tax return. Even if you don’t have to file a tax return, you may be 
eligible for a refund if box 2 shows an amount or if you are eligible for any credit.  (See also Notice to Employee on this page.)
Copies B and C; corrections. File Copy B of this form with your 2024 American          Box 5. You may be required to report this amount on Form 8959. See the Form 
Samoa income tax return. Keep Copy C for your records. If your name, social            1040 instructions to determine if you are required to complete Form 8959.
security number (SSN), or address is incorrect, correct Copies B and C and ask         Box 6. This amount includes the 1.45% Medicare tax withheld on all Medicare 
your employer to correct your employment record. Be sure to ask your employer          wages and tips shown in box 5, as well as the 0.9% Additional Medicare Tax on 
to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security          any of those Medicare wages and tips above $200,000.
Administration (SSA) to correct any name, amount, or SSN error reported to the 
SSA. Be sure to get your copies of Form W-2c from your employer for all                Box 11. This amount is (a) reported in box 1 if it is a distribution made to you from 
corrections made so you may file them with your tax return.                            a nonqualified deferred compensation or nongovernmental section 457(b) plan, or 
Estimated tax. If you expect to owe $1,000 or more in tax for 2025, you may have       (b) included in box 3 and/or box 5 if it is a prior year deferral under a nonqualified or 
to make estimated tax payments to your local territory tax department. You may         section 457(b) plan that became taxable for social security and Medicare taxes this 
also have to make estimated tax payments to the U.S. Internal Revenue Service if       year because there is no longer a substantial risk of forfeiture of your right to the 
you are subject to self-employment taxes. See Pub. 570 for additional information.     deferred amount. This box shouldn’t be used if you had a deferral and a distribution 
                                                                                       in the same calendar year. If you made a deferral and received a distribution in the 
Employee’s social security number (SSN). For your protection, this form may            same calendar year, and you are or will be age 62 by the end of the calendar year, 
show only the last four digits of your SSN. However, your employer has reported        your employer should file Form SSA-131, Employer Report of Special Wage 
your complete SSN to the American Samoa Tax Office and the SSA.                        Payments, with the Social Security Administration and give you a copy.
Clergy and religious workers. If you aren’t subject to social security and             Box 12. The following list explains the codes shown in box 12. You may need this 
Medicare taxes, see Pub. 517.                                                          information to complete your tax return. Elective deferrals (codes D, E, F, and S) 
Cost of employer-sponsored health coverage (if such cost is provided by the            and designated Roth contributions (codes AA, BB, and EE) under all plans are 
employer). The reporting in box 12, using code DD, of the cost of employer-            generally limited to a total of $23,000 ($16,000 if you have only SIMPLE plans; 
sponsored health coverage is for your information only. The amount reported            $26,000 for section 403(b) plans if you qualify for the 15-year rule explained in 
with code DD is not taxable.                                                           Pub. 571). Deferrals under code G are limited to $23,000. Deferrals under code H 
                                                                                       are limited to $7,000.
Credit for excess social security tax. If you had more than one employer in 2024 
and more than $10,453.20 in social security tax was withheld, you can have the         However, if you were at least age 50 in 2024, your employer may have allowed an 
excess refunded by filing Form 843 with the Department of the Treasury, Internal       additional deferral of up to $7,500 ($3,500 for section 401(k)(11) and 408(p) SIMPLE 
Revenue Service Center, Austin, TX 73301-0215, USA. However, if you are                plans). This additional deferral amount is not subject to the overall limit on elective 
required to file Form 1040 or 1040-SR with the United States, you must claim the       deferrals. For code G, the limit on elective deferrals may be higher for the last 3 
excess tax as a credit on Form 1040 or 1040-SR.                                        years before you reach retirement age. Contact your plan administrator for more 
                                                                                       information. Amounts in excess of the overall elective deferral limit must be included 
Unreported tip income. You must file Form 4137 with your income tax return to          in income. See the “Wages, Salaries, Tips, etc.” line instructions for your tax return. 
figure the social security and Medicare tax owed on tips you didn’t report to your                                                (continued on back of Copy C)
employer. Enter this amount on the wages line of your tax return. (Form 1040-SS 

                                     a  Employee’s social security number
                                                                          OMB No. 1545-0008 
b  Employer identification number (EIN)                                         1   Wages, tips, other compensation   2   Samoa income tax withheld

c  Employer’s name, address, and ZIP code                                       3   Social security wages             4   Social security tax withheld

