Enlarge image
8888 CORRECTED
FILER’S name, street address, city or town, province or state, country, ZIP Filer is an (check one): OMB No. 1545-0123
or foreign postal code, and telephone no. Third-Party
Employer
Sick Pay
Insurer/Agent 2021 Recap
Form 8922
FILER’S employer identification number
OTHER PARTY’S name (see instructions before entering) 1 Sick pay subject to federal 2 Federal income tax withheld
income tax from sick pay
$ $
3 Sick pay subject to social 4 Social security tax withheld
security tax from sick pay
$ $
OTHER PARTY’S employer identification number (see instructions before 5 Sick pay subject to 6 Medicare tax withheld from
entering) Medicare tax sick pay
$ $
Instructions for Form 8922 If your principal place of business is outside the United States, file
Section references are to the Internal Revenue Code unless otherwise with the Internal Revenue Service, IRS SSA CAWR, Philadelphia, PA
noted. 19255-0533.
Future Developments Private delivery services. Private delivery services can’t deliver to the
For the latest information about developments related to Form 8922 addresses shown above. If you choose to use a private delivery
and its instructions, such as legislation enacted after they were service, send Form 8922 to the address shown below based on the
published, go to www.irs.gov/Form8922. location of your principal business, office, or agency.
Internal Revenue Service
General Instructions Mail Stop 4-G08 151
Don’t send this form to the Social Security Administration. 2970 Market St
This form is processed solely by the IRS for third-party sick Philadelphia, PA 19104
▲! pay reporting. Internal Revenue Service
CAUTION 5333 Getwell Rd Stop 814 D6
Memphis, TN 38118
Purpose of Form Go to www.irs.gov/PDS for the current list of designated services.
Form 8922 is filed to reconcile employment tax returns (for example,
Form 941) with Forms W-2 when third-party sick pay is paid. For more Substitute Forms
information, see Sick Pay Reporting in Pub. 15-A. For purposes of The IRS accepts quality substitute tax forms that are consistent with
these instructions, all references to “sick pay” mean ordinary sick pay, the official forms and have no adverse impact on our processing. The
not qualified sick leave wages. See the instructions for your official Form 8922 is the standard for substitute forms. Because a
employment tax return for more information about qualified sick leave substitute form is a variation from the official form, you should know
wages. the requirements of the official form for the year of use before you
Who Must File create a substitute version. For details on the requirements for
Generally, if the liability for the employer’s share of social security tax substitute forms, see Pub. 1167.
and Medicare tax is reported on the employer’s employment tax Specific Instructions
return, Form 8922 must be filed by: Check box for employer or insurer/agent. Check the appropriate
• The employer, if sick pay is reported on Forms W-2 under the name box to state whether you’re the employer or the insurer/agent filing
and EIN of the insurer or agent. Form 8922.
• The insurer or agent, if sick pay is reported on Forms W-2 under the Filer’s name. If the Employer box is checked, the employer for whom
name and EIN of the employer. the sick pay was paid by the insurer or agent will complete the
For more information on who must file Form 8922, see Pub. 15-A. information with the employer’s name, address, and phone number.
When To File If the Insurer/Agent box is checked, the insurer or agent who paid
File Form 8922 by February 28, 2022. the sick pay will complete the information with the insurer/agent’s
name, address, and phone number.
Where To File Filer’s EIN. If the Employer box is checked, enter the EIN of the
Send Form 8922 to the following: employer.
If your principal business, office, Use the following If the Insurer/Agent box is checked, enter the EIN of the insurer or
or agency▲ is located in address▲ agent.
Other party’s name and EIN. If the Employer box is checked, the
Alabama, Alaska, Arizona, Arkansas, Internal Revenue Service employer must provide the name and EIN of the insurer or agent. If the
Colorado, Florida, Georgia, Hawaii, Memphis Service Center employer has contracts with more than one insurer or agent, the
Kansas, Louisiana, Mississippi, Missouri, P.O. Box 87 Mail Stop 814D6 employer must file a separate Form 8922 for the wages and taxes
Nevada, New Mexico, Oklahoma, Memphis, TN 38101-0087 related to each contract.
Tennessee, Texas, Utah, Washington If the Insurer/Agent box is checked, the insurer or agent may, but
California, Connecticut, Delaware, District isn’t required to, provide the name and EIN of the employer. If it is
of Columbia, Idaho, Illinois, Indiana, Iowa, providing this information, and if it has contracts with more than one
Kentucky, Maine, Maryland, employer, it must file a separate Form 8922 for the wages and taxes
Massachusetts, Michigan, Minnesota, Internal Revenue Service related to each employer. Alternatively, it may file a separate Form
Montana, Nebraska, New Hampshire, IRS SSA CAWR 8922 for the wages and taxes related to each employer for which it is
New Jersey, New York, North Carolina, Philadelphia, PA 19255-0533
North Dakota, Ohio, Oregon,
Pennsylvania, Rhode Island, South
Carolina, South Dakota, Vermont, Virginia,
West Virginia, Wisconsin, Wyoming
Form 8922 Cat. No. 37734T www.irs.gov/Form8922 Department of the Treasury - Internal Revenue Service
