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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Exhibit B
Form W-3c 0.50 in
Red-Ink DO NOT CUT, FOLD, OR STAPLE
a Tax year/Form corrected For Official Use Only
55555 / W- OMB No. 1545-0008
b Employer’s name, address, and ZIP code c Kind of Payer (Check one) Kind of Employer (Check one) Third-party
941/941-SS Military 943 944 None apply 501c non-govt. sick pay
1.00 in
Hshld. Medicare State/local State/local Federal (Check if
3.18 in CT-1 emp. govt. emp. non-501c 501c govt. applicable)
d Number of Forms W-2c e Employer’s Federal EIN f Establishment number g Employer’s state ID number
Complete boxes h, i, or j only if h Employer’s originally reported Federal EIN i Incorrect establishment number j Employer's incorrect state ID number
incorrect on last form filed.
Total of amounts previously reported Total of corrected amounts as Total of amounts previously reported Total of corrected amounts as
as shown on enclosed Forms W-2c. shown on enclosed Forms W-2c. as shown on enclosed Forms W-2c. shown on enclosed Forms W-2c.
1 Wages, tips, other compensation 1 Wages, tips, other compensation 2 Federal income tax withheld 2 Federal income tax withheld
3 Social security wages 3 Social security wages 4 Social security tax withheld 4 Social security tax withheld
0.50 in 0.50 in
5 Medicare wages and tips 5 Medicare wages and tips 6 Medicare tax withheld 6 Medicare tax withheld
7 Social security tips 7 Social security tips 8 Allocated tips 7.19 in 8 Allocated tips
9 9 10 Dependent care bene ts 10 Dependent care bene ts
1.90 in 1.90 in
11 Nonqualified plans 11 Nonqualified plans 12a Deferred compensation 12a Deferred compensation
14 Inc. tax w/h by third-party sick pay payer 14 Inc. tax w/h by third-party sick pay payer 12b 12b
16 State wages, tips, etc. 16 State wages, tips, etc. 17 State income tax 17 State income tax
7.50 in
18 Local wages, tips, etc. 18 Local wages, tips, etc. 19 Local income tax 19 Local income tax
Explain decreases here: 0.33 in
Has an adjustment been made on an employment tax return led with the Internal Revenue Service? Yes No
If “Yes,” give date the return was led
Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true,
correct, and complete. 0.50 in
Signature Title Date
Employer's contact person Employer's telephone number For Official Use Only
Employer's fax number Employer's email address
Department of the Treasury
Form W-3c (Rev. 11-2015) Transmittal of Corrected Wage and Tax Statements Internal Revenue Service
Purpose of Form When To File
Use this form to transmit Copy A of the most recent version of Form(s) W-2c, File this form and Copy A of Form(s) W-2c with the Social Security Administration
Corrected Wage and Tax Statement. Make a copy of Form W-3c and keep it with as soon as possible after you discover an error on Forms W-2, W-2AS, W-2GU,
Copy D (For Employer) of Forms W-2c for your records. File Form W-3c even if W-2CM, W-2VI, or W-2c. Provide Copies B, C, and 2 of Form W-2c to your
only one Form W-2c is being led or if those Forms W-2c are being led only to employees as soon as possible.
correct an employee’s name and social security number (SSN) or the employer Where To File
identi cation number (EIN). See the General Instructions for Forms W-2 and W-3
for information on completing this form. If you use the U.S. Postal Service, send Forms W-2c and W-3c to the following address:
E-Filing Social Security Administration
Data Operations Center
The SSA strongly suggests employers report Form W-3c and Forms W-2c Copy A P.O. Box 3333
electronically instead of on paper. The SSA provides two free e- ling options on its Wilkes-Barre, PA 18767-3333
Business Services Online (BSO) website: If you use a carrier other than the U.S. Postal Service, send Forms W-2c and W-3c
• W-2c Online. Use ll-in forms to create, save, print, and submit up to 25 Forms to the following address:
W-2c at a time to the SSA. Social Security Administration
• File Upload. Upload wage les to the SSA you have created using payroll or tax Data Operations Center
software that formats the les according to the SSA’s Specifications for Filing Attn: W-2c Process
Forms W-2c Electronically (EFW2C). 1150 E. Mountain Drive
For more information, go to www.socialsecurity.gov/employer. First time lers, Wilkes-Barre, PA 18702-7997
select "Go to Register"; returning lers select "Go To Log In."
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10164R
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