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Department of the Treasury
Internal Revenue Service                                                                                            PRSRT STD
Ogden, UT 84201
                                                                                                              Postage and Fees Paid
Official Business                                                                                                Internal Revenue Service
Penalty for Private Use, $300
                                                                                                                 Permit No. G-48

          Department of the Treasury
          Internal Revenue Service

2009                                                                 Federal Employment Tax Forms

Publication 393                                                        W-2

Federal Employment Tax Forms                                           W-3

Reminders                                                            Show the correct social security numbers of all employees on
                                                                     Forms W-2 and be sure all copies are legible. If any employees’
How to get forms and publications. To get forms and                  names changed during the year, encourage the employees to
publications, see Quick and Easy Access to IRS Tax Help and Tax      contact their local Social Security Administration (SSA) office and
Products on page 2. To place an order for 2009 and 2010              request a corrected social security card.
employer-related forms and publications online for delivery by
mail, access www.irs.gov/businesses and click on “Online Ordering      Having employees secure a corrected social security card will
for Information Returns and Employer Returns.”                       allow the SSA to process the information correctly and properly
                                                                     credit employees’ social security earnings. It will also help the
Social security wage base for 2009. Do not withhold social           employees report their wages on their income tax returns.
security tax after an employee reaches $106,800 in social security
wages for 2009. (There is no limit on the amount of wages            Furnish Copies B, C, and 2 of Form W-2 to your employees by
subject to Medicare tax.)                                            February 1, 2010.
                                                                     
What forms and publications will IRS send automatically? IRS will      Prepare and file Forms W-2 either alphabetically by employees’
send you either Pub. 15 (Circular E) or Pub. 51 (Circular A) in      last names or numerically by employees’ social security numbers.
December. These publications explain your tax responsibilities as an Use Form W-3 to send Copy A of all Forms W-2 to the SSA by
employer and will provide federal income tax withholding and advance March 1, 2010. Be sure to fill in your name, address, and correct EIN.
earned income credit payment tables for 2010. You will also receive  Electronic filing option for small businesses. Small submitters may
employment tax returns for each quarterly or annual return period    be able to file Forms W-2 electronically. Electronic filing is free, fast,
unless you filed electronically or used a paid preparer:             and secure with a later filing deadline (March 31, 2010, versus March
Form 940, Employer’s Annual Federal Unemployment (FUTA) Tax        1, 2010, for other filing methods). To register for electronic filing or to
Return                                                               get more information, visit www.socialsecurity.gov/employer and
Form 941, Employer’s QUARTERLY Federal Tax Return                  click on “Electronically File Your W-2s.” Do not mail paper Forms
                                                                     W-2 or Forms W-3 to SSA if you file electronically.

  Form 943, Employer’s Annual Federal Return for Agricultural        Information return questions. If you have questions about
Employees                                                            information returns (Forms 1096, 1098, 1099, 1042-S, 5498, W-2,
Form 944, Employer’s ANNUAL Federal Tax Return                     W-2G, and W-3), call 1-866-455-7438 (toll free) or 304-263-8700 (toll
Schedule H (Form 1040), Household Employment Taxes                 call) Monday through Friday, 8:30 a.m. to 4:30 p.m., Eastern time.
                                                                     Recordkeeping. Keep copies of Forms W-2 and W-3 and all other
How to complete Forms W-2 and W-3. When you complete and             employment tax records for at least 4 years.
file your 2009 Form W-2, Wage and Tax Statement(s), and 2009
Form W-3, Transmittal of Wage and Tax Statements:
                                                                                                              Publication 393
                                                                                                              Cat. No. 11071P



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Quick and Easy Access to IRS Tax Help and Tax Products

Internet                      Online Services & Tax Help                                 View & Download Products
                              Access the IRS website 24 hours a day, 7 days a week at    Visit the IRS website at www.irs.gov and select Forms
                              www.irs.gov to obtain information on:                      and Publications, or simply type www.irs.gov/formspubs
                              Online Services — Conduct business with the IRS          in your Internet search window to:
                                electronically                                           view or download current and previous year tax
                              Taxpayer Advocate Service — Helps taxpayers resolve        products
                                problems with the IRS.                                   order current year tax products online
                              Free File and e-file — Free Federal Online Filing        The Forms and Publications page provides links to
                                                                                         access and acquire both electronic and print media.
                              Where’s My Refund— Your refund status anytime from       Additionally, the Search function provides basic and
                                anywhere                                                 advanced search capabilitites for published products
                              Free Tax Return Preparation— Free tax assistance and     available on IRS.gov.
                                preparation
                              Recent Tax Changes — Highlights on newly-enacted         Online Ordering of Products
                                tax law                                                  To order Tax Products delivered by mail, go to
                              Innocent Spouses — Tax Information for Innocent          www.irs.gov/formspubs
                                Spouses                                                  For current year products, select “Forms and
                              Disaster Tax Relief — Tax relief provisions for disaster   publications by U.S. mail”
To get IRS information, forms   situations                                               For a tax booklet of forms and instructions, select
and publications in Spanish,  Identity Theft and Your Tax Records — Safeguard your       “Tax packages”
select Español in upper right   identity and tax records                                 For Employer Products (e.g. W-4, Pub. 15) and
corner of www.irs.gov.        Online Payment Agreement (OPA) Application —               Information Returns (e.g. W-2, W-3, 1099 series),
                                                                                           select “Employer forms and instructions”
                                Online agreements                                        For tax products on a DVD, select “Tax products on
                              Applying for Offers in Compromise — Information on         DVD (Pub. 1796)” See DVD below
                                Offers in Compromise

                              Tax Forms & Publications                                   Tax Help & Questions
Telephone
                              1-800-829-3676                                             Individuals: 1-800-829-1040
                              Call to order current and prior year forms, instructions,  Business & Specialty Tax: 1-800-829-4933
                              and publications.                                          Hearing Impaired TTY/TDD: 1-800-829-4059
                              You should receive your order within 10 working days.      TeleTax - 24 hour tax information: 1-800-829-4477
                              National Taxpayer Advocate Helpline                        See instructions 1040, 1040A, or 1040EZ for topic
                              1-877-777-4778                                             numbers and details.
                                                                                         Refund Hotline: 1-800-829-1954

                              You can pick up some of the most requested forms,          Also some grocery stores, copy centers, city and county
Community                     instructions, and publications at many IRS offices, post   government offices, and credit unions have reproducible
Locations                     offices, and libraries.                                    tax form products available to photocopy or print from a
                                                                                         DVD.

                              You can receive tax products within 10 working days after  Send written request to:
Mail                          receipt of your order.                                     Internal Revenue Service
                              Do not send your tax return to the address                 1201 N. Mitsubishi Motorway
                              shown here. Instead, see the tax form                      Bloomington, IL 61705-6613
                              instructions.

                              Purchase the IRS Publication 1796 (IRS Tax Products).      Telephone:         NTIS at 1-877-233-6767
DVD
                              Internet:                                                                              or
                              National Technical Information Service (NTIS) at                            GPO at 1-866-512-1800
                                www.irs.gov/cdorders                                     Availability:
                                                                                                           First release—early January 
                                                      or                                                   Final release—early March 
                              Government Printing Office (GPO) at
                                http://bookstore.gpo.gov (search for Pub. 1796)

          Department of the Treasury                                                               Publication 2053-A (Rev. 9-2009)
          Internal Revenue Service                                                                 Cat. No. 23267Z
          www.irs.gov



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                                                                  DO NOT STAPLE
                   a  Control number                   For Official Use Only
  33333                                                OMB No. 1545-0008
  b                   941       Military   943         944        1  Wages, tips, other compensation  2     Federal income tax withheld
    Kind
                                                       Third-party
    Payer             CT-1      emp.       govt. emp.                Social security wages                  Social security tax withheld
    of                          Hshld.     Medicare    sick pay   3                                   4

  cd 5Total number of Forms W-2          Establishment number        Medicare wages and tips          6     Medicare tax withheld

  e   Employer identification number (EIN)                        7  Social security tips             8     Allocated tips

  f   Employer’s name                                             9  Advance EIC payments             10    Dependent care benefits

                                                                  11 Nonqualified plans               12    Deferred compensation

                                                                  13 For third-party sick pay use only

                                                                  14 Income tax withheld by payer of third-party sick pay
  g   Employer’s address and ZIP code
  h   Other EIN used this year

15    State  Employer’s state ID number                           16 State wages, tips, etc.          17    State income tax

                                                                  18 Local wages, tips, etc.          19    Local income tax

  Contact person                                                  Telephone number                          For Official Use Only
                                                                  ()
  Email address                                                   Fax number
                                                                  ()
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.

Signature                                                         Title                                                  Date
                                                                                                                          Department of the Treasury
Form  W-3 Transmittal of Wage and Tax Statements                                                      2009                   Internal Revenue Service
Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration.
Do not send any payment (cash, checks, money orders, etc.) with Forms W-2 and W-3.
Reminder                                                                      Upload a file for employers who use payroll/tax software to print
                                                                              Form(s) W-2, if the vendor software creates a file that can be
Separate instructions. See the 2009 Instructions for Forms W-2                uploaded to SSA.
and W-3 for information on completing this form.                                For more information, go to www.socialsecurity.gov/employer and
                                                                              select “First Time Filers” or “Returning Filers” under “BEFORE YOU
Purpose of Form                                                               FILE.”
A Form W-3 Transmittal is completed only when paper Copy A of
Form(s) W-2, Wage and Tax Statement, are being filed. Do not file             When To File
Form W-3 alone. Do not file Form W-3 for Form(s) W-2 that were                Mail any paper Forms W-2 under cover of this Form W-3
submitted electronically to the Social Security Administration (see           Transmittal by March 1, 2010. Electronic fill-in forms or uploads are
below). All paper forms must comply with IRS standards and be                 filed through SSA’s Business Services Online (BSO) Internet site
machine readable. Photocopies and hand-printed forms are not                  and will be on time if submitted by March 31, 2010.
acceptable. Use a Form W-3 even if only one paper Form W-2 is
being filed. Make sure both the Form W-3 and Form(s) W-2 show                 Where To File Paper Forms
the correct tax year and Employer Identification Number (EIN). Make           Send this entire page with the entire Copy A page of Form(s) W-2
a copy of this form and keep it with Copy D (For Employer) of                 to:
Form(s) W-2 for your records.
                                                                                          Social Security Administration
Electronic Filing                                                                         Data Operations Center
The Social Security Administration strongly suggests employers                            Wilkes-Barre, PA 18769-0001
report Form W-3 and W-2 Copy A electronically instead of on                   Note. If you use “Certified Mail” to file, change the ZIP code to
paper. SSA provides two e-file options:                                       “18769-0002.” If you use an IRS-approved private delivery service, add
Free online, fill-in Forms W-2 for employers who file 20 or fewer           “ATTN: W-2 Process, 1150 E. Mountain Dr.” to the address and change
Form(s) W-2.                                                                  the ZIP code to “18702-7997.” See Publication 15 (Circular E),
                                                                              Employer’s Tax Guide, for a list of IRS-approved private delivery services.

                              For Privacy Act and Paperwork Reduction Act Notice, see the back of Copy D of Form W-2.
                                                                     Cat. No. 10159Y



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                                                                                                         Action                              Date          Signature
TLS, have you                                                                                            O.K. to print
transmitted all R                                                                                        T:FP:F
text files for this
cycle update?       Page 1 of 12 of Form W-2 (Page 2 Blank) 6 Part                                   6   O.K. to print
                    The type and rule above prints on all proofs including departmental                  Responsible
     DateDate       reproduction proofs. MUST be removed before printing.                                scan organization
                                                                                                         Revised proofs
                                                                                                         requested
                    Separation 1: prints red
                    Separation 2: prints black

                                     a Employee’s social security number For Official Use Only
   22222            Void                                                 OMB No. 1545-0008
b  Employer identification number (EIN)                                           1  Wages, tips, other compensation                      2  Federal 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  Allocated tips

d  Control number                                                                 9  Advance EIC payment                              10     Dependent care benefits

                                                                             Suff.
e  Employee’s first name and initial    Last name                                 11 Nonqualified plans                               12adeoCSee instructions for box 12

                                                                                  13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                  14 Other                                            deo12cC

                                                                                                                                      deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc.  17 State income tax  18 Local wages, tips, etc.              19 Local income tax     20 Locality name

                    Wage and Tax                                                                         Department of the Treasury—Internal Revenue Service
Form W-2            Statement                                            2 009                                         For Privacy Act and Paperwork Reduction
Copy A For Social Security Administration —       Send this entire page with                                                                Act Notice, see back of Copy D.
Form W-3 to the Social Security Administration; photocopies are not acceptable.                                                                            Cat. No. 10134D

         Do Not Cut, Fold, or Staple Forms on This Page — Do Not Cut, Fold, or Staple Forms on This Page



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Page 3 of 12 of Form W-2 (Page 4 is blank)                                                                       6 Part                                         6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

                                     a Employee’s social security number
   22222                                                                OMB No. 1545-0008
b  Employer identification number (EIN)                                         1  Wages, tips, other compensation                      2  Federal 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  Allocated tips

d  Control number                                                               9  Advance EIC payment                              10     Dependent care benefits

                                                                           Suff.
e  Employee’s first name and initial    Last name                               11 Nonqualified plans                               12aCoed

                                                                                13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                14 Other                                            deo12cC

                                                                                                                                    deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.              19 Local income tax  20 Locality name

                    Wage and Tax                                                                                 Department of the Treasury—Internal Revenue Service
Form W-2            Statement                                           2 009
Copy 1—For State, City, or Local Tax Department



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Page 5 of 12 of Form W-2                                                    6 Part                                                                               6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

                                     a Employee’s social security number                            Safe, accurate,                             Visit the IRS website
                                                                         OMB No. 1545-0008          FAST! Use                                   at www.irs.gov/efile.
b  Employer identification number (EIN)                                          1  Wages, tips, other compensation                      2  Federal 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  Allocated tips

d  Control number                                                                9  Advance EIC payment                              10     Dependent care benefits

                                                                            Suff.
e  Employee’s first name and initial    Last name                                11 Nonqualified plans                               12adeoCSee instructions for box 12

                                                                                 13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                 14 Other                                            deo12cC

                                                                                                                                     deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc.  17 State income tax 18 Local wages, tips, etc.              19 Local income tax     20 Locality name

                    Wage and Tax                                                                                  Department of the Treasury—Internal Revenue Service
Form W-2            Statement                                            2 009
Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.



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Page 6 of 12 of Form W-2                              (Back of Copy B)                    6 Part                  6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Notice to Employee

Refund. Even if you do not have to file a tax return, you        Corrections. If your name, SSN, or address is incorrect,
should file to get a refund if box 2 shows federal income tax    correct Copies B, C, and 2 and ask your employer to correct
withheld or if you can take the earned income credit.            your employment record. Be sure to ask the employer to file
Earned income credit (EIC). You must file a tax return if        Form W-2c, Corrected Wage and Tax Statement, with the
any amount is shown in box 9.                                    Social Security Administration (SSA) to correct any name,
                                                                 SSN, or money amount error reported to the SSA on Form
You may be able to take the EIC for 2009 if (a) you do not       W-2. If your name and SSN are correct but are not the same
have a qualifying child and you earned less than $13,440         as shown on your social security card, you should ask for a
($16,560 if married filing jointly), (b) you have one qualifying new card that displays your correct name at any SSA office
child and you earned less than $35,463 ($38,583 if married       or by calling 1-800-772-1213.
filing jointly), or (c) you have more than one qualifying child  Credit for excess taxes. If you had more than one
and you earned less than $40,295 ($43,415 if married filing
                                                                 employer in 2009 and more than $6,621.60 in social security
jointly). You and any qualifying children must have valid
                                                                 and/or Tier I railroad retirement (RRTA) taxes were withheld,
social security numbers (SSNs). You cannot take the EIC if
                                                                 you may be able to claim a credit for the excess against
your investment income is more than $3,100. Any EIC that
                                                                 your federal income tax. If you had more than one railroad
is more than your tax liability is refunded to you, but only
                                                                 employer and more than $3,088.80 in Tier II RRTA tax was
if you file a tax return. If you have at least one qualifying
                                                                 withheld, you also may be able to claim a credit. See your
child, you may get as much as $1,826 of the EIC in advance
                                                                 Form 1040 or Form 1040A instructions and Publication 505,
by completing Form W-5, Earned Income Credit Advance
                                                                 Tax Withholding and Estimated Tax.
Payment Certificate, and giving it to your employer.
Clergy and religious workers. If you are not subject to          (Also see Instructions for Employee on the back of Copy C.)
social security and Medicare taxes, see Publication 517,
Social Security and Other Information for Members of the
Clergy and Religious Workers.



