Form It-2102.6 - Certificate Of Income Tax Withheld

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IT-2102.6
New York State Department of Taxation and Finance
Certificate of Income Tax Withheld
(9/99)
New York State • City of New York • City of Yonkers
Use only when a taxpayer is unable to obtain NYS Form IT-2102 or federal Form W-2 from the employer
(see instructions on back).
Social security number
Type
Indicate calendar year for which
or
print
this certificate is being filed ..................... __________
First name and initial
Last name
Total wages before any deductions ........ $ _______________
Mailing address (number and street or rural route)
Apt no.
New York State income tax withheld ....... $ _______________
City of New York income tax withheld ..... $ _______________
City, village or post office
State
ZIP code
City of Yonkers income tax withheld ....... $ _______________
Employer’s name
I certify that the total amount of wages paid and New York State, city of New
York and city of 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
Address (name and street or rural route)
obtain either New York State Form IT-2102 or federal Form W-2 from the
employer for the reason noted on the back of this form.
City, village or post office
State
ZIP code
Your signature
Date
IT-2102.6 (9/99) (back)
Instructions
Privacy Notification
File this certificate with your tax return as a substitute for Wage and
Tax Statement (New York State Form IT-2102 or federal Form W-2 only
The right of the Commissioner of Taxation and Finance and the Department of Taxation
where every effort to get a Form IT-2102 or W-2 from your employer
and Finance to collect and maintain personal information, including mandatory
has failed.
disclosure of social security numbers in the manner required by tax regulations,
instructions, and forms, is found in Articles 22, 26, 26-A, 26-B, 30, 30-A, and 30-B of the
Complete both sides of this form and sign it on the front.
Tax Law; Article 2-E of the General City Law; and 42 USC 405(c)(2)(C)(i).
File a separate certificate for each employer.
The Tax Department uses this information primarily to determine and administer tax
Why were you unable to obtain a Form IT-2102 or W-2 from your
liabilities due the state and city of New York and the city of Yonkers. We also use this
employer? __________________________________________________
information for certain tax offset and exchange of tax information programs authorized
_____________________________________________________________
by law, and for any other purpose authorized by law.
______________________________________________________________
Information concerning quarterly wages paid to employees and identified by unique
random identifying code numbers to preserve the privacy of the employees’ names and
Employer’s present name and address if other than that shown on
social security numbers is provided to certain state agencies, for research purposes to
front: ________________________________________________________
evaluate the effectiveness of certain employment and training programs.
______________________________________________________________
Failure to provide the required information may subject you to civil or criminal penalties,
______________________________________________________________
or both, under the Tax Law.
Enter other information, such as the employer identification number
This information is maintained by the Director of the Registration and Data Services
(EIN) (or if you prefer, attach a copy of a payroll stub) to help the Tax
Bureau, NYS Tax Department, Building 8 Room 924, W A Harriman Campus, Albany
Department locate your employer:
NY 12227; telephone 1 800 225-5829. From areas outside the U.S. and outside
________________________________________________________
Canada, call (518) 485-6800.
_______________________________________________________

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