Instructions For Schedule H (Form 1040) Household Employment Taxes - 2005 Page 9

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Note: Although not shown, Susan also enters on Form W-2 the
Visit the SSA website at to file
required state or local income tax information in boxes 15 through 20.
Copy A of Form W-2 electronically.
a
Control number
For Official Use Only
22222
Void
OMB No. 1545-0008
b
Employer identification number (EIN)
1
Wages, tips, other compensation
2
Federal income tax withheld
00-1234567
2475.95
c
Employer’s name, address, and ZIP code
3
Social security wages
4
Social security tax withheld
Susan Green
2300.00
142.60
16 Gray Street
5
Medicare wages and tips
6
Medicare tax withheld
2300.00
33.35
Anyplace, CA 92665
7
Social security tips
8
Allocated tips
d
Employee’s social security number
9
Advance EIC payment
10
Dependent care benefits
000-00-4567
e
Employee’s first name and initial
Last name
11
Nonqualified plans
12a
See instructions for box 12
C
o
Helen R.
Maple
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
C
19 Pine Avenue
o
d
e
Anycity, CA 92666
14
Other
12c
C
o
d
e
12d
C
o
d
e
f
Employee’s address and ZIP code
15
Employer’s state ID number
16
State wages, tips, etc.
17
State income tax
18
Local wages, tips, etc.
19
Local income tax
20
Locality name
State
Wage and Tax
W-2
Department of the Treasury—Internal Revenue Service
2
0 5
0
Statement
For Privacy Act and Paperwork Reduction
Form
Act Notice, see back of Copy D.
Copy A For Social Security Administration — Send this
entire page with Form W-3 to the Social Security
Administration; photocopies are not acceptable.
Cat. No. 10134D
a
Control number
For Official Use Only
33333
OMB No. 1545-0008
b
941
Military
943
1
Wages, tips, other compensation
2
Federal income tax withheld
2475.95
Kind
Hshld.
Medicare
Third-party
of
3
Social security wages
4
Social security tax withheld
CT-1
emp.
govt. emp.
sick pay
Payer
2300.00
142.60
X
c
Total number of Forms W-2
d
Establishment number
5
Medicare wages and tips
6
Medicare tax withheld
1
2300.00
33.35
e
Employer identification number (EIN)
7
Social security tips
8
Allocated tips
00-1234567
f
Employer’s name
9
Advance EIC payments
10
Dependent care benefits
Susan Green
11
Nonqualified plans
12
Deferred compensation
16 Gray Street
13
For third-party sick pay use only
Anyplace, CA 92665
14
Income tax withheld by payer of third-party sick pay
g
Employer’s address and ZIP code
h
Other EIN used this year
15
State
Employer’s state ID number
16
State wages, tips, etc.
17
State income tax
18
Local wages, tips, etc.
19
Local income tax
Contact person
Telephone number
For Official Use Only
123
456-7890
(
)
Email address
Fax number
(
)
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.
1/29/06
Signature
Title
Date
W-3
2 0
0 5
Department of the Treasury
Transmittal of Wage and Tax Statements
Form
Internal Revenue Service
● Do not round money amounts—show the cents portion.
Note: When you fill in Forms W-2 and W-3, please—
● Type or print entries, if possible, using black ink.
● Enter all money amounts without the dollar sign and comma,
but with the decimal point (for example, 2475.95 not $2,475.95).
H-9

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