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Page 7 of 12 of Form W-2                                                    6 Part                                                                               6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

                                     a Employee’s social security number                     This information is being furnished to the Internal Revenue Service. If you
                                                                         OMB No. 1545-0008   are required to file a tax return, a negligence penalty or other sanction
                                                                                             may be imposed on you if this income is taxable and you fail to report it.
b  Employer identification number (EIN)                                          1  Wages, tips, other compensation                      2  Federal 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  Allocated tips

d  Control number                                                                9  Advance EIC payment                              10     Dependent care benefits

                                                                            Suff.
e  Employee’s first name and initial    Last name                                11 Nonqualified plans                               12adeoCSee instructions for box 12

                                                                                 13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                 14 Other                                            deo12cC

                                                                                                                                     deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc.  17 State income tax 18 Local wages, tips, etc.              19 Local income tax     20 Locality name

                    Wage and Tax                                                                                  Department of the Treasury—Internal Revenue Service
Form W-2            Statement                                            2 009                                    Safe, accurate,
Copy C—For EMPLOYEE’S RECORDS (See Notice to                                                                      FAST!              Use
Employee on the back of Copy B.)



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Page 8 of 12                                                                                                                  6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Employee (Also see Notice to                        qualify for the 15-year rule explained in Pub. 571). Deferrals
                                                                     under code G are limited to $16,500. Deferrals under code H
Employee, on the back of Copy B.)                                    are limited to $7,000.
Box 1. Enter this amount on the wages line of your tax return.       However, if you were at least age 50 in 2009, your employer
Box 2. Enter this amount on the federal income tax withheld          may have allowed an additional deferral of up to $5,500 ($2,500
line of your tax return.                                             for section 401(k)(11) and 408(p) SIMPLE plans). This additional
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For       deferral amount is not subject to the overall limit on elective
information on how to report tips on your tax return, see your       deferrals. For code G, the limit on elective deferrals may be
Form 1040 instructions.                                              higher for the last 3 years before you reach retirement age.
                                                                     Contact your plan administrator for more information. Amounts
Box 9. Enter this amount on the advance earned income credit         in excess of the overall elective deferral limit must be included
payments line of your Form 1040 or Form 1040A.                       in income. See the “Wages, Salaries, Tips, etc.” line instructions
Box 10. This amount is the total dependent care benefits that        for Form 1040.
your employer paid to you or incurred on your behalf (including      Note. If a year follows code D through H, S, Y, AA, or BB, you
amounts from a section 125 (cafeteria) plan). Any amount over        made a make-up pension contribution for a prior year(s) when
$5,000 is also included in box 1. You must complete Schedule         you were in military service. To figure whether you made excess
2 (Form 1040A) or Form 2441, Child and Dependent Care                deferrals, consider these amounts for the year shown, not the
Expenses, to compute any taxable and nontaxable amounts.             current year. If no year is shown, the contributions are for the
Box 11. This amount is (a) reported in box 1 if it is a distribution current year.
made to you from a nonqualified deferred compensation or             A—Uncollected social security or RRTA tax on tips. Include this
nongovernmental section 457(b) plan or (b) included in box 3         tax on Form 1040. See “Total Tax” in the Form 1040
and/or 5 if it is a prior year deferral under a nonqualified or      instructions.
section 457(b) plan that became taxable for social security and
Medicare taxes this year because there is no longer a                B—Uncollected Medicare tax on tips. Include this tax on Form
substantial risk of forfeiture of your right to the deferred         1040. See “Total Tax” in the Form 1040 instructions.
amount.                                                              C—Taxable cost of group-term life insurance over $50,000
Box 12. The following list explains the codes shown in               (included in boxes 1, 3 (up to social security wage base), and 5)
box 12. You may need this information to complete your tax           D—Elective deferrals to a section 401(k) cash or deferred
return. Elective deferrals (codes D, E, F, and S) and designated     arrangement. Also includes deferrals under a SIMPLE retirement
Roth contributions (codes AA and BB) under all plans are             account that is part of a section 401(k) arrangement.
generally limited to a total of $16,500 ($11,500 if you only have    E—Elective deferrals under a section 403(b) salary reduction
SIMPLE plans; $19,500 for section 403(b) plans if you                agreement
                                                                                           (continued on back of Copy 2)



- 10 -
Page 9 of 12 of Form W-2 (Page 10 is blank)                                                                      6 Part                                         6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

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

d  Control number                                                               9  Advance EIC payment                              10     Dependent care benefits

                                                                           Suff.
e  Employee’s first name and initial    Last name                               11 Nonqualified plans                               12aCoed

                                                                                13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                14 Other                                            deo12cC

                                                                                                                                    deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.              19 Local income tax  20 Locality name

                    Wage and Tax                                                                                 Department of the Treasury—Internal Revenue Service
Form W-2            Statement                                           2 009
Copy 2—To Be Filed With Employee’s State, City, or Local
Income Tax Return.



- 11 -
  Page 10 of 12                                                                                                    6
  The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Employee (continued from back of           S—Employee salary reduction contributions under a section
                                                            408(p) SIMPLE (not included in box 1)
Copy C)
                                                            T—Adoption benefits (not included in box 1). You must
F—Elective deferrals under a section 408(k)(6) salary       complete Form 8839, Qualified Adoption Expenses, to
reduction SEP                                               compute any taxable and nontaxable amounts.
G—Elective deferrals and employer contributions (including  V—Income from exercise of nonstatutory stock option(s)
nonelective deferrals) to a section 457(b) deferred         (included in boxes 1, 3 (up to social security wage base),
compensation plan                                           and 5)
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt  W—Employer contributions to your Health Savings Account.
organization plan. See “Adjusted Gross Income” in the Form  Report on Form 8889, Health Savings Accounts (HSAs).
1040 instructions for how to deduct.                        Y—Deferrals under a section 409A nonqualified deferred
J—Nontaxable sick pay (information only, not included in    compensation plan.
boxes 1, 3, or 5)                                           Z—Income under section 409A on a nonqualified deferred
K—20% excise tax on excess golden parachute payments.       compensation plan. This amount is also included in box 1. It
See “Total Tax” in the Form 1040 instructions.              is subject to an additional 20% tax plus interest. See “Total
L—Substantiated employee business expense                   Tax” in the Form 1040 instructions.
reimbursements (nontaxable)                                 AA—Designated Roth contributions under a section 401(k)
M—Uncollected social security or RRTA tax on taxable cost   plan.
of group-term life insurance over $50,000 (former employees BB—Designated Roth contributions under a section 403(b)
only). See “Total Tax” in the Form 1040 instructions.       plan.
N—Uncollected Medicare tax on taxable cost of group-term    Box 13. If the “Retirement plan” box is checked, special
life insurance over $50,000 (former employees only). See    limits may apply to the amount of traditional IRA
“Total Tax” in the Form 1040 instructions.                  contributions that you may deduct.
P—Excludable moving expense reimbursements paid             Note. Keep Copy C of Form W-2 for at least 3 years after
directly to employee (not included in boxes 1, 3, or 5)     the due date for filing your income tax return. However, to
Q—Nontaxable combat pay. See the instructions for Form      help protect your social security benefits, keep Copy C
                                                            until you begin receiving social security benefits, just in case
1040 or Form 1040A for details on reporting this amount.
                                                            there is a question about your work record and/or earnings
R—Employer contributions to your Archer MSA. Report on      in a particular year. Compare the Social Security wages and
Form 8853, Archer MSAs and Long-Term Care Insurance         the Medicare wages to the information shown on your
Contracts.                                                  annual (for workers over 25) Social Security Statement.



- 12 -
Page 11 of 12 of Form W-2                                                  6 Part                                                                               6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

                                     a Employee’s social security number
                    Void
                                                                        OMB No. 1545-0008
b  Employer identification number (EIN)                                         1  Wages, tips, other compensation                      2  Federal 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  Allocated tips

d  Control number                                                               9  Advance EIC payment                              10     Dependent care benefits

                                                                           Suff.
e  Employee’s first name and initial    Last name                               11 Nonqualified plans                               12adeoCSee instructions for box 12

                                                                                13StatutoryemployeeplanRetirementsickThird-partypay ed12bCo

                                                                                14 Other                                            deo12cC

                                                                                                                                    deo12dC
f  Employee’s address and ZIP code
15 State Employer’s state ID number          16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.              19 Local income tax     20 Locality name

                    Wage and Tax                                                                                 Department of the Treasury—Internal Revenue Service
Form W-2            Statement                     2 009                                                              For Privacy Act and Paperwork Reduction
Copy D—For Employer.                                                                                                                Act Notice, see the back of Copy D.



- 13 -
Page 12 of 12 of Form W-2                             (Back of Copy D)                   6 Part                           6
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Employers, Please Note—
Specific information needed to complete Form W-2 is           You are not required to provide the information requested
available in a separate booklet titled 2009 Instructions for  on a form that is subject to the Paperwork Reduction Act
Forms W-2 and W-3. You can order those instructions and       unless the form displays a valid OMB control number. Books
additional forms by calling 1-800-TAX-FORM                    or records relating to a form or its instructions must be
(1-800-829-3676). You can also get forms and instructions     retained as long as their contents may become material in
from the IRS website at www.irs.gov.                          the administration of any Internal Revenue law.
Caution. You cannot file Forms W-2/W-2c and W-3/W-3c          Generally, tax returns and return information are
that you print from the IRS website with SSA because they     confidential, as required by section 6103. However,
process paper forms by machine. Instead, you can use the      section 6103 allows or requires the Internal Revenue
SSA website at www.ssa.gov/employer/bsohbnew.htm to           Service to disclose or give the information shown on your
create and file electronic fill-in versions of Forms W-2/W-2c return to others as described in the Code. For example, we
and W-3/W-3c. If you use SSA’s online application to create   may disclose your tax information to the Department of
W-2 or W-2c, the W-3 or W-3c will be automatically created.   Justice for civil and/or criminal litigation, and to cities,
Due dates. Furnish Copies B, C, and 2 to the employee         states, the District of Columbia, and U.S. commonwealths
generally by February 1, 2010.                                and possessions for use in administering their tax laws. We
File Copy A with the SSA by March 1, 2010. Send all           may also disclose this information to other countries under a
Copies A with Form W-3, Transmittal of Wage and Tax           tax treaty, to federal and state agencies to enforce federal
Statements. If you file electronically, the due date is March nontax criminal laws, or to federal law enforcement and
31, 2010.                                                     intelligence agencies to combat terrorism.
                                                              The time needed to complete and file these forms will vary
Privacy Act and Paperwork Reduction Act Notice. We ask        depending on individual circumstances. The estimated
for the information on Forms W-2 and W-3 to carry out the     average times are: Form W-2—30 minutes, and Form
Internal Revenue laws of the United States. We need it to     W-3—28 minutes. If you have comments concerning the
figure and collect the right amount of tax. Section 6051 and  accuracy of these time estimates or suggestions for making
its regulations require you to furnish wage and tax           these forms simpler, we would be happy to hear from you.
statements to employees and to the Social Security            You can write to the Internal Revenue Service, Tax Products
Administration. Section 6109 requires you to provide your     Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
employer identification number (EIN). If you fail to provide  Constitution Ave. NW, IR-6526, Washington, DC 20224. Do
this information in a timely manner, you may be subject to    not send Forms W-2 and W-3 to this address. Instead, see
penalties.                                                    Where to file paper forms in the Instructions for Forms W-2
                                                              and W-3.



- 14 -
                                                                                            Department of the Treasury
                                                                                            Internal Revenue Service
2009

Instructions for Forms W-2

and W-3
Wage and Tax Statement and
Transmittal of Wage and Tax Statements

Section references are to the Internal Revenue Code unless   Electronic payee statements.   If your employees give their
otherwise noted.                                             consent, you may be able to furnish Copies B, C, and 2 of
Contents                                             Page    Forms W-2 to your employees electronically. See Pub. 15-A,
What’s New ..................................1               Employer’s Supplemental Tax Guide, for additional
Reminders ...................................1               information.
Need Help? ..................................1               Extended due date for electronic filers.  If you file your
How To Get Forms and Publications ...............2           2009 Forms W-2 with the Social Security Administration
Common Errors on Forms W-2 ...................2              (SSA) electronically, the due date is extended to
General Instructions for Forms W-2 and W-3 ........2         March 31, 2010. For information on how to file electronically,
Special Reporting Situations for Form W-2 ..........4        see Online filing of Forms W-2 and W-3 below and
Penalties ....................................8              Electronic reporting on page 3.
Specific Instructions for Form W-2 ................9         Form 944.   Use the “944” checkbox in box b of Form W-3 if
Specific Instructions for Form W-3 ...............1 4        you filed Form 944, Employer’s ANNUAL Federal Tax
Reconciling Forms W-2, W-3, 941, 943, 944,                   Return. Also use the “944” checkbox if you filed Forma
CT-1, and Schedule H (Form 1040)   .............1 5          944(SP), the Spanish version of Form 944.
Form W-2 Reference Guide for Box 12 Codes .......1 6         Nonqualified deferred compensation plans.     Section
Index ......................................1 6              409A, added by the American Jobs Creation Act of 2004,
                                                             provides that all amounts deferred under a nonqualified
                                                             deferred compensation (NQDC) plan for all taxable years
What’s New                                                   are includible in gross income unless certain requirements
                                                             are satisfied. See Nonqualified deferred compensation plans
Military differential pay. Payments made after 2008 to       on page 7.
former employees while they are on active duty for more
than 30 days in the Armed Forces or other uniformed          Online filing of Forms W-2 and W-3.   You may file Forms
services are now treated as wages. Report these payments     W-2 and W-3 electronically by visiting SSA’s website at
in box 1 of Form W-2.                                        www.socialsecurity.gov/employer, and selecting “Business
                                                             Services Online (BSO).” Once registered, you can upload
Reporting for nonqualified deferred compensation             electronic wage files or use SSA’s “Create Forms W-2
plans. You are not required to complete box 12 with code     Online” to send electronic information to Social Security.
Y (deferrals under nonqualified plans subject to section     W-2 Online allows you to create “fill-in” versions of Forms
409A).                                                       W-2 for filing with the SSA and to print out copies of the
                                                             forms for filing with state or local governments, distribution
Reminders                                                    to your employees, and for your records. Form W-3 will be
                                                             calculated for you based on your Forms W-2. For more
Distributions from governmental section 457(b) plans of      information, see Online wage reporting on page 2.
state and local agencies.  Generally, report distributions
from section 457(b) plans of state and local agencies on     Substitute forms.   If you are not using the official IRS form
Form 1099-R, Distributions From Pensions, Annuities,         to furnish Form W-2 to employees or to file with the SSA,
Retirement or Profit-Sharing Plans, IRAs, Insurance          you may use an acceptable substitute form that complies
Contracts, etc. See Notice 2003-20 for details. You can find with the rules in Pub. 1141, General Rules and
Notice 2003-20 on page 894 of Internal Revenue Bulletin      Specifications for Substitute Forms W-2 and W-3.
2003-19 at www.irs.gov/pub/irs-irbs/irb03-19.pdf.            Pub. 1141, which is revised annually, is a revenue
                                                             procedure that explains the requirements for format and
Earned income credit (EIC) notice. You must notify           content of substitute Forms W-2 and W-3. Your substitute
employees who have no income tax withheld that they may      forms must comply with the requirements in Pub. 1141.
be able to claim an income tax refund because of the EIC.
You can do this by using the official IRS Form W-2 with the
EIC notice on the back of Copy B or a substitute Form W-2    Need Help?
with the same statement. You must give your employee         Information reporting customer service site.     The IRS
Notice 797, Possible Federal Tax Refund Due to the Earned    operates a centralized customer service site to answer
Income Credit (EIC), or your own statement that contains     questions about reporting on Forms W-2, W-3, 1099, and
the same wording if (a) you use a substitute Form W-2 that   other information returns. If you have questions about
does not contain the EIC notice, (b) you are not required to reporting on these forms, call 1-866-455-7438 (toll free). If
furnish Form W-2, or (c) you do not furnish a timely Form    you have questions about electronic filing of Forms W-2,
W-2 to your employee. For more information, see section 10   contact the SSA at 1-800-772-6270 or visit the SSA website
in Pub. 15 (Circular E).                                     at www.socialsecurity.gov/employer.
                                                     Cat. No. 25979S



