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                   Form                                                       (MM/DD/YY)
                   548         Employee’s Substitute Wage and Tax Statement

Social Security Number

                           -             -
Taxpayer Name

Address                                                            City                                                    State ZIP Code

E-mail Address

                   I have been unable to obtain a Form W-2 from my employer, named below, and have so notified the Missouri Department of Revenue, 
                   Taxation Division. The amounts shown below are my best estimates of the gross wages paid to me and the federal income tax withheld, 
                   Missouri state income tax withheld and F.I.C.A. employee tax withheld by this employer during the following tax year.
         Affidavit Tax Year

                   2    0

                   Business Name                                              Owner Name

                   Address                                           City                                                  State ZIP Code

         Employer
                   Gross Wages                Federal Tax Withheld         Missouri State Tax Withheld       F.I.C.A. Employee Tax Withheld

                                         . 00                      . 00                 .              00                                .     00
                   Please indicate the reason Form W-2 was not obtained from this employer. Provide an explanation of how you arrived at the 
                   estimated figures and attach copies of check stubs or other documentation pertinent to this calculation.

         Reason

                   Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
                   Signature of Employee             Printed Name             Date Signed (MM/DD/YYYY)
         Signature

                                           Attach your completed Form 548 to your Missouri Income Tax Return.
                                                                                                                           Form 548 (Revised 05-2018)
Taxation Division                             Phone: (573) 751-3505         
P.O. Box 500                                  Fax: (573) 522-1762             Visit dor.mo.gov
Jefferson City, MO 65105-0500                 E-mail:  income@dor.mo.gov      for additional information.

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