Form W-2 Draft - Withholding Declaration - Montana Department Of Revenue
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1MONTANA
2101
Rev. 06-10
W-2 Withholding Declaration
Please print or type.
Taxpayer Name (employee) _________________________________________________________
Social Security Number
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Employer Name ___________________________________________________________________
Business Name ___________________________________________________________________
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Type of Business __________________________________________________________________
Federal Employer Identifi cation Number (FEIN) __________________________________________
Tax Year
Total Wages Paid ................................................................................................... $ _______________
Federal Income Tax Withheld (attach supporting documentation) ....................... $ _______________
Montana Income Tax Withheld (attach supporting documentation) ...................... $ _______________
I declare under penalty of false swearing that I was an employee of the employer identifi ed above and
the employer,
(check one)
did not furnish
refused to furnish
to me Federal Form W-2 showing the Montana income tax that was withheld from my wages. The
amount stated above as Montana income tax withheld was calculated as described in the documents
I have attached to this form.
________________________________________________________
____________________
Signature of taxpayer (required)
Date
Questions? Please call us toll free at (866) 859-2254 (in Helena, 444-6900).
When you fi le your Montana income tax return electronically, you represent that you have retained all documents required as a tax record and that you
will provide a copy to the department upon request. If you fi le electronically, you do not need to mail this form to us unless we contact you for a copy.
*12010101*
1201
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