- 15 -
Help for people with disabilities.                                                                                                                                                             Telephone help is                                                                                      fee) or call 1-877-233-6767 toll free to purchase the DVD for
available using TTY/TDD equipment. If you have questions                                                                                                                                                                                                                                              $30 (plus a $6 handling fee).
about reporting on information returns (Forms 1096, 1098,                                                                                                                                                                                                                                             By phone and in person.                                                                                                             You can order forms and
1099, 3921, 3922, 5498, W-2, W-2G, and W-3) you may call                                                                                                                                                                                                                                              publications by calling 1-800-TAX-FORM (1-800-829-3676).
304-267-3367. For any other tax information, call                                                                                                                                                                                                                                                     You can also get most forms and publications at your local
1-800-829-4059.                                                                                                                                                                                                                                                                                       IRS office.
Online wage reporting.                                                                                                           Using a personal computer, you
can access SSA’s Business Services Online (BSO) to                                                                                                                                                                                                                                                    Common Errors on Forms W-2
electronically report wage data. To obtain information                                                                                                                                                                                                                                                Forms W-2 provide information to your employees, the SSA,
regarding filing wage data electronically with SSA or to                                                                                                                                                                                                                                              the IRS, and state and local governments. Avoid making the
access BSO, visit the SSA’s W- 2 Filing Instructions and                                                                                                                                                                                                                                              following errors, which cause processing delays.
Information website at www.socialsecurity.gov/employer.
Corrections to previously filed wage data can be made by                                                                                                                                                                                                                                              Do not:
accessing BSO. Call the SSA at 1-888-772-2970 if you                                                                                                                                                                                                                                                  Omit the decimal point and cents from entries.
experience problems using any of the services within BSO.                                                                                                                                                                                                                                             Use ink that is too light to make entries. Use only black
        The website includes information on electronic filing,                                                                                                                                                                                                                                        ink.
some IRS and SSA publications, and general topics of                                                                                                                                                                                                                                                  Make entries that are too small or too large. Use 12-point
interest about annual wage reporting. You can also use                                                                                                                                                                                                                                                Courier font, if possible.
BSO to ask questions about wage reporting.                                                                                                                                                                                                                                                            Add dollar signs to the money-amount boxes. They have
        Employers can also electronically file EFW2 (formerly                                                                                                                                                                                                                                         been removed from Copy A and are not required.
MMREF-1) wage reports. See Electronic reporting on                                                                                                                                                                                                                                                    Inappropriately check the “Retirement plan” checkbox in
page 3.                                                                                                                                                                                                                                                                                               box 13. See Retirement plan on page 13.
Employment tax information.                                                                                                                                     Detailed employment tax                                                                                                               Misformat the employee’s name in box e. Enter the
information is given in:                                                                                                                                                                                                                                                                              employee’s first name and middle initial in the first box, his
      Pub. 15 (Circular E), Employer’s Tax Guide,                                                                                                                                                                                                                                                   or her surname in the second box, and his or her suffix
      Pub. 15-A, Employer’s Supplemental Tax Guide,                                                                                                                                                                                                                                                 (optional) in the third box.
      Pub. 15-B, Employer’s Tax Guide to Fringe Benefits, and
      Pub. 51 (Circular A), Agricultural Employer’s Tax Guide.                                                                                                                                                                                                                                      General Instructions for Forms
        You can also call the IRS with your employment tax
questions at 1-800-829-4933 or visit the IRS website at                                                                                                                                                                                                                                               W-2 and W-3
www.irs.gov and type “Employment Taxes” in the Keyword/                                                                                                                                                                                                                                               Who must file Form W-2.                                                                                                             Employers must file Form W-2
Search Terms box.                                                                                                                                                                                                                                                                                     for wages paid to each employee from whom:
                                                                                                                                                                                                                                                                                                      Income, social security, or Medicare tax was withheld or
How To Get Forms and Publications                                                                                                                                                                                                                                                                     Income tax would have been withheld if the employee had
                                                                                                                                                                                                                                                                                                      claimed no more than one withholding allowance or had not
Internet.                         You can access the IRS website 24 hours a day,                                                                                                                                                                                                                      claimed exemption from withholding on Form W-4,
7 days a week at www.irs.gov to:                                                                                                                                                                                                                                                                      Employee’s Withholding Allowance Certificate.
      Download forms, instructions, and publications.
      Order IRS products online.                                                                                                                                                                                                                                                                      Also, every employer engaged in a trade or business who
      See answers to frequently asked tax questions.                                                                                                                                                                                                                                                pays remuneration for services performed by an employee,
      Search publications online by topic or keyword.                                                                                                                                                                                                                                               including noncash payments, must file a Form W-2 for each
      Send us comments or request help by email.                                                                                                                                                                                                                                                    employee even if the employee is related to the employer.
      Sign up to receive local and national tax news by email.                                                                                                                                                                                                                                        If you are required to file 250 or more Forms W-2, see
                                                                                                                                                                                                                                                                                                      Electronic reporting on page 3.
                 Do not file Copy A of Forms W-2, W-3, W-2c, and
        !        W-3c downloaded from the IRS website with the                                                                                                                                                                                                                                        Who must file Form W-3.                                                                                                             Anyone required to file Form
CAUTION          SSA. They are provided for informational purposes                                                                                                                                                                                                                                    W-2 must file Form W-3 to transmit Copy A of Forms W-2.
only. A penalty of $50 per information return may be                                                                                                                                                                                                                                                  Make a copy of Form W-3; keep it and Copy D (For
imposed for filing such forms that cannot be scanned.                                                                                                                                                                                                                                                 Employer) of Forms W-2 with your records for 4 years. Be
                                                                                                                                                                                                                                                                                                      sure to use Form W-3 for the correct year. If you are filing
                 DVD for Tax Products. You can order Publication                                                                                                                                                                                                                                      Forms W-2 electronically, see Electronic reporting on
                 1796, IRS Tax Products DVD, and obtain:                                                                                                                                                                                                                                              page 3.

InternalPrior-yearTaxTaxTaxCurrent-yearFill-in,lawMap:Topicsprint,Revenuefrequentlyanforms,fromandelectronicforms,savetheinstructions,Code—Titleaskedinstructions,IRSfeaturesresearchtelephonequestions.and26forandtoolmostpublications.responseandpublications.taxfindingforms.system.aid.   in1040),instructions.FormidentificationhouseholdboxHouseholdW-2.b.HouseholdForemployeeOnYounumbermoreFormemployers.mustEmploymentinformation,W-3(EIN)musthavecheck fileonanEvenFormpageseeEIN.Taxes,theemployersSchedule“Hshld.9.W-3SeeandifBoxfilingitsemp.”withHb—Employerseparate(Formacheckboxpaperonly one
      Internal Revenue Bulletins.                                                                                                                                                                                                                                                                   Who may sign Form W-3.                                                                                                                  A transmitter or sender
      Toll-free and email technical support.                                                                                                                                                                                                                                                        (including a service bureau, reporting agent, paying agent,
      The DVD is released twice during the year.                                                                                                                                                                                                                                                    or disbursing agent) may sign Form W-3 (or use its PIN on
                                                                                                                                                                                                                                                                                                      electronic filings) for the employer or payer only if the
        –The first release will ship the beginning of January                                                                                                                                                                                                                                         sender:
2009.                                                                                                                                                                                                                                                                                                 Is authorized to sign by an agency agreement (either oral,
        –The final release will ship the beginning of March 2009.                                                                                                                                                                                                                                     written, or implied) that is valid under state law and
                                                                                                                                                                                                                                                                                                      Writes “For (name of payer)” next to the signature (paper
                                                                                                                                                                                                                                                                                                      Form W-3 only).
        Purchase the DVD from National Technical Information                                                                                                                                                                                                                                            If an authorized sender signs for the payer, the payer is
Service (NTIS) at www.irs.gov/cdorders for $30 (no handling                                                                                                                                                                                                                                           still responsible for filing, when due, a correct and complete
                                                                                                                                                                                                                                                                                                   -2-



- 16 -
Form W-3 and related Forms W-2, and is subject to any                  You are encouraged to file electronically even if
penalties that result from not complying with these             TIP    you are filing fewer than 250 Forms W-2. Small
requirements. Be sure that the payer’s name and employer               submitters may be able to file Forms W-2 online. For
identification number (EIN) on Forms W-2 and W-3 are the        more information, visit SSA’s Business Services Online
same as those used on the Form 941, Employer’s                  website at www.socialsecurity.gov/bso/bsowelcome.htm and
QUARTERLY Federal Tax Return; Form 943, Employer’s              select “Tutorial.”
Annual Federal Tax Return for Agricultural Employees;             You may request a waiver on Form 8508, Request
Form 944, Employer’s ANNUAL Federal Tax Return; Form            for Waiver From Filing Information Returns Electronically.
CT-1, Employer’s Annual Railroad Retirement Tax Return;         Submit Form 8508 to the IRS at least 45 days before the
or Schedule H (Form 1040) filed by or for the payer.            due date of Form W-2. See Form 8508 for filing information.
When to file.  File Copy A of Form W-2 with the entire                 If you file electronically, do not file the same returns
page of Form W-3 by March 1, 2010. However, if you file           !    on paper.
electronically, the due date is March 31, 2010. You may owe     CAUTION
a penalty for each Form W-2 that you file late. See Penalties
on page 8. If you terminate your business, see Terminating        Electronic reporting specifications for Form W-2 are in the
a business on page 7.                                           SSA’s EFW2 (formerly MMREF-1), a publication that can be
                                                                downloaded by accessing SSA’s W-2 Filing Instructions and
Extension to file. You may request an automatic                 Information website at www.socialsecurity.gov/employer and
extension of time to file Form W-2 with the SSA by sending      selecting “E-Filing Format (formerly MMREF).” You can also
Form 8809, Application for Extension of Time To File            get electronic specifications by calling SSA’s Employer
Information Returns, to the address shown on Form 8809.         Reporting Branch at 1-800-772-6270.
You must request the extension before the due date of
Forms W-2. You will have an additional 30 days to file. See       Reporting instructions for electronic filing differ in a few
Form 8809 for details.                                          situations from paper reporting instructions. For example,
                                                                electronic filers may enter more than four items in box 12 in
        Even if you request an extension to file Form W-2,      one individual’s wage report, but paper filers are limited to
!       you must still furnish Form W-2 to your employees       four entries in box 12 on Copy A of each Form W-2. See TIP
CAUTION by February 1, 2010. But see Extension to furnish       On Copy A (Form W-2), do not enter more than four
Forms W-2 to employees below.                                   items in box 12 on page 11.
                                                                Furnishing Copies B, C, and 2 to employees.      Furnish
Where to file paper forms. File the entire Copy A page of       Copies B, C, and 2 of Form W-2 to your employees,
Form W-2 with the entire page of Form W-3 at the following      generally, by February 1, 2010. You will meet the “furnish”
address:                                                        requirement if the form is properly addressed and mailed on
                                                                or before the due date.
Social Security Administration                                    If employment ends before December 31, 2009, you may
Data Operations Center                                          furnish copies to the employee at any time after employment
Wilkes-Barre, PA 18769-0001                                     ends, but no later than February 1, 2010. If an employee
                                                                asks for Form W-2, give him or her the completed copies
        If you use “Certified Mail” to file, change the ZIP     within 30 days of the request or within 30 days of the final
TIP     code to “18769-0002.” If you use an IRS-approved        wage payment, whichever is later. However, if you terminate
        private delivery service, add “ATTN: W-2 Process,       your business, see Terminating a business on page 7.
1150 E. Mountain Dr.” to the address and change the ZIP
code to “18702-7997.” See Pub. 15 (Circular E) for a list of      You may furnish Forms W-2 to employees on IRS official
IRS-approved private delivery services.                         forms or on acceptable substitute forms. See Substitute
                                                                forms on page 1. Be sure the Forms W-2 you provide to
        Do not send cash, checks, money orders, etc., with      employees are clear and legible and comply with the
!       the Forms W-2 and W-3 that you submit to the SSA.       requirements in Pub. 1141.
CAUTION Employment tax forms (for example, Form 941 or            Extension to furnish Forms W-2 to employees.       You
Form 943), remittances, and Forms 1099 must be sent to          may request an extension of time to furnish Forms W-2 to
the IRS.                                                        employees by sending a letter to:
Send Copy 1 of Form W-2 to your state, city, or local tax
department. For more information concerning Copy 1                IRS–Enterprise Computing Center–Martinsburg
(including how to complete boxes 15 through 20), contact          Information Reporting Program
your state, city, or local tax department.                        Attn: Extension of Time Coordinator
Shipping and mailing.  If you file more than one type of          240 Murall Drive
employment tax form, group Forms W-2 of the same type             Kearneysville, WV 25430
with a separate Form W-3 for each type, and send them in          Mail your letter on or before the due date for furnishing
separate groups. See the specific instructions for box b of     Forms W-2 to employees. It must include:
Form W-3 on page 14.                                            Your name and address,
                                                                Your employer identification number (EIN),
Prepare and file Forms W-2 either alphabetically by             A statement that you are requesting an extension to
employees’ last names or numerically by employees’ social       furnish “Forms W-2” to employees,
security numbers. Do not staple or tape Form W-3 to the         Reason for delay, and
related forms W-2 or Forms W-2 to each other. These forms       Your signature or that of your authorized agent.
are machine read. Staple holes or tears interfere with            Undeliverable Forms W-2. Keep for 4 years any
machine reading. Also, do not fold Forms W-2 and W-3.           employee copies of Forms W-2 that you tried to but could
Send the forms to the SSA in a flat mailing.                    not deliver. However, if the undelivered W-2 can be
Electronic reporting.   If you are required to file 250 or      produced electronically through April 15th of the fourth year
more Forms W-2, you must file them electronically unless        after the year of issue, you do not need to keep
the IRS granted you a waiver. You may be charged a              undeliverable employee copies. Do not send undeliverable
penalty if you fail to file electronically when required.       Forms W-2 to SSA.
                                                             -3-