                                                                                5   Medicare wages and tips           6   Medicare tax withheld

                                                                                7   Social security tips              8   

d  Control number                                                               9                                     10   

e  Employee’s first name and initial    Last name                         Suff. 11   Nonqualified plans               12a Cdoe See instructions for box 12  
                                                                                13  Statutory Retirement  Third-party 
                                                                                    employee  plan        sick pay
                                                                                                                      12bCdoe
                                                                                14  Other
                                                                                                                      12cCdoe
                                                                                                                      12dCo 
f  Employee’s address and ZIP code                                                                                    de

                             American Samoa                                                        Department of the Treasury—Internal Revenue Service
Form  W-2AS                  Wage and Tax Statement                      2024                                         This information is being furnished to 
Copy C—For EMPLOYEE’S RECORDS                                                                                           the American Samoa Tax Office, 
(See Notice to Employee on the back of Copy B.)                                                                         Government of American Samoa. 

Instructions for Employee (continued from back of Copy B)                          R—Employer contributions to your Archer MSA. Report on Form 8853.
Box 12 (continued)                                                                 S—Employee salary reduction contributions under a section 408(p) SIMPLE plan 
                                                                                   (not included in box 1)
Note: If a year follows code D through H, S, Y, AA, BB, or EE, you made a make-    T—Adoption benefits (not included in box 1). Complete Form 8839 to figure 
up pension contribution for a prior year(s) when you were in military service. To  taxable and nontaxable amounts.
figure whether you made excess deferrals, consider these amounts for the year 
shown, not the current year. If no year is shown, the contributions are for the    V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3 
current year.                                                                      (up to the social security wage base), and 5). See Pub. 525 for reporting 
A—Uncollected social security tax on tips. Report on U.S. Form 1040 or 1040-SR.    requirements.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.               W—Employer contributions (including amounts the employee elected to contribute 
B—Uncollected Medicare tax on tips. Report on U.S. Form 1040 or 1040-SR.           using a section 125 (cafeteria) plan) to your health savings account (HSA). Report 
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.               on Form 8889.
C—Taxable cost of group-term life insurance over $50,000 included in boxes 1, 3    Y—Deferrals under a section 409A nonqualified deferred compensation plan
(up to the social security wage base), and 5                                       Z—Income under a nonqualified deferred compensation plan that fails to satisfy 
                                                                                   section 409A. This amount is also included in box 1. It is subject to an additional 
D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also                                                              
                                                                                   20% tax plus interest. See Other Taxes
includes deferrals under a SIMPLE retirement account that is part of a section                                               in the instructions for your tax return.
401(k) arrangement.                                                                AA—Designated Roth contributions under a section 401(k) plan
E—Elective deferrals under a section 403(b) salary reduction agreement             BB—Designated Roth contributions under a section 403(b) plan
F—Elective deferrals under a section 408(k)(6) salary reduction SEP                DD—Cost of employer-sponsored health coverage.The amount reported with 
G—Elective deferrals and employer contributions (including nonelective deferrals)  code DD is not taxable.
to a section 457(b) deferred compensation plan                                     EE—Designated Roth contributions under a governmental section 457(b) plan. 
                                                                                   This amount does not apply to contributions under a tax-exempt organization 
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan. (You section 457(b) plan.
may be able to deduct.)
J—Nontaxable sick pay (information only, not included in box 1, 3, or 5)           FF—Permitted benefits under a qualified small employer health reimbursement 
                                                                                   arrangement
M—Uncollected social security tax on taxable cost of group-term life insurance     GG—Income from qualified equity grants under section 83(i)
over $50,000 (former employees only). Report on U.S. Form 1040 or 1040-SR. 
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.               HH—Aggregate deferrals under section 83(i) elections as of the close of the 
                                                                                   calendar year
N—Uncollected Medicare tax on taxable cost of group-term life insurance over 
$50,000 (former employees only). Report on U.S. Form 1040 or 1040-SR. Report       II—Medicaid waiver payments excluded from gross income under Notice 2014-7.
on Form 1040-SS if not required to file Form 1040 or 1040-SR.                      Box 13. If the “Retirement plan” box is checked, special limits may apply to the 
P—Excludable moving expense reimbursements paid directly to a member of the        amount of traditional IRA contributions that you may deduct. See Pub. 590-A. 
U.S. Armed Forces (not included in box 1, 3, or 5)                                 Note: Keep Copy C of Form W-2AS for at least 3 years after the due date for filing 
Q—Nontaxable combat pay. See your tax return instructions for details on           your income tax return. However, to help protect your social security benefits, 
reporting this amount.                                                             keep Copy C until you begin receiving social security benefits just in case there is 
                                                                                   a question about your work record and/or earnings in a particular year.