Form It-2102.6 - Certificate Of Income Tax Withheld
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1IT-2102.6
New York State Department of Taxation and Finance
Certificate of Income Tax Withheld
(8/05)
Enter any other information, such as the employer identification
Instructions
number (EIN), that will help the Tax Department locate your
If every effort to get a federal Form W-2, Wage and Tax Statement,
employer, or if you prefer, attach a copy of your payroll stub:
from your employer has failed, file this certificate with your tax return
instead of federal Form W-2 or New York State Form IT-2, Summary of
Federal Form W-2 Statements, for this employer. If you were unable to
get a federal Form W-2 from more than one employer, file a separate
certificate for each employer. Complete this form, sign, and attach it
to your return.
Privacy notification — The Commissioner of Taxation and Finance may
collect and maintain personal information pursuant to the New York State
Explain why you were unable to obtain a federal Form W-2 from your
Tax Law, including but not limited to, sections 171, 171-a, 287, 308, 429, 475,
employer:
505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of
social security numbers pursuant to 42 USC 405(c)(2)(C)(i).
This information will be used to determine and administer tax liabilities and,
when authorized by law, for certain tax offset and exchange of tax information
programs as well as for any other lawful purpose.
Information concerning quarterly wages paid to employees is provided to
certain state agencies for purposes of fraud prevention, support enforcement,
evaluation of the effectiveness of certain employment and training programs
Enter your employer’s present name and address if different from
and other purposes authorized by law.
that entered on the certificate:
Failure to provide the required information may subject you to civil or criminal
penalties, or both, under the Tax Law.
This information is maintained by the Director of Records Management and
Data Entry, NYS Tax Department, W A Harriman Campus, Albany NY 12227;
telephone 1 800 225-5829. From areas outside the United States and outside
Canada, call (518) 485-6800.
Do not detach.
IT-2102.6
Certificate of Income Tax Withheld
New York State • New York City • Yonkers
Employee’s first name and initial
Last name
Your social security number
Mailing address (number and street or rural route)
Apt no.
City, village, or post office
State
ZIP code
Use this form only
when you are unable to
Employer’s name
obtain federal Form W-2
from your employer.
Address (number and street or rural route)
City, village, or post office
State
ZIP code
1 Indicate calendar year for which this certificate is being filed ...............................................................
1.
Dollars
Cents
2 Total wages before any deductions.......................................................................................................
2.
3 New York State income tax withheld .....................................................................................................
3.
4 New York City income tax withheld .......................................................................................................
4.
5 Yonkers income tax withheld.................................................................................................................
5.
I certify that the total amount of wages paid and New York State, New York City, and Yonkers tax withheld by the employer shown on this form are, to the
best of my knowledge, correct. I further state that it was not possible to obtain federal Form W-2 from the employer for the reason noted above.
Employee signature
Date
Please file this original scannable
1101050094
form with the Tax Department.
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