- 17 -
Taxpayer identification numbers (TINs).    Employers use          employer, the employee should claim a refund on Form 843,
an employer identification number (EIN) (00-0000000).             Claim for Refund and Request for Abatement.
Employees use a social security number (SSN)                      Archer MSA.  An employer’s contribution to an employee’s
(000-00-0000). When you list a number, separate the nine          Archer MSA is not subject to federal income tax withholding,
digits properly to show the kind of number. Do not accept an      or social security, Medicare, or railroad retirement taxes if it
individual taxpayer identification number (ITIN) for              is reasonable to believe at the time of the payment that the
employment purposes. For more information, see section 4          contribution will be excludable from the employee’s income.
of Pub. 15 (Circular E).                                          However, if it is not reasonable to believe at the time of
 The IRS uses SSNs to check the payments that you                 payment that the contribution will be excludable from the
report against the amounts shown on the employees’ tax            employee’s income, employer contributions are subject to
returns. The SSA uses SSNs to record employees’ earnings          income tax withholding and social security and Medicare
for future social security and Medicare benefits. When you        taxes (or railroad retirement taxes, if applicable) and must
prepare Form W-2, be sure to show the correct SSN for             be reported in boxes 1, 3, and 5.
each employee. For information on verification of SSNs, see       You must report all employer contributions to an Archer
section 4 of Pub. 15 (Circular E) or go to www.                   MSA in box 12 of Form W-2 with code R. Employer
socialsecurity.gov/employer/ssnv.htm.                             contributions to an Archer MSA that are not excludable from
                                                                  the income of the employee also must be reported in box 1.
Special Reporting Situations for
                                                                  An employee’s contributions to an Archer MSA are
Form W-2                                                          includible in income as wages and are subject to federal
Adoption benefits. Amounts paid or expenses incurred by           income tax withholding and social security and Medicare
an employer for qualified adoption expenses under an              taxes (or railroad retirement taxes, if applicable). Employee
adoption assistance program are not subject to federal            contributions are deductible, within limits, on the employee’s
income tax withholding and are not reportable in box 1.           Form 1040.
However, these amounts (including adoption benefits paid          See Notice 96-53, 1996-2 C.B. 219 and Pub. 969, Health
from a section 125 (cafeteria) plan, but not including            Savings Accounts and Other Tax-Favored Health Plans, for
adoption benefits forfeited from a cafeteria plan) are subject    more information. You can find Notice 96-53 on page 5 of
to social security, Medicare, and railroad retirement taxes       Internal Revenue Bulletin 1996-51 at www.irs.gov/pub/
and must be reported in boxes 3 and 5. Also, the total            irs-irbs/irb96-51.pdf.
amount must be reported in box 12 with code T.                    Clergy and religious workers.     For certain members of
See Notice 97-9, 1997-1 C.B. 365, for more information            the clergy and religious workers who are not subject to
on adoption benefits. You can find Notice 97-9 on page 35         social security and Medicare taxes as employees, boxes 3
of Internal Revenue Bulletin 1997-2 at                            and 5 of Form W-2 should be left blank. You may include a
www.irs.gov/pub/irs-irbs/irb97-02.pdf. Advise your                minister’s parsonage and/or utilities allowance in box 14. For
employees to see the Instructions for Form 8839, Qualified        information on the rules that apply to ministers and certain
Adoption Expenses.                                                other religious workers, see Pub. 517, Social Security and
Agent reporting. Generally, an agent who has an                   Other Information for Members of the Clergy and Religious
approved Form 2678, Employer/Payer Appointment of                 Workers, and Section 4–Religious Exemptions in
Agent, should enter the agent’s name as the employer in           Pub. 15-A.
box c of Form W-2, and file only one Form W-2 for each            Corrections.  Use the current version of Form W-2c,
employee. However, if the agent (a) is acting as an agent for     Corrected Wage and Tax Statement, to correct errors (such
two or more employers or is an employer and is acting as an       as incorrect name, SSN, or amount) on a previously filed
agent for another employer, and (b) pays social security          Form W-2. To file your corrections electronically, see Online
wages for more than one employer in excess of the wage            wage reporting on page 2.
base to an individual, the agent must file separate Forms          If the SSA issues your employee a replacement card
W-2 for the affected employee reflecting the wages paid by        after a name change, or a new card with a different social
each employer. On each Form W-2, the agent should enter           security number after a change in alien work status, file a
the following in box c of Form W-2:                               Form W-2c to correct the name/SSN reported on the most
(Name of agent)                                                   recently filed Form W-2. It is not necessary to correct the
Agent for (name of employer)                                      prior years if the previous name and number were used for
Address of agent                                                  the years prior to the most recently filed Form W-2.
                                                                  File Form W-3c, Transmittal of Corrected Wage and Tax
Each Form W-2 should reflect the EIN of the agent in box          Statements, whenever you file a Form W-2c with the SSA,
b. An agent files one Form W-3 for all of the Forms W-2 and       even if you are only filing a Form W-2c to correct an
enters its own information in boxes e, f, and g of Form W-3       employee’s name or SSN. However, see Incorrect address
as it appears on the agent’s related employment tax returns       on employee’s Form W-2 on page 5 for information on
(for example, Form 941). Enter the client-employer’s EIN in       correcting an employee’s address. See the Instructions for
box h of Form W-3 if the Forms W-2 relate to only one             Forms W-2c and W-3c if an error was made on a previously
employer (other than the agent); if not, leave box h blank.       filed Form W-3.
See Rev. Proc. 70-6, 1970-1 C.B. 420, for procedures to be
followed in applying to be an agent.                              If you discover an error on Form W-2 after you issue it to
                                                                  your employee but before you send it to the SSA, check the
    Generally, an agent is not responsible for refunding          “Void” box at the top of the incorrect Form W-2 on Copy A.
TIP excess social security or railroad retirement (RRTA)          Prepare a new Form W-2 with the correct information, and
    tax on employees. If an employee worked for more              send Copy A to the SSA. Write “CORRECTED” on the
than one employer during 2009 and had more than                   employee’s new copies (B, C, and 2), and furnish them to
$6,621.60 in social security and Tier I RRTA tax withheld, he     the employee. If the “Void” Form W-2 is on a page with a
or she should claim the excess on the appropriate line of         correct Form W-2, send the entire page to the SSA. The
Form 1040 or Form 1040A. If an employee had more than             “Void” form will not be processed. Do not write
$3,088.80 in Tier II RRTA tax withheld from more than one         “CORRECTED” on Copy A of Form W-2.
                                                               -4-



- 18 -
  After December 31, 2008, if you are making a correction                                                  Box f – Employee A’s address
for a previously filed Form 941, Form 943, or Form 944, use                                                Box 1 – 10000.00 (does not include the $3,000 accrued
Form 941-X, Adjusted Employer’s QUARTERLY Federal                                                          wages and vacation pay)
Tax Return or Claim for Refund, Form 943-X, Adjusted                                                       Box 2 – 1500.00
Employer’s ANNUAL Federal Tax Return for Agricultural                                                      Box 3 – 13000.00 (includes the $3,000 accrued wages
Employees or Claim for Refund, or Form 944-X, Adjusted                                                     and vacation pay)
Employer’s ANNUAL Federal Tax Return or Claim for                                                          Box 4 – 806.00 (6.2% of the amount in box 3)
Refund, for the return period in which you found the error.                                                Box 5 – 13000.00 (includes the $3,000 accrued wages
See the Instructions for Form 941-X for more details. Issue                                                and vacation pay)
the employee a Form W-2c if the error discovered was for                                                   Box 6 – 188.50 (1.45% of the amount in box 5)
the prior year. If you are correcting social security or
Medicare wages or tips, also file the entire Copy A page of                                                         Employer X also must complete Form 1099-MISC as
Form W-2c and Form W-3c with the SSA to correct the                                                        CAUTION! follows:

FormsocialW-2security(or previouslyrecords andfiledanyFormotherW-2c)itemsthatonwerethe originalin error.   Boxes for: Recipient’s name, address, and TIN—The
                                                                                                           estate’s name, address, and TIN
  Incorrect address on employee’s Form W-2.                                        If you                  Box 3: 3000.00 (Even though amounts were withheld for
filed a Form W-2 with the SSA showing an incorrect address                                                 social security and Medicare taxes, the gross amount is
for the employee but all other information on the Form W-2                                                 reported here.)
is correct, do not file Form W-2c with the SSA merely to
correct the address. However, if the address was incorrect                                                   If Employer X made the payment after the year of death,
on the Form W-2 furnished to the employee, you must do                                                     the $3,000 would not be subject to social security and
one of the following.                                                                                      Medicare taxes and would not be shown on Form W-2.
Issue a new, corrected Form W-2 to the employee,                                                         However, the employer would still file Form 1099-MISC.
including the new address. Indicate “REISSUED                                                              Designated Roth contributions. Under section 402A, a
STATEMENT” on the new copies. Do not send copy A to the                                                    participant in a section 401(k) plan or under a 403(b) salary
SSA.                                                                                                       reduction agreement that includes a qualified Roth
Issue a Form W-2c to the employee showing the correct                                                    contribution program may elect to make designated Roth
address in box i and all other correct information. Do not                                                 contributions to the plan or program in lieu of elective
send copy A to the SSA.                                                                                    deferrals. Designated Roth contributions are subject to
Reissue a Form W-2 with the incorrect address to the                                                     federal income tax withholding and social security and
employee in an envelope showing the correct address or                                                     Medicare taxes (and railroad retirement taxes, if applicable)
otherwise deliver it to the employee.                                                                      and must be reported in boxes 1, 3, and 5.
Deceased employee’s wages.                            If an employee dies during                             Section 402A requires separate reporting of the yearly
the year, you must report the accrued wages, vacation pay,                                                 designated Roth contributions. Designated Roth
and other compensation paid after the date of death. Follow                                                contributions to 401(k) plans will be reported using code AA
the instructions below even if you reissued the deceased                                                   in box 12; designated Roth contributions under 403(b) salary
employee’s uncashed paycheck in the name of his or her                                                     reduction agreements will be reported using code BB in
estate or beneficiary.                                                                                     box 12. For reporting instructions, see Code AA and Code
                                                                                                           BB on page 13.
  If you made the payment in the same year the employee
died, you must withhold social security and Medicare taxes                                                 Educational assistance programs.      A $5,250 exclusion
on the payment and report the payment on the employee’s                                                    for employer-provided educational assistance applies to
Form W-2 only as social security and Medicare wages to                                                     benefits provided to your employees under an educational
ensure proper social security and Medicare credit is                                                       assistance program. However, educational assistance that
received.                                                                                                  exceeds $5,250 may be excludable from an employee’s
                                                                                                           wages if it qualifies as a working condition benefit. See Pub.
  On the employee’s Form W-2, show the payment as                                                          970, Tax Benefits for Education, and section 2 of Pub. 15-B
social security wages (box 3) and Medicare wages and tips                                                  for more information. Also see Box 1—Wages, tips, other
(box 5) and the social security and Medicare taxes withheld                                                compensation on page 9.
in boxes 4 and 6. Do not show the payment in box 1.                                                        Election workers. Report on Form W-2 payments of $600
   If you made the payment after the year of death, do not                                                 or more to election workers for services performed in state,
report it on Form W-2, and do not withhold social security                                                 county, and municipal elections. File Form W-2 for
and Medicare taxes.                                                                                        payments of less than $600 paid to election workers if social
  Whether the payment is made in the year of death or                                                      security and Medicare taxes were withheld under a section
after the year of death, you also must report it in box 3 of                                               218 (Social Security Act) agreement. Do not report election
Form 1099-MISC, Miscellaneous Income, for the payment to                                                   worker payments on Form 1099-MISC.
the estate or beneficiary. Use the name and taxpayer                                                         If the election worker is employed in another capacity
identification number (TIN) of the payment recipient on Form                                               with the same government entity, see Rev. Rul. 2000-06 on
1099-MISC.                                                                                                 page 512 of Internal Revenue Bulletin 2000-06 at
  Example.       Before Employee A’s death on June 15, 2009,                                               www.irs.gov/pub/irs-irbs/irb00-06.pdf.
A was employed by Employer X and received $10,000 in                                                       Employee business expense reimbursements.
wages on which federal income tax of $1,500 was withheld.                                                  Reimbursements to employees for business expenses must
When A died, X owed A $2,000 in wages and $1,000 in                                                        be reported as follows:
accrued vacation pay. The total of $3,000 (less the social                                                 Generally, payments made under an accountable plan are
security and Medicare taxes withheld) was paid to A’s estate                                               excluded from the employee’s gross income and are not
on July 20, 2009. Because X made the payment during the                                                    reported on Form W-2. However, if you pay a per diem or
year of death, X must withhold social security and Medicare                                                mileage allowance and the amount paid for substantiated
taxes on the $3,000 payment and must complete Form W-2                                                     miles or days traveled exceeds the amount treated as
as follows:                                                                                                substantiated under IRS rules, you must report as wages on
Box a – Employee A’s SSN                                                                                 Form W-2 the amount in excess of the amount treated as
Box e – Employee A’s name                                                                                substantiated. The excess amount is subject to income tax
                                                                                                        -5-



- 19 -
withholding and social security and Medicare taxes. Report          year and full social security and Medicare taxes for part of
the amount treated as substantiated (that is, the nontaxable        the year.
portion) in box 12 using code L. See Code L—                        Option one (which the SSA prefers) is to file a single
Substantiated employee business expense reimbursements              Form W-2 reflecting the employees’ wages for the entire
onPaymentspage 12.made under a nonaccountable plan are            year,both socialeven ifsecurityonly partandofMedicarethe year’staxes.wagesThewasFormsubjectW-3to
reported as wages on Form W-2 and are subject to federal            must have the “941” box checked in box b. The wages in
income tax withholding and social security and Medicare             box 5 must be equal to or greater than the wages in box 3
taxes.                                                              on Form W-2.
  For more information on accountable plans,                        Option two is to file two Forms W-2 and two Forms W-3.
nonaccountable plans, amounts treated as substantiated              File one Form W-2 for wages subject to Medicare tax only.
under a per diem or mileage allowance, the standard                 Be sure to check the “Medicare govt. emp.” box in box b of
mileage rate, the per diem substantiation method, and the           Form W-3. File the second Form W-2 for wages subject to
high-low substantiation method, see Pub. 463, Travel,               both social security and Medicare taxes with the “941” box
Entertainment, Gift, and Car Expenses; Pub. 1542, Per               checked in box b of Form W-3. The wages in box 5 on each
Diem Rates; and section 5 of Pub. 15 (Circular E).                  Form W-2 must be equal to or greater than the wages in
Employee’s social security and Medicare taxes paid by               box 3 on that same Form W-2.
employer.   If you paid your employee’s share of social             Group-term life insurance.                       If you paid for group-term life
security and Medicare taxes rather than deducting them              insurance over $50,000 for an employee or a former
from the employee’s wages, you must include these                   employee, you must report the taxable cost of excess
payments as wages subject to federal income tax                     coverage, determined by using the table in section 2 of Pub.
withholding and social security, Medicare, and federal              15-B, in boxes 1, 3, and 5 of Form W-2. Also, show the
unemployment (FUTA) taxes. The amount to include as                 amount in box 12 with code C. For employees, you must
wages is determined by using the formula contained in the           withhold social security and Medicare taxes, but not federal
discussion of Employee’s Portion of Taxes Paid by                   income tax. Former employees must pay the employee part
Employer in section 7 of Pub. 15-A.                                 of social security and Medicare taxes on the taxable cost of
          This does not apply to household and agricultural         group-term life insurance over $50,000 on Form 1040. You
  !      employers. If you pay a household or agricultural          are not required to collect those taxes. However, you must
CAUTION  employee’s social security and Medicare taxes, you         report the uncollected social security tax with code M and
must include these payments in the employee’s wages for             the uncollected Medicare tax with code N in box 12 of
income tax withholding purposes. However, the wage                  Form W-2.
increase due to the tax payments is not subject to social           Health Savings Account (HSA).                            An employer’s
security, Medicare, or FUTA taxes. For information on               contribution (including an employee’s contributions through
completing Forms W-2 and W-3 in this situation, see the             a cafeteria plan) to an employee’s HSA is not subject to
Instructions for Schedule H (Form 1040), Household                  federal income tax withholding, or social security, Medicare,
Employers, and section 3 of Pub. 51 (Circular A).                   or railroad retirement taxes (or FUTA tax) if it is reasonable
                                                                    to believe at the time of the payment that the contribution
Fringe benefits.    Include all taxable fringe benefits in box 1    will be excludable from the employee’s income. However, if
of Form W-2 as wages, tips, and other compensation and, if          it is not reasonable to believe at the time of payment that the
applicable, in boxes 3 and 5 as social security and Medicare        contribution will be excludable from the employee’s income,
wages. Although not required, you may include the total             employer contributions are subject to federal income tax
value of fringe benefits in box 14 (or on a separate                withholding and social security and Medicare taxes (or
statement). However, if you provided your employee a                railroad retirement taxes, if applicable) and FUTA tax and
vehicle and included 100% of its annual lease value in the          must be reported in boxes 1, 3, and 5 (and on Form 940,
employee’s income, you must separately report this value to         Employer’s Annual Federal Unemployment (FUTA) Tax
the employee in box 14 (or on a separate statement). The            Return).
employee can then figure the value of any business use of
the vehicle and report it on Form 2106, Employee Business           You must report all employer contributions to an HSA in
Expenses. Also see Pub. 15-B for more information.                  box 12 of Form W-2 with code W. Employer contributions to
                                                                    an HSA that are not excludable from the income of the
         If you used the commuting rule or the vehicle              employee also must be reported in boxes 1, 3, and 5.
CAUTION! cents-per-mile rule to value the personal use of the       An employee’s contributions to an HSA (unless made
         vehicle, you cannot include 100% of the value of the       through a cafeteria plan) are includible in income as wages
use of the vehicle in the employee’s income. See Pub. 15-B.         and are subject to federal income tax withholding and social
Golden parachute payments.       Include any golden                 security and Medicare taxes (or railroad retirement taxes, if
parachute payments in boxes 1, 3, and 5 of Form W-2.                applicable). Employee contributions are deductible, within
Withhold federal income, social security, and Medicare              limits, on the employee’s Form 1040. For more information
taxes as usual and report them in boxes 2, 4, and 6,                about HSAs, see Notice 2004-2 and Notice 2004-50. You
respectively. Excess parachute payments are also subject to         can find Notice 2004-2 on page 269 of Internal Revenue
a 20% excise tax. If the excess payments are considered             Bulletin 2004-2 at www.irs.gov/pub/irs-irbs/irb04-02.pdf. You
wages, withhold the 20% excise tax and include it in box 2          can find Notice 2004-50 on page 196 of Internal Revenue
as income tax withheld. Also report the excise tax in box 12        Bulletin 2004-33 at www.irs.gov/pub/irs-irbs/irb04-33.pdf.
with code K. For definitions and additional information, see        Also see Form 8889, Health Savings Accounts (HSAs), and
Regulations section 1.280G-1 and Rev. Proc. 2003-68. You            Pub. 969.
can find Rev. Proc. 2003-68 on page 398 of Internal                 Lost Form W-2—reissued statement.                                     If an employee
Revenue Bulletin 2003-34 at www.irs.gov/pub/irs-irbs/               loses a Form W-2, write “REISSUED STATEMENT” on the
irb03-34.pdf.                                                       new copy and furnish it to the employee. You do not have to
Government employers.          Federal, state, and local            add “REISSUED STATEMENT” on Forms W-2 provided to
agencies have two options for reporting their employees’            employees electronically. Do not send Copy A of the
wages that are subject only to Medicare tax for part of the         reissued Form W-2 to the SSA. Employers are not
                                                                 -6-



