West Virginia 
                     Affidavit of West Virginia Income Tax                                  State Tax 
IT-102-1
Rev. 05/12                             Withheld by Employer                                 Department

This affidavit is to be used ONLY when taxpayer is unable to secure Form W-2.
                     NOTE: Prepare a separate affidavit for each employer.
                           READ INSTRUCTIONS BELOW

Taxable year 
of Withholding
Employer’s Name and Address (please type or print)            Your Name and Address (please type or print)

TOTAL WAGES RECEIVED FROM THIS                       WEST VIRGINIA INCOME TAX WITHHELD.
EMPLOYER

$                        .                           $                        .

AFFIDAVIT: The undersigned, being duly sworn, states that the total amount of wages received from 
the employer named and the West Virginia income tax withheld by the employer as shown on this form 
are correct for the calendar year ____________. I further state that it was not possible to obtain Form 
W-2 from this employer for the reasons noted on this form.

Signature of Employee

Signature of Officer Administering Oath

County:                                              State:                        Date:

INSTRUCTIONS
► File this affidavit as a substitute for Withholding Tax Statement (Form W-2) only if every effort to obtain Form W-2 
  from employer has failed.
► File a separate affidavit for each such employer.
► Enclose this affidavit with your income tax return.
► Complete all of this form and have your signature notarized.

ADDITIONAL INFORMATION
Reason why employer did not give you a Form W-2:

_________________________________________________________________________________________________

Employer’s Present Name and Address if different from what is given above:

_________________________________________________________________________________________________

Any other information to assist the West Virginia State Tax Department in locating employer:

_________________________________________________________________________________________________