Form Rpd - 41079 - Employee'S Substitute Wage And Tax Statement Form - Revenue Processing Division - New Mexico

RPD - 41079

State of New Mexico - Revenue Processing Division

REV. 08/2001

EMPLOYEE'S SUBSTITUTE

WAGE AND TAX STATEMENT

Name

Social Security Number

Address

State

Zip Code

City

I have been unable to obtain a W-2 Form from my employer, named below. The amounts shown

below are my best estimates of the gross wages paid to me and the New Mexico income tax withheld

by this employer during 20 _______ .

Wages Paid Subject

Federal Income

State Income

Name of State

to Withholding

Tax Withheld

Name and Address of Employer

Where in New Mexico were you employed?

Reason the federal W-2 Form was not obtained from your employer:

I declare that the projected amount of wages shown above is not less than the gross wages paid by the above named

employer and that the amount shown as state income tax withheld is not more than the amount actually withheld.

Signature of Employee

Date

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Parent category: Financial