- 20 -
prohibited (by the Internal Revenue Code) from charging a          information will help the employee account for such
fee for the issuance of a duplicate Form W-2.                      repayments on his or her federal income tax return.
Moving expenses. Report moving expenses as follows:                If the repayment was for a prior year, you must file Form
Qualified moving expenses that an employer paid to a             W-2c with the SSA to correct only social security and
third party on behalf of the employee (for example, to a           Medicare wages and taxes. Do not correct “Wages” in box 1
moving company) and services that an employer furnished            on Form W-2c for the amount paid in error. For information
in kind to an employee are not reported on Form W-2.               on reporting adjustments to Form 941, Form 943, or Form
Qualified moving expense reimbursements paid directly to         944, see section 13 of Pub. 15 (Circular E) or section 9 of
an employee by an employer are reported only in box 12 of          Pub. 51 (Circular A).
Form W-2 with code P.
Nonqualified moving expense reimbursements are                       Tell your employee that the wages paid in error in a
reported in boxes 1, 3, and 5 of Form W-2. These amounts           TIP prior year remain taxable to him or her for that year.
are subject to federal income tax withholding and social               This is because the employee received and had use
security and Medicare taxes (or railroad retirement taxes, if      of those funds during that year. The employee is not entitled
applicable).                                                       to file an amended return (Form 1040X) to recover the
                                                                   income tax on these wages. Instead, the employee is
Nonqualified deferred compensation plans.     Section              entitled to a deduction (or a credit, in some cases) for the
409A, added by the American Jobs Creation Act of 2004,             repaid wages on his or her Form 1040 for the year of
provides that all amounts deferred under a nonqualified            repayment.
deferred compensation (NQDC) plan for all tax years are
currently includible in gross income unless certain                Scholarship and fellowship grants.    Give a Form W-2 to
requirements are met. If section 409A requires an amount to        each recipient of a scholarship or fellowship grant only if you
be included in gross income, the section imposes a                 are reporting amounts includible in income under section
substantial additional tax. Section 409A, generally, is            117(c) (relating to payments for teaching, research, or other
effective with respect to amounts deferred in tax years            services required as a condition for receiving the qualified
beginning after December 31, 2004, but deferrals made              scholarship). Also see Pub. 15-A and Pub. 970. These
prior to that year may be subject to section 409A under            payments are subject to federal income tax withholding.
some circumstances.                                                However, their taxability for social security and Medicare
                                                                   taxes depends on the nature of the employment and the
  It is not necessary to show amounts deferred during the          status of the organization. See Students in section 15 of
year under an NQDC plan subject to section 409A. For more          Pub. 15 (Circular E).
information, see Notice 2008-115 available at www.irs.gov/
irb/2008-52_IRB/index.html. If you report section 409A             Sick pay. If you had employees who received sick pay in
deferrals, show the amount in Box 12 using code Y.                 2009 from an insurance company or other third-party payer
                                                                   and the third party notified you of the amount of sick pay
  Income included under section 409A from an NQDC plan             involved, you may be required to report the information on
will be reported in box 1, and in box 12 using code Z. This        the employees’ Forms W-2. If the insurance company or
income is also subject to an additional tax reported on Form       other third-party payer did not notify you in a timely manner
1040. For more information, see section 5 of Pub. 15-A. For        about the sick pay payments, it must prepare Forms W-2
more information on amounts includible in gross income,            and W-3 for your employees showing the sick pay. For
see Notice 2008-113, available at www.irs.gov/irb/                 specific reporting instructions, see Sick Pay Reporting in
2008-51_IRB/ar12.html and Notice 2008-115, available at            section 6 of Pub. 15-A.
www.irs.gov/irb/2008-52_IRB/index.html.
Railroad employers.     Railroad employers must file Form          SIMPLE retirement account.     An employee’s salary
W-2 to report their employees’ wages and income tax                reduction contributions to a SIMPLE (savings incentive
withholding in boxes 1 and 2. Electronic reporting may be          match plan for employees) retirement account are not
required; see Electronic reporting on page 3. If you have          subject to federal income tax withholding but are subject to
both FICA employees and RRTA employees, you must file a            social security, Medicare, and railroad retirement taxes. Do
separate Form W-3 to transmit the Forms W-2 for each               not include an employee’s contribution in box 1 but do
group of employees.                                                include it in boxes 3 and 5. An employee’s total contribution
                                                                   also must be included in box 12 with code D or S.
  If an employee is covered by social security and
Medicare, also complete boxes 3, 4, 5, 6, and 7 of Form            An employer’s matching or nonelective contribution to an
W-2 to show the social security and Medicare wages and             employee’s SIMPLE is not subject to federal income tax
the amounts withheld for social security and Medicare taxes.       withholding or social security, Medicare, or railroad
On the Form W-3 used to transmit these Forms W-2, check            retirement taxes and is not to be shown on Form W-2.
the “941” box in box b.                                            See Notice 98-4, 1998-1 C.B. 269, for more information
  For employees covered by RRTA tax, you also must                 on SIMPLE retirement accounts. You can find Notice 98-4
report the Tier I and Tier II taxes withheld in box 14 of Form     on page 25 of Internal Revenue Bulletin 1998-2 at www.irs.
W-2. Label them “Tier I tax” and “Tier II tax.” Boxes 3, 4, 5,     gov/pub/irs-irbs/irb98-02.pdf.
6, and 7 apply only to covered social security and Medicare        Successor/predecessor employers.      If you buy or sell a
employees and are not to be used to report railroad                business during the year, see Rev. Proc. 2004-53 for
retirement wages and taxes. On the Form W-3 used to                information on who must file Forms W-2 and employment
transmit these Forms W-2, check the “CT-1” box in box b.           tax returns. You can find Rev. Proc. 2004-53 on page 320 of
Repayments.  If an employee repays you for wages                   Internal Revenue Bulletin 2004-34 at www.irs.gov/pub/
received in error, do not offset the repayments against            irs-irbs/irb04-34.pdf.
current year’s wages unless the repayments are for                 Terminating a business. If you terminate your business,
amounts received in error in the current year. Repayments          you must provide Forms W-2 to your employees for the
made in the current year, but related to a prior year or years,    calendar year of termination by the due date of your final
must be repaid in gross, not net, and require special tax          Form 941. You must also file Forms W-2 with the SSA by
treatment by employees in some cases. You may advise the           the last day of the month that follows the due date of your
employee of the total repayments made during the current           final Form 941. If filing on paper, make sure you obtain
year and the amount (if any) related to prior years. This          Forms W-2 and W-3 preprinted with the correct year. If filing
                                                                -7-



- 21 -
electronically, make sure your software has been updated                                              Exceptions to the penalty.                                                    The following are
for the current tax year.                                                                          exceptions to the failure to file correct information returns
  However, if any of your employees are immediately                                                penalty:
employed by a successor employer, see Successor/                                                      1. The penalty will not apply to any failure that you can
predecessor employers on page 7. Also, see Rev. Proc.                                              show was due to reasonable cause and not to willful
96-57, 1996-2 C.B. 389 for information on automatic                                                neglect. In general, you must be able to show that your
extensions for furnishing Forms W-2 to employees and filing                                        failure was due to an event beyond your control or due to
Forms W-2. You can find Rev. Proc. 96-57 on page 14 of                                             significant mitigating factors. You must also be able to show
Internal Revenue Bulletin 1996-53 at www.irs.gov/pub/                                              that you acted in a responsible manner and took steps to
irs-irbs/irb96-53.pdf.                                                                             avoid the failure.
                                                                                                      2. An inconsequential error or omission is not considered
           Get Schedule D (Form 941), Report of Discrepancies                                      a failure to include correct information. An inconsequential
  TIP      Caused by Acquisitions, Statutory Mergers, or                                           error or omission does not prevent or hinder the SSA/IRS
           Consolidations, for information on reconciling wages                                    from processing the Form W-2, from correlating the
and taxes reported on Forms W-2 with amounts reported on                                           information required to be shown on the form with the
Forms 941, Form 943, or Form 944.                                                                  information shown on the payee’s tax return, or from
Uniformed Services Employment and Reemployment                                                     otherwise putting the form to its intended use. Errors and
Rights Act of 1994 (USERRA) makeup amounts to a                                                    omissions that are never inconsequential are those relating
pension plan.                   If an employee returned to your employment                         to:
after military service and certain makeup amounts were                                                  A TIN,
contributed to a pension plan for a prior year(s) under the                                             A payee’s surname, and
USERRA, report the prior year contributions separately in                                               Any money amounts.
box 12. See the TIP above Code D on page 12. You also                                                 3. De minimis rule for corrections. Even though you
may report certain makeup amounts in box 14. See                                                   cannot show reasonable cause, the penalty for failure to file
Box 14—Other on page 14.                                                                           correct Forms W-2 will not apply to a certain number of

chooseInsteadto provideof reportinga separatein box 12statement(or boxto14),youryouemployeemay     returnsFiledif you:those Forms W-2 on or before the required filing
mustshowingidentifyUSERRAthe typemakeupof plan,contributions.the year(s) toThewhichstatementthe    date,Either failed to include all of the information required on
year.contributions relate, and the amount contributed for each                                     theformFiledorcorrectionsincluded incorrectof theseinformation,forms by Augustand                                2.
                                                                                                      If you meet all of the conditions above, the penalty for
Penalties                                                                                          filing incorrect information returns (including Form W-2) will
The following penalties generally apply to the person                                              not apply to the greater of 10 information returns (including
required to file Form W-2. The penalties apply to paper filers                                     Form W-2) or 1/ 2                          of 1% of the total number of information
as well as to electronic filers.                                                                   returns (including Form W-2) that you are required to file for
                                                                                                   the calendar year.
           Use of a reporting agent or other third-party payroll                                      Lower maximum penalties for small businesses.                                                                                 For
CAUTION!   service provider does not relieve an employer of the                                    purposes of the lower maximum penalties shown in
           responsibility to ensure that Forms W-2 are furnished                                   parentheses above, you are a small business if your
to employees and are filed correctly and on time.                                                  average annual gross receipts for the 3 most recent tax
Failure to file correct information returns by the due                                             years (or for the period that you were in existence, if shorter)
date.      If you fail to file a correct Form W-2 by the due date                                  ending before the calendar year in which the Forms W-2
and cannot show reasonable cause, you may be subject to                                            were due are $5 million or less.
a penalty as provided under section 6721. The penalty                                                 Intentional disregard of filing requirements.                                                                      If any

appliesFailFail totoiffileincludeyou:timely,all information required to be shown on              disregardthefailurepenaltyto fileofistheaatcorrectfilingleastor$100FormcorrectperW-2Forminformationis dueW-2to intentionalwithrequirements,no maximum
Form W-2,Include incorrect information on Form W-2,                                               penalty.
File on paper when you were required to file                                                     Failure to furnish correct payee statements.                                                                       If you fail to
electronically,                                                                                    provide correct payee statements (Forms W-2) to your
Report an incorrect TIN,                                                                         employees and you cannot show reasonable cause, you
Fail to report a TIN, or                                                                         may be subject to a penalty. The penalty applies if you fail to
Fail to file paper Forms W-2 that are machine readable.                                          provide the statement by February 1, if you fail to include all
                                                                                                   information required to be shown on the statement, or if you
  The amount of the penalty is based on when you file the                                          include incorrect information on the statement.
correct Form W-2. The penalty is:
$15 per Form W-2 if you correctly file within 30 days;                                              The penalty is $50 per statement, no matter when the
maximum penalty $75,000 per year ($25,000 for small                                                correct statement is furnished, with a maximum of $100,000
businesses, defined later).                                                                        per year. The penalty is not reduced for furnishing a correct
$30 per Form W-2 if you correctly file more than 30 days                                         statement by August 2.
after the due date but by August 2; maximum penalty                                                   Exception.                         An inconsequential error or omission is not
$150,000 per year ($50,000 for small businesses).                                                  considered a failure to include correct information. An
$50 per Form W-2 if you file after August 2 or you do not                                        inconsequential error or omission cannot reasonably be
file required Forms W-2; maximum penalty $250,000 per                                              expected to prevent or hinder the payee from timely
year ($100,000 for small businesses).                                                              receiving correct information and reporting it on his or her
                                                                                                   income tax return or from otherwise putting the statement to
           If you do not file corrections and you do not meet any                                  its intended use. Errors and omissions that are never
  !        of the exceptions to the penalty stated below, the                                      inconsequential are those relating to:
CAUTION    penalty is $50 per information return.                                                  A dollar amount,
                                                                                                -8-



