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FORM L-15                        STATE OF HAWAII — DEPARTMENT OF TAXATION 
(REV. 2018)                    SUBSTITUTE FOR FORM HW-2 or W-2, WAGE AND TAX STATEMENT
                                 ( A separate Form L-15 must be submitted for each employer.  
                                                          Attach to Form N-11 or N-15.)
PLEASE TYPE OR PRINT

1.  NAME (First, middle, last)                                                          2.  SOCIAL SECURITY NUMBER

3.  ADDRESS (Number, street, city, State, Postal/ZIP code)  Has your present address been furnished to employer or payer?     Yes     No

4.  EMPLOYER’S OR PAYER’S NAME, ADDRESS, AND POSTAL/ZIP CODE                            5.  EMPLOYER’S OR PAYER’S  
                                                                                          IDENTIFICATION NUMBER (If known) 
                                                                                          
                                                                                        6. TYPE OF BUSINESS:

7. TAX YEAR                     8.  GROSS WAGES*                                       9.  STATE INCOME TAX WITHHELD
             20     

*NOTE:   Include the total wages paid, noncash payments, tips/reported, and all other compensation before deductions for taxes, insurance, etc. 

10.  Check applicable box and give all facts relating to your situation:

            Employer has not furnished me with Form HW-2 or W-2.

            Form HW-2 or W-2 given to me by my employer is incorrect.

11.  How did you estimate the above gross wages and State income tax withheld? (Submit copies of payroll statements or show computation below.) 
 Wages were paid by:             Check         Cash

12.  Give reason Form HW-2, W-2 or W-2c, Statement of Corrected Income and Tax Amounts, was not furnished by employer or payer, if 
 known, and explain your efforts to obtain it.

I declare under penalties set forth in section 231-36, HRS, the above statements made by me are true, correct, and complete, to the 
best of my knowledge and belief.
13. Your Signature                                                                      14.  Date

L15_I 2018A 01 VID01                                      ID NO 01