- 22 -
A significant item in a payee’s address, and                         If the employee has applied for a card but the number is
The appropriate form for the information provided, such           not received in time for filing, enter “Applied For” in box a on
as whether the form is an acceptable substitute for the             paper Forms W-2 filed with the SSA. (Enter zeros
official IRS form.                                                  (000-00-0000) if Form W-2 is filed electronically with the
  Intentional disregard of payee statement                          SSA.)
requirements.  If any failure to provide a correct payee               Ask the employee to inform you of the number and name
statement (Form W-2) to an employee is due to intentional           as they are shown on the social security card when it is
disregard of the requirements to furnish a correct payee            received. Then correct your previous report by filing Form
statement, the penalty is at least $100 per Form W-2 with no        W-2c showing the employee’s SSN. If the employee needs
maximum penalty.                                                    to change his or her name from that shown on the card, the
Civil damages for fraudulent filing of Forms W-2. If you            employee should call the SSA at 1-800-772-1213.
willfully file a fraudulent Form W-2 for payments that you             If you do not provide the correct employee name and TIN
claim you made to another person, that person may be able           on Form W-2, you may owe a penalty unless you have
to sue you for damages. You may have to pay $5,000 or               reasonable cause. For more information, see Publication
more.                                                               1586, Reasonable Cause Regulations and Requirements for
                                                                    Missing/Incorrect Name/TINs.
                                                                    Box b—Employer identification number (EIN).     Show the
Specific Instructions for Form W-2                                  employer identification number (EIN) assigned to you by the
                                                                    IRS (00-0000000). This should be the same number that
How to complete Form W-2.   Form W-2 is a six-part form.            you used on your federal employment tax returns (Form
Ensure all copies are legible. Send Copy A to the SSA;              941, Form 943, Form 944, Form CT-1, or Schedule H (Form
Copy 1 to your state, city, or local tax department; and            1040)). Do not use a prior owner’s EIN. If you do not have
Copies B, C, and 2 to your employee. Keep Copy D, and a             an EIN when filing Forms W-2, enter “Applied For” in box b;
copy of Form W-3, with your records for 4 years.                    do not use your SSN. You can get an EIN by applying online
  Type the entries on Form W-2 using black ink in 12-point          at www.irs.gov, by calling the toll-free number
Courier font. Copy A is read by machine and must be typed           1-800-829-4933, or by filing Form SS-4, Application for
clearly with no corrections made to the entries or entries          Employer Identification Number. Also see Agent reporting
exceeding the size of the boxes. Entries completed by hand,         on page 4.
in script or italics fonts, or in colors other than black cannot    Box c—Employer’s name, address, and ZIP code.           This
be read by the machines. Make all dollar entries on Copy A          entry should be the same as shown on your Form 941, Form
without the dollar sign and comma but with the decimal point        943, Form 944, Form CT-1, or Schedule H (Form 1040).
(00000.00). Show the cents portion of the money amounts.            Also see Agent reporting on page 4.
If a box does not apply, leave it blank.                            Box d—Control number.     You may use this box to identify
  Send the whole Copy A page of Form W-2 with Form                  individual Forms W-2. You do not have to use this box.
W-3 to SSA even if one of the Forms W-2 on the page is              Boxes e and f—Employee’s name and address.           Enter
blank or void. Do not staple Forms W-2 together or to Form          the name as shown on your employee’s social security card
W-3. File Forms W-2 either alphabetically by employees’             (first, middle initial, last). Generally, do not enter “Jr.,” “Sr.,”
last names or numerically by employees’ SSNs.                       etc., in the “Suff.” box on Copy A unless the suffix appears
Calendar year basis.   The entries on Form W-2 must be              on the card. However, SSA still prefers that you do not enter
based on wages paid during the calendar year. Use Form              the suffix on Copy A. If the name does not fit, you may show
W-2 for the correct tax year. For example, if the employee          first name initial, middle initial, and last name (and ignore
worked from December 21, 2009, through January 3, 2010,             the vertical line). If the name has changed, the employee
and the wages for that period were paid on January 5, 2010,         must get a corrected card from any SSA office. Use the
include those wages on the 2010 Form W-2.                           name on the original card until you see the corrected card.
Multiple forms.    If necessary, you can issue more than one        Do not show titles or academic degrees, such as “Dr.,” “RN,”
Form W-2 to an employee. For example, you may need to               or “Esq.,” at the beginning or end of the employee’s name.
report more than four coded items in box 12 or you may                  Include in the address the number, street, and apartment
want to report other compensation on a second form. If you          or suite number (or P.O. box number if mail is not delivered
issue a second Form W-2, complete boxes b, c, d, e, and f           to a street address). For a foreign address, give the
with the same information as on the first Form W-2. Show            information in the following order: city, province or state, and
any items that were not included on the first Form W-2 in the       country. Follow the country’s practice for entering the postal
appropriate boxes. Also, see the TIP below Box 12—Codes             code. Do not abbreviate the country name.
on page 11.                                                            Third-party payers of sick pay filing third-party sick pay
  Do not report the same federal tax data to the SSA on             recap Forms W-2 and W-3 must enter “Third-Party Sick Pay
more than one Copy A.                                               Recap” in place of the employee’s name in box e. Also, do
                                                                    not enter the employee’s SSN in box a. See Sick Pay
      For each Form W-2 showing an amount in box 3 or               Reporting in section 6 of Pub. 15-A.
TIP   box 7, make certain that box 5 equals or exceeds the
      sum of boxes 3 and 7.                                         Box 1—Wages, tips, other compensation.          Show the
                                                                    total taxable wages, tips, and other compensation (before
Void.  Check this box when an error is made on Form W-2             any payroll deductions) that you paid to your employee
and you are voiding it because you are going to complete a          during the year. However, do not include elective deferrals
new Form W-2. Do not include any amounts shown on                   (such as employee contributions to a section 401(k) or
“Void” forms in the totals you enter on Form W-3. See               403(b) plan) except section 501(c)(18) contributions. Include
Corrections on page 4.                                              the following:
Box a—Employee’s social security number.       Enter the               1. Total wages, bonuses (including signing bonuses),
number shown on the employee’s social security card. If the         prizes, and awards paid to employees during the year. See
employee does not have a card, he or she should apply for           Calendar year basis above.
one by completing Form SS-5, Application for a Social                  2. Total noncash payments, including certain fringe
Security Card.                                                      benefits. See Fringe benefits on page 6.
                                                                 -9-



- 23 -
3. Total tips reported by the employee to the employer                                              security tax but not including social security tips and
(not allocated tips).                                                                               allocated tips. See Box 7—Social security tips and
4. Certain employee business expense reimbursements                                                 Box 8—Allocated tips on page 11. Generally, noncash
(see Employee business expense reimbursements on                                                    payments are considered to be wages. Include employee
page 5).                                                                                            business expense reimbursements reported in box 1. If you
5. The cost of accident and health insurance premiums                                               paid the employee’s share of social security and Medicare
for 2% or more shareholder-employees paid by an S                                                   taxes rather than deducting them from wages, see
corporation.                                                                                        Employee’s social security and Medicare taxes paid by
6. Taxable benefits from a section 125 (cafeteria) plan if                                          employer on page 6. The total of boxes 3 and 7 cannot
the employee chooses cash.                                                                          exceed $106,800 (2009 maximum social security wage
7. Employee contributions to an Archer MSA.                                                         base). Include in box 5 any amounts reported in box 3.
8. Employer contributions to an Archer MSA if includible
in the income of the employee. See Archer MSA on page 4.                                              Report in box 3 elective deferrals to certain qualified cash
9. Employer contributions for qualified long-term care                                              or deferred compensation arrangements and to retirement
services to the extent that such coverage is provided                                               plans described in box 12 (codes D, E, F, G, and S) even
through a flexible spending or similar arrangement.                                                 though the deferrals are not includible in box 1. Also report
10. Taxable cost of group-term life insurance in excess of                                          in box 3 designated Roth contributions made under a
$50,000. See Group-term life insurance on page 6.                                                   section 401(k) plan or under a section 403(b) salary
11. Unless excludable under Educational assistance                                                  reduction agreement described in box 12 (codes AA
programs (see page 5), payments for non-job-related                                                 and BB).
education expenses or for payments under a                                                            Amounts deferred (plus earnings) under a nonqualified or
nonaccountable plan. See Pub. 970.                                                                  section 457(b) plan must be included in boxes 3 and/or 5 as
12. The amount includible as wages because you paid                                                 social security and/or Medicare wages as of the later of
your employee’s share of social security and Medicare                                               when the services giving rise to the deferral are performed
taxes. See Employee’s social security and Medicare taxes                                            or when there is no substantial forfeiture risk of the rights to
paid by employer on page 6. If you also paid your                                                   the deferred amount. Include both elective and nonelective
employee’s income tax withholding, treat the grossed-up                                             deferrals for purposes of section 457(b) plans.
amount of that withholding as supplemental wages and
report those wages in boxes 1, 3, 5, and 7. No exceptions to                                        Also include in box 3:
this treatment apply to household or agricultural wages.                                            Signing bonuses an employer pays for signing or ratifying
13. Designated Roth contributions made under a section                                              an employment contract. See Rev. Rul. 2004-109. You can
401(k) plan or under a section 403(b) salary reduction                                              find Rev. Rul. 2004-109 on page 958 of Internal Revenue
agreement. See Designated Roth contributions on page 5.                                             Bulletin 2004-50 at www.irs.gov/pub/irs-irbs/irb04-50.pdf.
14. Distributions to an employee or former employee from                                            Taxable cost of group-term life insurance over $50,000
an NQDC plan (including a rabbi trust) or a                                                         included in box 1. See Group-term life insurance on page 6.
nongovernmental section 457(b) plan.                                                                Cost of accident and health insurance premiums for 2% or
15. Amounts includible in income under section 457(f)                                               more shareholder-employees paid by an S corporation, but
because the amounts are no longer subject to a substantial                                          only if not excludable under section 3121(a)(2)(B).
risk of forfeiture.                                                                                 Employee and nonexcludable employer contributions to
16. Payments to statutory employees who are subject to                                              an MSA or HSA. However, do not include employee
social security and Medicare taxes but not subject to federal                                       contributions to an HSA that were made through a cafeteria
income tax withholding must be shown in box 1 as other                                              plan. See Archer MSA on page 4 and Health Savings
compensation. See Statutory employee on page 13.                                                    Account (HSA) on page 6.
compensatory17. Cost of currentsplit-dollarinsurancelife insuranceprotectionarrangement.under a     Employee contributions to a SIMPLE retirement account.
(HSA).18. Employee contributions to a Health Savings Account                                        SeeAdoption SIMPLEbenefits.retirementSeeaccount Adoptiononbenefitspage 7.on page 4.
19. Employer contributions to an HSA if includible in the                                           Box 4—Social security tax withheld.                         Show the total
income of the employee. See Health Savings Account                                                  employee social security tax (not your share) withheld,
(HSA) on page 6.                                                                                    including social security tax on tips. Do not reduce this
20. Amounts includible in income under an NQDC plan                                                 amount by any advance EIC payments made to the
because of section 409A. See Nonqualified deferred                                                  employee. For 2009, the amount should not exceed
compensation plans on page 7.                                                                       $6,621.60 ($106,800  ×6.2%). Include only taxes withheld
21. Payments made to former employees while they are                                                (or paid by you for the employee) for 2009 wages and tips. If
on active duty for more than 30 days in the Armed Forces or                                         you paid your employee’s share, see Employee’s social
other uniformed services.                                                                           security and Medicare taxes paid by employer on page 6.
22. All other compensation, including certain scholarship
and fellowship grants (see page 7). Other compensation                                              Box 5—Medicare wages and tips.                               The wages and tips
includes taxable amounts that you paid to your employee                                             subject to Medicare tax are the same as those subject to
from which federal income tax was not withheld. You may                                             social security tax (boxes 3 and 7) except that there is no
show other compensation on a separate Form W-2. See                                                 wage base limit for Medicare tax. Enter the total Medicare
Multiple forms on page 9.                                                                           wages and tips in box 5. Be sure to enter tips that the
                                                                                                    employee reported even if you did not have enough
Box 2—Federal income tax withheld.                                Show the total                    employee funds to collect the Medicare tax for those tips.
federal income tax withheld from the employee’s wages for                                           See Box 3—Social security wages above for payments to
the year (do not reduce the wages by any advance EIC                                                report in this box. If you paid your employee’s share of
payments made to the employee). Include the 20% excise                                              taxes, see Employee’s social security and Medicare taxes
tax withheld on excess parachute payments. See Golden                                               paid by employer on page 6.
parachute payments on page 6.                                                                         If you are a federal, state, or local agency with employees
Box 3—Social security wages.                             Show the total wages                       paying only the 1.45% Medicare tax, enter the Medicare
paid (before payroll deductions) subject to employee social                                         wages in this box. See Government employers on page 6.
                                                                                                -10-



- 24 -
Example of how to report social security and                                                                                                   Annuities, Retirement or Profit-Sharing Plans, IRAs,
Medicare wages.                 You paid your employee $140,000 in                                                                             Insurance Contracts, etc., not in box 1 of Form W-2.
wages. Enter in box 3 (social security wages) 106800.00 but                                                                                    If you did not make distributions this year, show deferrals
enter in box 5 (Medicare wages and tips) 140000.00. There                                                                                      (plus earnings) under a nonqualified or any section 457(b)
is no limit on the amount reported in box 5. If the amount of                                                                                  plan that became taxable for social security and Medicare
wages paid was $106,800 or less, the amounts entered in                                                                                        taxes during the year (but were for prior year services)
boxes 3 and 5 would be the same.                                                                                                               because the deferred amounts were no longer subject to a
Box 6—Medicare tax withheld.                                              Enter the total employee                                             substantial risk of forfeiture. Also report these amounts in
Medicare tax (not your share) withheld. Include only tax                                                                                       boxes 3 (up to the social security wage base) and 5. Do not
withheld for 2009 wages and tips. Do not reduce this                                                                                           report in box 11 deferrals included in boxes 3 and/or 5 and
amount by any advance EIC payments made to the                                                                                                 deferrals for current year services (such as those with no
employee. If you paid your employee’s share of the taxes,                                                                                      risk of forfeiture).
see Employee’s social security and Medicare taxes paid by
employer on page 6.                                                                                                                                     If you made distributions and are also reporting any
Box 7—Social security tips.                                              Show the tips that the                                                CAUTION! deferrals in box(es) 3 and/or 5, do not complete box
employee reported to you even if you did not have enough                                                                                                11. See Pub. 957, Reporting Back Pay and Special
employee funds to collect the social security tax for the tips.                                                                                Wage Payments to the Social Security Administration, and
The total of boxes 3 and 7 should not be more than                                                                                             Form SSA-131, Employer Report of Special Wage
$106,800 (the maximum social security wage base for                                                                                            Payments, for instructions on reporting these and other
2009). Report all tips in box 1 along with wages and other                                                                                     kinds of compensation earned in prior years. However, do
compensation. Include any tips reported in box 7 in box 5                                                                                      not file Form SSA-131 if this situation applies but the
also.                                                                                                                                          employee will not be age 62 or older by the end of that
                                                                                                                                               year.
Box 8—Allocated tips.                                    If you are a food or beverage
establishment, show the tips allocated to the employee. See                                                                                    Unlike qualified plans, NQDC plans do not meet the
the Instructions for Form 8027, Employer’s Annual                                                                                              qualification requirements for tax-favored status for this
Information Return of Tip Income and Allocated Tips. Do not                                                                                    purpose. NQDC plans include those arrangements
include this amount in boxes 1, 3, 5, or 7.                                                                                                    traditionally viewed as deferring the receipt of current
                                                                                                                                               compensation. Accordingly, welfare benefit plans, stock
Box 9—Advance EIC payment.                                                Show the total paid to the                                           option plans, and plans providing dismissal pay, termination
employee as advance earned income credit (EIC)                                                                                                 pay, or early retirement pay are not NQDC plans.
payments.

programBoxdependent10—Dependent(sectioncare benefits129)carepaidunderbenefits.or incurreda dependentShowby youcarethefortotalassistanceyour    beneficiariesonReportForm W-2.distributionsof deceasedfromemployeesNQDC oronsectionForm4571099-R,plansnotto
employee. Include the fair market value (FMV) of care in a                                                                                     Military employers must report military retirement
daycare facility provided or sponsored by you for your                                                                                         payments on Form 1099-R.
employee and amounts paid or incurred for dependent care
assistance in a section 125 (cafeteria) plan. Report all                                                                                                Do not report special wage payments, such as
amounts paid or incurred (regardless of any employee                                                                                           TIP      accumulated sick pay or vacation pay, in box 11. For
forfeitures), including those in excess of the $5,000                                                                                                   more information on reporting special wage
exclusion. This may include (a) the FMV of benefits provided                                                                                   payments, see Pub. 957.
in kind by the employer, (b) an amount paid directly to a                                                                                      Box 12—Codes.                    Complete and code this box for all items
daycare facility by the employer or reimbursed to the                                                                                          described below. Note that the codes do not relate to where
employee to subsidize the benefit, or (c) benefits from the                                                                                    they should be entered in boxes 12a–12d on Form W-2. For
pre-tax contributions made by the employee under a section                                                                                     example, if you are only required to report code D in box 12,
125 dependent care flexible spending account. Include any                                                                                      you can enter code D and the amount in box 12a of Form
amounts over $5,000 in boxes 1, 3, and 5. For more                                                                                             W-2. Do not report in box 12 any items that are not listed as
information, see Pub. 15-B.                                                                                                                    codes A–BB. Also, do not report in box 12 section 414(h)(2)
                                                                                                                                               contributions (relating to certain state or local government
      An employer that amends its cafeteria plan to                                                                                            plans). Instead, use box 14 for these items and any other
TIP   provide a grace period for dependent care                                                                                                information that you wish to give to your employee. For
      assistance may continue to rely on Notice 89-111, by                                                                                     example, union dues and uniform payments may be
reporting in Box 10 of Form W-2 the salary reduction                                                                                           reported in box 14.
amount elected by the employee for the year for dependent
care assistance (plus any employer matching contributions                                                                                               On Copy A (Form W-2), do not enter more than
attributable to dependent care).                                                                                                               TIP      four items in box 12. If more than four items need
Box 11—Nonqualified plans.                                               The purpose of box 11 is                                                       to be reported in box 12, use a separate Form W-2
for the SSA to determine if any part of the amount reported                                                                                    to report the additional items (but enter no more than four
in box 1 or boxes 3 and/or 5 was earned in a prior year. The                                                                                   items on each Copy A (Form W-2)). On all other copies of
SSA uses this information to verify that they have properly                                                                                    Form W-2 (Copies B, C, etc.), you may enter more than four
applied the social security earnings test and paid the correct                                                                                 items in box 12 when using an approved substitute Form
amount of benefits.                                                                                                                            W-2. See Multiple forms on page 9.
      Reporting in box 11 is unaffected by the changes                                                                                         Use the IRS code designated below for the item you are
TIP   made by the American Jobs Creation Act of 2004.                                                                                          entering, followed by the dollar amount for that item. Even if
                                                                                                                                               only one item is entered, you must use the IRS code
                                                                                                                                               designated for that item. Enter the code using a capital
Show distributions to an employee from a nonqualified                                                                                          letter. Use decimal points but not dollar signs or commas.
plan or a nongovernmental section 457(b) plan. Also report                                                                                     For example, if you are reporting $5,300.00 in elective
these distributions in box 1. Make only one entry in this box.                                                                                 deferrals under a section 401(k) plan, the entry would be
Distributions from governmental section 457(b) plans must                                                                                      D 5300.00 (not A 5300.00 even though it is the first or only
be reported on Form 1099-R, Distributions From Pensions,                                                                                       entry in this box). Report the IRS code to the left of the
                                                                                                                                           -11-



- 25 -
vertical line in boxes 12a–12d and money amount to the            Employer matching contributions.
right of the vertical line.                                         Code D—Elective deferrals under section 401(k) cash
  See the Form W-2 Reference Guide for Box 12 Codes on            or deferred arrangement (plan). Also show deferrals
page 16. See also the detailed instructions below for each        under a SIMPLE retirement account that is part of a section
code.                                                             401(k) arrangement.
  Code A—Uncollected social security or RRTA tax on                 Example of reporting excess elective deferrals and
tips.  Show the employee social security or Railroad              designated Roth contributions under a section 401(k)
Retirement Tax Act (RRTA) tax on all of the employee’s tips       plan. For 2009, Employee A (age 45) elected to defer
that you could not collect because the employee did not           $18,300 under a section 401(k) plan. The employee also
have enough funds from which to deduct it. Do not include         made a designated Roth contribution to the plan of $1,000,
this amount in box 4.                                             and made a voluntary (non-Roth) after-tax contribution of
  Code B—Uncollected Medicare tax on tips.          Show          $600. In addition, the employer, on A’s behalf, made a
the employee Medicare tax or RRTA Medicare tax on tips            qualified nonelective contribution of $2,000 to the plan and a
that you could not collect because the employee did not           nonelective profit-sharing employer contribution of $3,000.
have enough funds from which to deduct it. Do not include           Even though the 2009 limit for elective deferrals and
this amount in box 6.                                             designated Roth contributions is $16,500, the employee’s
  Code C—Taxable cost of group-term life insurance                total elective deferral amount of $18,300 is reported in box
over $50,000.  Show the taxable cost of group-term life           12 with code D (D 18300.00). The designated Roth
insurance coverage over $50,000 provided to your                  contribution is reported in box 12 with code AA (AA
employee (including a former employee). See Group-term            1000.00). The employer must separately report the actual
life insurance on page 6. Also include this amount in boxes       amounts of $18,300 and $1,000 in box 12 with the
1, 3 (up to the social security wage base), and 5.                appropriate codes. The amount deferred in excess of the
                                                                  limit is not reported in box 1. The return of excess salary
  Codes D through H, S, Y, AA, and BB. Use these                  deferrals and excess designated contributions, including
codes to show elective deferrals and designated Roth              earnings on both, is reported on Form 1099-R.
contributions made to the plans listed. Do not report
amounts for other types of plans. See below for an example          The $600 voluntary after-tax contribution may be reported
of reporting elective deferrals under a section 401(k) plan.      in box 14 (this is optional) but not in box 12. The $2,000
                                                                  nonelective contribution and the $3,000 nonelective
  The amount reported as elective deferrals and                   profit-sharing employer contribution are not required to be
designated Roth contributions is only the part of the             reported on Form W-2, but may be reported in box 14.
employee’s salary (or other compensation) that he or she
did not receive because of the deferrals or designated Roth         Check the “Retirement plan” box in box 13.
contributions. Only elective deferrals and designated Roth          Code E—Elective deferrals under a section 403(b)
contributions should be reported in box 12 for all coded          salary reduction agreement.
plans; except, when using code G for section 457(b) plans,          Code F—Elective deferrals under a section 408(k)(6)
include both elective and nonelective deferrals.                  salary reduction SEP.
  For employees who were 50 years of age or older at any            Code G—Elective deferrals and employer
time during the year and made elective deferral and/or            contributions (including nonelective deferrals) to any
designated Roth “catch-up” contributions, report the elective     governmental or nongovernmental section 457(b)
deferrals and the elective deferral “catch-up” contributions      deferred compensation plan.    Do not report either section
as a single sum in box 12 using the appropriate code, and         457(b) or section 457(f) amounts that are subject to a
the designated Roth contributions and designated Roth             substantial risk of forfeiture.
“catch-up” contributions as a single sum in box 12 using the        Code H—Elective deferrals under section
appropriate code.                                                 501(c)(18)(D) tax-exempt organization plan.  Be sure to
      If any elective deferrals, salary reduction amounts, or     include this amount in box 1 as wages. The employee will
TIP   nonelective contributions under a section 457(b) plan       deduct the amount on his or her Form 1040.
      during the year are makeup amounts under the                  Code J—Nontaxable sick pay.     Show any sick pay that
Uniformed Services Employment and Reemployment Rights             was paid by a third-party and was not includible in income
Act of 1994 (USERRA) for a prior year, you must enter the         (and not shown in boxes 1, 3, and 5) because the employee
prior year contributions separately. Beginning with the           contributed to the sick pay plan. Do not include nontaxable
earliest year, enter the code, the year, and the amount. For      disability payments made directly by a state.
example, elective deferrals of $2,250 for 2007 and $1,250           Code K—20% excise tax on excess golden parachute
for 2008 under USERRA under a section 401(k) plan are             payments. If you made excess “golden parachute”
reported in box 12 as follows:                                    payments to certain key corporate employees, report the
  D 07 2250.00, D 08 1250.00. A 2009 contribution of              20% excise tax on these payments. If the excess payments
$7,000 does not require a year designation; enter it as           are considered to be wages, report the 20% excise tax
D 7000.00. Report the code (and year for prior year               withheld as income tax withheld in box 2.
USERRA contributions) to the left of the vertical line in           Code L—Substantiated employee business expense
boxes 12a through 12d.                                            reimbursements.  Use this code only if you reimbursed
  The following are not elective deferrals and may be             your employee for employee business expenses using a per
reported in box 14, but not in box 12.                            diem or mileage allowance and the amount that you
Nonelective employer contributions made on behalf of an         reimbursed exceeds the amount treated as substantiated
employee.                                                         under IRS rules. See Employee business expense
After-tax contributions that are not designated Roth            reimbursements on page 5.
contributions, such as voluntary contributions to a pension         Report in box 12 only the amount treated as
plan that are deducted from an employee’s pay. See the            substantiated (such as the nontaxable part). In boxes 1, 3
instructions in codes AA and BB for reporting designated          (up to the social security wage base), and 5, include the part
Roth contributions on page 13.                                    of the reimbursement that is more than the amount treated
Required employee contributions.                                as substantiated.
                                                              -12-



- 26 -
Code M—Uncollected social security or RRTA tax on                    current year and prior year deferrals. See Nonqualified
taxable cost of group-term life insurance over $50,000               deferred compensation plans on page 7.
(for former employees). If you provided your former
employees (including retirees) more than $50,000 of                    Code Z—Income under section 409A on a
group-term life insurance coverage for periods during which          nonqualified deferred compensation plan.   Enter all
an employment relationship no longer exists, enter the               amounts deferred (including earnings on amounts deferred)
amount of uncollected social security or RRTA tax on the             that are includible in income under section 409A because
coverage in box 12. Also see Group-term life insurance on            the NQDC plan fails to satisfy the requirements of section
page 6.                                                              409A. Do not include amounts properly reported on a Form
                                                                     1099-MISC, corrected Form 1099-MISC, Form W-2, or Form
Code N—Uncollected Medicare tax on taxable cost of                   W-2c for a prior year. Also, do not include amounts that are
group-term life insurance over $50,000 (for former                   considered to be subject to a substantial risk of forfeiture for
employees). If you provided your former employees                    purposes of section 409A. For more information, see
(including retirees) more than $50,000 of group-term life            Regulations sections 1.409A-1 through 1.409A-6, Notice
insurance coverage for periods during which an employment            2008-113, available at www.irs.gov/irb/2008-51_IRB/ar12.
relationship no longer exists, enter the amount of                   html, and Notice 2008-115, available at www.irs.gov/irb/
uncollected Medicare tax or RRTA Medicare tax on the                 2008-52_IRB/index.html.
coverage in box 12. Also see Group-term life insurance on
page 6.                                                                The amount reported in box 12 using code Z is also
Code P—Excludable moving expense                                     reported in box 1, and is subject to an additional tax
reimbursements paid directly to employee.    Show the                reported on the employee’s Form 1040. See Nonqualified
total moving expense reimbursements that you paid directly           deferred compensation plans on page 7.
to your employee for qualified (deductible) moving                     Code AA—Designated Roth contributions under a
expenses. See Moving expenses on page 7.                             section 401(k) plan. Use this code to report designated
Code Q—Nontaxable combat pay.       If you are a military            Roth contributions under a section 401(k) plan. Do not use
employer, report any nontaxable combat pay in box 12.                this code to report elective deferrals under code D. See
                                                                     Designated Roth contributions on page 5.
Code R—Employer contributions to an Archer MSA.
Show any employer contributions to an Archer MSA. See                  Code BB—Designated Roth contributions under a
Archer MSA on page 4.                                                section 403(b) plan. Use this code to report designated
Code S—Employee salary reduction contributions                       Roth contributions under a section 403(b) plan. Do not use
under a section 408(p) SIMPLE.     Show deferrals under a            this code to report elective deferrals under code E. See
section 408(p) salary reduction SIMPLE retirement account.           Designated Roth contributions on page 5.
However, if the SIMPLE is part of a section 401(k)                   Box 13—Checkboxes.     Check all boxes that apply.
arrangement, use code D. If you are reporting prior year             Statutory employee. Check this box for statutory
contributions under USERRA, see the TIP above Code D on              employees whose earnings are subject to social security
page 12.                                                             and Medicare taxes but not subject to federal income tax
Code T—Adoption benefits.          Show the total that you           withholding. Do not check this box for common-law
paid or reimbursed for qualified adoption expenses                   employees. There are workers who are independent
furnished to your employee under an adoption assistance              contractors under the common-law rules but are treated by
program. Also include adoption benefits paid or reimbursed           statute as employees. They are called statutory employees.
from the pre-tax contributions made by the employee under              1. A driver who distributes beverages (other than milk),
a section 125 (cafeteria) plan. However, do not include              or meat, vegetable, fruit, or bakery products; or who picks
adoption benefits forfeited from a section 125 (cafeteria)           up and delivers laundry or dry cleaning if the driver is your
plan. Report all amounts including those in excess of the            agent or is paid on commission.
$12,150 exclusion. For more information, see Adoption                  2. A full-time life insurance sales agent whose principal
benefits on page 4.                                                  business activity is selling life insurance or annuity
Code V—Income from the exercise of nonstatutory                      contracts, or both, primarily for one life insurance company.
stock option(s). Show the spread (that is, the fair market             3. An individual who works at home on materials or
value of stock over the exercise price of option(s) granted to       goods that you supply and that must be returned to you or to
your employee with respect to that stock) from your                  a person you name if you also furnish specifications for the
employee’s (or former employee’s) exercise of nonstatutory           work to be done.
stock option(s). Include this amount in boxes 1, 3 (up to the          4. A full-time traveling or city salesperson who works on
social security wage base), and 5.                                   your behalf and turns in orders to you from wholesalers,
                                                                     retailers, contractors, or operators of hotels, restaurants, or
This reporting requirement does not apply to the exercise            other similar establishments. The goods sold must be
of a statutory stock option, or the sale or disposition of stock     merchandise for resale or supplies for use in the buyer’s
acquired pursuant to the exercise of a statutory stock option.       business operation. The work performed for you must be the
For more information about the taxability of employee stock          salesperson’s principal business activity.
options, see Pub. 15-B.                                                For details on statutory employees and common-law
Code W—Employer contributions to a Health                            employees, see section 1 in Pub. 15–A.
Savings Account (HSA).  Show any employer                            Retirement plan. Check this box if the employee was an
contributions (including amounts the employee elected to             “active participant” (for any part of the year) in any of the
contribute using a section 125 (cafeteria) plan) to an HSA.          following:
See Health Savings Account (HSA) on page 6.                            1. A qualified pension, profit-sharing, or stock-bonus plan
Code Y—Deferrals under a section 409A nonqualified                   described in section 401(a) (including a 401(k) plan).
deferred compensation plan.   It is not necessary to show              2. An annuity plan described in section 403(a).
deferrals in box 12 with code Y. For more information, see             3. An annuity contract or custodial account described in
Notice 2008-115, available at www.irs.gov/irb/2008-52_IRB/           section 403(b).
index.html. However, if you report these deferrals, show               4. A simplified employee pension (SEP) plan described
current year deferrals, including earnings during the year on        in section 408(k).
                                                                 -13-



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  5. A SIMPLE retirement account described in section                W-3. Type entries using black ink. Scanners will not read
408(p).                                                              entries if type is too light.
  6. A trust described in section 501(c)(18).
  7. A plan for federal, state, or local government                       Amounts reported on related employment tax forms
employees or by an agency or instrumentality thereof (other          TIP  (for example, Form W-2, Form 941, Form 943, or
than a section 457(b) plan).                                              Form 944) should agree with the amounts reported
  Generally, an employee is an active participant if covered         on Form W-3. If there are differences, you may be contacted
by (a) a defined benefit plan for any tax year that he or she        by the IRS and SSA. You should retain a reconciliation for
is eligible to participate in or (b) a defined contribution plan     future reference. See Reconciling Forms W-2, W-3, 941,
(for example, a section 401(k) plan) for any tax year that           943, 944, CT-1, and Schedule H (Form 1040) on page 15.
employer or employee contributions (or forfeitures) are              Box a—Control number.        This is an optional box that you
added to his or her account. For additional information on           may use for numbering the whole transmittal.
employees who are eligible to participate in a plan, contact         Box b—Kind of Payer.         Check the box that applies to you.
your plan administrator. For details on the active participant       Check only one box unless the second checked box is
rules, see Notice 87-16, 1987-1 C.B. 446, Notice 98-49,              “Third-party sick pay.” If you have more than one type of
1998-2 C.B. 365, section 219(g)(5), and Pub. 590, Individual         Form W-2, send each type (except “Third-party sick pay”)
Retirement Arrangements (IRAs). You can find Notice 98-49            with a separate Form W-3. (The “Third-party sick pay”
on page 5 of Internal Revenue Bulletin 1998-38 at                    indicator box does not designate a separate kind of payer.)
www.irs.gov/pub/irs-irbs/irb98-38.pdf.                               941. Check this box if you file Form 941, Employer’s
                                                                     QUARTERLY Federal Tax Return, and no other category
    Do not check this box for contributions made to a                (except “Third-party sick pay”) applies. A church or church
TIP nonqualified or section 457(b) plan.                             organization should check this box even if it is not required
                                                                     to file Form 941 or Form 944.
Third-party sick pay. Check this box only if you are a             Military. Check this box if you are a military employer
third-party sick pay payer filing a Form W-2 for an insured’s        sending Forms W-2 for members of the uniformed services.
employee or are an employer reporting sick pay payments
made by a third party. See Sick Pay Reporting in section 6           943. Check this box if you are an agricultural employer
of Pub. 15-A.                                                        and file Form 943, Employer’s Annual Federal Tax Return
                                                                     for Agricultural Employees, and you are sending Forms W-2
Box 14—Other.  The lease value of a vehicle provided to              for agricultural employees. For nonagricultural employees,
your employee and reported in box 1 must be reported here            send their Forms W-2 with a separate Form W-3, checking
or on a separate statement to your employee. You may also            the appropriate box.
use this box for any other information that you want to give         944. Check this box if you file Form 944, Employer’s
to your employee. Label each item. Examples include state            ANNUAL Federal Tax Return (or Forma 944(SP), its
disability insurance taxes withheld, union dues, uniform             Spanish version), and no other category (except “Third-party
payments, health insurance premiums deducted, nontaxable             sick pay”) applies.
income, educational assistance payments, or a member of
the clergy’s parsonage allowance and utilities. In addition,         CT-1. Check this box if you are a railroad employer
you may enter the following contributions to a pension plan:         sending Forms W-2 for employees covered under the
(a) nonelective employer contributions made on behalf of an          Railroad Retirement Tax Act (RRTA). Do not show
employee, (b) voluntary after-tax contributions (but not             employee RRTA tax in boxes 3–7. These boxes are only for
designated Roth contributions) that are deducted from an             social security and Medicare information. If you also have
employee’s pay, (c) required employee contributions, and             employees who are subject to social security and Medicare
(d) employer matching contributions.                                 taxes, send that group’s Forms W-2 with a separate Form
                                                                     W-3 and check the “941” box on that Form W-3.
  If you are reporting prior year contributions under                Hshld. emp. Check this box if you are a household
USERRA (see the TIP above Code D on page 12 and                      employer sending Forms W-2 for household employees and
Uniformed Services Employment and Reemployment Rights                you did not include the household employee’s taxes on
Act of 1994 (USERRA) makeup amounts to a pension plan                Form 941, Form 943, or Form 944.
on page 8), you may report in box 14 makeup amounts for
nonelective employer contributions, voluntary after-tax              Medicare govt. emp.          Check this box if you are a U.S.,
contributions, required employee contributions, and                  state, or local agency filing Forms W-2 for employees
employer matching contributions. Report such amounts                 subject only to the 1.45% Medicare tax. See Government
separately for each year. Railroad employers, see page 7.            employers on page 6.
                                                                     Third-party sick pay.        Check this box and another box
Boxes 15 through 20—State and local income tax                       such as the “941” box if you are a third-party sick pay payer
information.  Use these boxes to report state and local              (or are reporting sick pay payments made by a third party)
income tax information. Enter the two-letter abbreviation for        filing Forms W-2 with the “Third-party sick pay” checkbox in
the name of the state. The employer’s state ID numbers are           box 13 checked. File a single Form W-3 for the regular and
assigned by the individual states. The state and local               “Third-party sick pay” Forms W-2. See 941 above.
information boxes can be used to report wages and taxes              Box c—Total number of Forms W-2.     Show the number
for two states and two localities. Keep each state’s and             of completed individual Forms W-2 that you are transmitting
locality’s information separated by the broken line. If you          with this Form W-3. Do not count “Void” Forms W-2.
need to report information for more than two states or
localities, prepare a second Form W-2. See Multiple forms            Box d—Establishment number.     You may use this box to
on page 9. Contact your state or locality for specific               identify separate establishments in your business. You may
reporting information.                                               file a separate Form W-3, with Forms W-2, for each
                                                                     establishment even if they all have the same EIN; or you
                                                                     may use a single Form W-3 for all Forms W-2 of the same
                                                                     type.
Specific Instructions for Form W-3                                   Box e—Employer identification number (EIN).     If you
How to complete Form W-3.    The instructions under How              received a preprinted Form W-3 from the IRS with Pub. 393,
to complete Form W-2 on page 9 generally apply to Form               Federal Employment Tax Forms, or Pub. 2184, Form W-3
                                                                 -14-



- 28 -
Package (Including Alternative Ways To Get Employment                                                  them as one sum in the appropriate box on Form W-3.
Tax Forms and Instructions), verify that your employer                                                 Verify the amount reported in each box is an accurate total
identification number (EIN) is correct. Make any necessary                                             of the Forms W-2.
corrections on the form.
If you did not receive a form with a preprinted EIN, enter                                             Reconciling Forms W-2, W-3, 941, 943, 944,
the nine-digit EIN assigned to you by the IRS. The number                                              CT-1, and Schedule H (Form 1040)
should be the same as shown on your Form 941, Form 943,
Form 944, Form CT-1, or Schedule H (Form 1040) and in                                                  Reconcile the amounts shown in boxes 2, 3, 5, 7, and 9
the following format: 00-0000000. Do not use a prior owner’s                                           from all 2009 Forms W-3 with their respective amounts from
EIN. See Box h—Other EIN used this year below.                                                         the 2009 yearly totals from the quarterly Forms 941, or
                                                                                                       annual Form 943, Form 944, Form CT-1 (box 2 only), and
If you do not have an EIN when filing your Form W-3,                                                   Schedule H (Form 1040). When there are discrepancies
enter “Applied For” in box e, not your social security number                                          between amounts reported on Forms W-2 and W-3 filed with
(SSN), and see Box b—Employer identification number                                                    the SSA and on Form 941, Form 943, Form 944, Form
(EIN) on page 9.                                                                                       CT-1, or Schedule H (Form 1040) filed with the IRS, you will
Box f—Employer’s name.                         If you are not using a                                  be contacted to resolve the discrepancies.
preprinted Form W-3, enter the same name as shown on
your Form 941, Form 943, Form 944, or Form CT-1. Make                                                     To help reduce discrepancies on Forms W-2:
any necessary corrections on your preprinted Form W-3.                                                 Report bonuses as wages and as social security and
                                                                                                       Medicare wages on Form W-2, and on Forms 941, 943, 944,
Box g—Employer’s address and ZIP code.                                       If you are                and Schedule H (Form 1040).
notanyusingnecessarya preprintedcorrectionsFormonW-3,yourenterpreprintedyour address.Form W-3.Make     Report both social security and Medicare wages and
                                                                                                       taxes separately on Forms W-2 and W-3, and on Forms
Box h—Other EIN used this year.                            If you have used an                         941, 943, 944, and Schedule H (Form 1040).
EIN (including a prior owner’s EIN) on Form 941, Form 943,                                             Report social security taxes withheld on Form W-2 in
Form 944, or Form CT-1 submitted for 2009 that is different                                            box 4, not in box 3.
fromEIN used.the EINAgentsreportedgenerallyon FormreportW-3theinemployer’sbox e, enterEINtheinother    Report Medicare taxes withheld on Form W-2 in box 6,
box h. See Agent reporting on page 4.                                                                  not in box 5.
                                                                                                       Make sure that the social security wage amount for each
Contact person, telephone number, fax number, and                                                      employee does not exceed the annual social security wage
email address.        Include this information for use by the SSA                                      base limit ($106,800 for 2009).
if any questions arise during processing.                                                              Do not report noncash wages that are not subject to
        The amounts to enter in boxes 1 through 19,                                                    social security or Medicare taxes as social security or
TIP     described below, are totals from only the Forms W-2                                            Medicare wages.
        that you are sending with this Form W-3.                                                       If you use an EIN on any quarterly Form 941 for the year
                                                                                                       (or annual Forms 943, 944, CT-1, and Schedule H (Form
Boxes 1 through 10.               Enter the totals reported in boxes 1                                 1040)) that is different from the EIN reported in box e on
through 10 on the Forms W-2.                                                                           Form W-3, enter the other EIN in box h on Form W-3.
Box 11—Nonqualified plans.                        Enter the total reported in
box 11 on Forms W-2.                                                                                     To reduce the discrepancies between amounts
                                                                                                       reported on Forms W-2 and W-3, and Forms 941, 943,
Box 12—Deferred compensation.                              Enter one total of all                      944, CT-1, and Schedule H (Form 1040):
amounts reported with codes D through H, S, Y, AA, and BB                                              Be sure that the amounts on Form W-3 are the total
in box 12 on Forms W-2. Do not enter a code.                                                           amounts from Forms W-2.
Box 13—For third-party sick pay use only.                                    Third-party               Reconcile Form W-3 with your four quarterly Forms 941
payers of sick pay (or employers using the optional rule for                                           (or annual Forms 943, 944, CT-1, and Schedule H (Form
Form W-2 described in section 6 of Pub. 15-A) filing                                                   1040)) by comparing amounts reported for:
third-party sick pay recap Forms W-2 and W-3 must enter                                                  1. Income tax withholding (box 2).
“Third-Party Sick Pay Recap” in this box.                                                                2. Social security wages, Medicare wages and tips, and
Box 14—Income tax withheld by payer of third-party                                                     social security tips (boxes 3, 5, and 7). Form W-3 should
sick pay.        Complete this box only if you are the employer                                        include Form 941 or Forms 943, 944, and Schedule H (Form
and have employees who had federal income tax withheld                                                 1040) adjustments only for the current year. If the Form 941,
on third-party payments of sick pay. Show the total income                                             Form 943, or Form 944 adjustments include amounts for a
tax withheld by third-party payers on payments to all of your                                          prior year, do not report those prior year adjustments on the
employees. Although this tax is included in the box 2 total, it                                        current year Forms W-2 and W-3.
must be separately shown here.                                                                           3. Social security and Medicare taxes (boxes 4 and 6).
Box 15—State/Employer’s state ID number.                                     Enter the                 The amounts shown on the four quarterly Forms 941 (or
two-letter abbreviation for the name of the state being                                                annual Form 943, Form 944, and Schedule H (Form 1040)),
reported on Form(s) W-2. Also enter your state-assigned ID                                             including current year adjustments, should be approximately
number. If the Forms W-2 being submitted with this Form                                                twice the amounts shown on Form W-3.
W-3 contain wage and income tax information from more                                                    4. Advance EIC payment (box 9).
than one state, enter an “X” under “State” and do not enter
any state ID number.
                                                                                                         Amounts reported on Forms W-2, and W-3, and Forms
Boxes 16—19.          Enter the total of state/local wages and                                         941, 943, 944, CT-1, and Schedule H (Form 1040) may not
income tax shown in their corresponding boxes on the                                                   match for valid reasons. If they do not match, you should
Forms W-2 included with this Form W-3. If the Forms W-2                                                determine that the reasons are valid. Keep your
show amounts from more than one state or locality, report                                              reconciliation in case of inquiries from the IRS or the SSA.
                                                                                                   -15-



- 29 -
  Form W-2 Reference Guide for Box 12 Codes (See the box 12 instructions.)
A Uncollected social security or RRTA tax on                                                                                                                                                            J     Nontaxable sick pay                                                                                                                                                                 S  Employee salary reduction contributions
  tips                                                                                                                                                                                                                                                                                                                                                                                               under a section 408(p) SIMPLE
B Uncollected Medicare tax on tips                                                                                                                                                                      K     20% excise tax on excess golden                                                                                                                                                     T  Adoption benefits
                                                                                                                                                                                                              parachute payments
C Taxable cost of group-term life insurance                                                                                                                                                             L     Substantiated employee business expense                                                                                                                                             V  Income from exercise of nonstatutory
  over $50,000                                                                                                                                                                                                reimbursements (federal rate)                                                                                                                                                          stock option(s)
D Elective deferrals under a section 401(k)                                                                                                                                                             M     Uncollected social security or RRTA tax on                                                                                                                                          W  Employer contributions (including
  cash or deferred arrangement (including a                                                                                                                                                                   taxable cost of group-term life (for former                                                                                                                                            employee contributions through a
  SIMPLE 401(k) arrangement)                                                                                                                                                                                  employees)                                                                                                                                                                             cafeteria plan) to an employee’s Health
                                                                                                                                                                                                                                                                                                                                                                                                     Savings Account (HSA)
E Elective deferrals under a section 403(b)                                                                                                                                                             N     Uncollected Medicare tax on taxable cost                                                                                                                                            Y  Deferrals under a section 409A
  salary reduction agreement                                                                                                                                                                                  of group-term life insurance over $50,000                                                                                                                                              nonqualified deferred compensation plan
                                                                                                                                                                                                              (for former employees)
F Elective deferrals under a section                                                                                                                                                                    P     Excludable moving expense                                                                                                                                                           Z  Income under section 409A on a
  408(k)(6) salary reduction SEP                                                                                                                                                                              reimbursements paid directly to employee                                                                                                                                               nonqualified deferred compensation plan
G Elective deferrals and employer                                                                                                                                                                       Q     Nontaxable combat pay                                                                                                                                                               AA Designated Roth contributions under a
  contributions (including nonelective                                                                                                                                                                                                                                                                                                                                                               section 401(k) plan
  deferrals) under a section 457(b) deferred
H Elective deferrals under a section                                                                                                                                                                    R     Employer contributions to an Archer MSA                                                                                                                                             BB Designated Roth contributions under a
  501(c)(18)(D) tax-exempt organization                                                                                                                                                                                                                                                                                                                                                              section 403(b) plan
  plan

Index

A                                                                                                                                                                                                       Golden parachute payments ..................6 ,  1 2                                                                                                                                      S
Adoption benefits ........................ 4 ,   10, 13                                                                                                                                                 Government employers ......................6 ,  1 4                                                                                                                                       Scholarships ................................... 7
Advance EIC payment .........................1 1                                                                                                                                                        Group-term life insurance ................ 6 ,   10, 12                                                                                                                                   Shipping and mailing ...........................3
Agent reporting ................................ 4                                                                                                                                                                                                                                                                                                                                                Sick pay ................................ 7 ,   12, 15
Agricultural employers .......................6 ,  1 4                                                                                                                                                  H                                                                                                                                                                                         Signing bonuses ..............................1 0
Allocated tips .................................1 1                                                                                                                                                     Health Savings Account (HSA) ................6 ,  1 3                                                                                                                                     SIMPLE retirement account............7 ,   10, 12, 13
Archer MSA ............................ 4 ,   10, 13                                                                                                                                                    Help .......................................... 1                                                                                                                                         Social security number .......................... 9
                                                                                                                                                                                                        Household employers ........................6 ,  1 4                                                                                                                                      Social security number (SSN) ....................4
C                                                                                                                                                                                                       How to complete Form W-2 ...................... 9                                                                                                                                         Social security tax withheld .....................1 0
Calendar year basis ............................ 9                                                                                                                                                      How to complete Form W-3 .....................1 4                                                                                                                                         Social security wages/tips .................. 10, 11
Clergy ........................................ 4                                                                                                                                                       How to get forms and publications ................ 2                                                                                                                                      State and local tax information ..................1 4
Codes for box 12, Form W-2 ....................1 1                                                                                                                                                                                                                                                                                                                                                Statutory employee ........................ 10, 13
Corrections and void Forms W-2 ...............4 ,  9                                                                                                                                                    I                                                                                                                                                                                         Successor/predecessor employers ............... 7Substitute forms ................................ 1
                                                                                                                                                                                                        Income tax withheld ....................... 10, 15
D

DeceasedDependentDeferred compensationemployee’scare benefitswages...........................................1....................10, 151                   5                                           LLost Form W-2 ................................. 6                                                                                                                                        TaxpayerTTerminatingidentificationa businessnumbers.........................(TINs) ...........7                                                                                                                            4
Designated Roth contributions ................5 ,  1 0                                                                                                                                                                                                                                                                                                                                            Tips.................................9 ,   10, 11, 12
Due date(s) ..................................1 ,  3                                                                                                                                                    M
                                                                                                                                                                                                        Medicare tax withheld ..........................1 1                                                                                                                                       U

EEducationalEarnedElectiveElectionincomedeferralsworkersassistancecredit.............................................................1notificationprograms.................1.............552,  1 0      MilitaryMovingMedicareMultipleemployersexpenses............................7FormswagesW-2and.........................issuedtips .......................1to employee11,, 141...........309 UncollectedUncollectedUndeliverableUSERRAinsurance...................................1contributionstaxestaxesFormsononW-2group-termtips..........................................1.......................life38 ,   12,3214
Electronic reporting ...........................1 ,  3                                                                                                                                                  N
Employee business expense reimbursements .... 5 ,                                                                                                                                                       Nonqualified deferred compensation plans ......1 ,  7                                                                                                                                     V
                                                                                                                                                                                                 10, 12 Nonqualified plans ......................... 11, 15                                                                                                                                       Void Forms W-2 ..............................4 ,  9
Employee’s taxes paid by employer ...........6 ,  1 0                                                                                                                                                   Nonstatutory stock option(s) ....................1 3
Employer identification number (EIN) ....... 4 ,  9 ,  1 4                                                                                                                                                                                                                                                                                                                                        W
Errors, common ................................ 2                                                                                                                                                       P                                                                                                                                                                                         Wages ........................................9
Extension to file/furnish Form(s) W-2 ............. 3                                                                                                                                                   Penalties ...................................... 8                                                                                                                                        When and where to file .......................... 3
                                                                                                                                                                                                                                                                                                                                                                                                  When to furnish Forms W-2 to employees ......... 3
F                                                                                                                                                                                                       R                                                                                                                                                                                         Who must file Forms W-2 and W-3 ............... 2
Fringe benefits ...............................6 ,  9
Fellowship grants ............................... 7                                                                                                                                                     Reconciling Forms W-2, W-3, 941, 943, 944, CT-1,Railroad employers ..........................7 ,  1 4                                                                                                                                                                                                                                                                                                                 
Furnishing Forms W-2 to employees .............. 3                                                                                                                                                        and Schedule H (Form 1040) .................1 5
                                                                                                                                                                                                        Reissued Form W-2 ............................ 6
G                                                                                                                                                                                                       Religious workers .............................. 4
Getting forms, publications, and help ............. 2                                                                                                                                                   Repayments, wages received in error ............. 7
                                                                                                                                                                                                                                                               -16-






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