Fillable Form 8922 - Third-Party Sick Pay Recap

CORRECTED

8888

FILER’S name, street address, city or town, province or state, country, ZIP

Filer is an (check one):

OMB No. 1545-0123

Third-Party

or foreign postal code, and telephone no.

2017

Employer

Sick Pay

Recap

Insurer/Agent

8922

Form

FILER’S employer identification number

1 Sick pay subject to federal

2 Federal income tax withheld

OTHER PARTY’S name (see instructions before entering)

income tax

from sick pay

3 Sick pay subject to social

4 Social security tax withheld

security tax

from sick pay

OTHER PARTY’S employer identification number (see instructions before

5 Sick pay subject to

6 Medicare tax withheld from

entering)

Medicare tax

sick pay

Instructions for Form 8922

If your principal place of business is outside the United States, file

with the Internal Revenue Service, IRS SSA CAWR, Philadelphia, PA

Section references are to the Internal Revenue Code unless otherwise

19255-0533.

noted.

Private delivery services. Private delivery services can’t deliver to the

Future Developments

addresses shown above. If you choose to use a private delivery

For the latest information about developments related to Form 8922

service, send Form 8922 to the address shown below based on the

and its instructions, such as legislation enacted after they were

location of your principal business, office, or agency.

published, go to

Internal Revenue Service

Mail Stop 4-G08 151

General Instructions

2970 Market St

Don’t send this form to the Social Security Administration.

▲

Philadelphia, PA 19104

This form is processed solely by the IRS for third-party sick

Internal Revenue Service

pay reporting.

5333 Getwell Rd Stop 814 D6

CAUTION

Memphis, TN 38118

Go to for the current list of designated services.

Purpose of Form

Form 8922 is filed to reconcile employment tax returns (for example,

Substitute Forms

Form 941) with Forms W-2 when third-party sick pay is paid. For more

The IRS accepts quality substitute tax forms that are consistent with

information, see Sick Pay Reporting in Pub. 15-A.

the official forms and have no adverse impact on our processing. The

Who Must File

official Form 8922 is the standard for substitute forms. Because a

substitute form is a variation from the official form, you should know

Generally, if the liability for the employer’s share of social security tax

the requirements of the official form for the year of use before you

and Medicare tax is reported on the employer’s employment tax

create a substitute version. For details on the requirements for

return, Form 8922 must be filed by:

substitute forms, see Pub. 1167.

• The employer, if sick pay is reported on Forms W-2 under the name

and EIN of the insurer or agent.

Specific Instructions

• The insurer or agent, if sick pay is reported on Forms W-2 under the

Check box for employer or insurer/agent. Check the appropriate

name and EIN of the employer.

box to state whether you’re the employer or the insurer/agent filing

For more information on who must file Form 8922, see Pub. 15-A.

Form 8922.

When To File

Filer’s name. If the Employer box is checked, the employer for whom

the sick pay was paid by the insurer or agent will complete the

File Form 8922 by February 28, 2018.

information with the employer’s name, address, and phone number.

Where To File

If the Insurer/Agent box is checked, the insurer or agent who paid

Send Form 8922 to the following:

the sick pay will complete the information with the insurer/agent’s

name, address, and phone number.

If your principal business, office,

Use the following

or agency is located in

address

Filer’s EIN. If the Employer box is checked, enter the EIN of the

employer.

If the Insurer/Agent box is checked, enter the EIN of the insurer or

Alabama, Alaska, Arizona, Arkansas,

Internal Revenue Service

agent.

Colorado, Florida, Georgia, Hawaii,

Memphis Service Center

Kansas, Louisiana, Mississippi, Missouri,

Other party’s name and EIN. If the Employer box is checked, the

P.O. Box 87 Mail Stop 814D6

Nevada, New Mexico, Oklahoma,

employer must provide the name and EIN of the insurer or agent. If the

Memphis, TN 38101-0087

Tennessee, Texas, Utah, Washington

employer has contracts with more than one insurer or agent, the

employer must file a separate Form 8922 for the wages and taxes

California, Connecticut, Delaware, District

related to each contract.

of Columbia, Idaho, Illinois, Indiana, Iowa,

Kentucky, Maine, Maryland,

If the Insurer/Agent box is checked, the insurer or agent may, but

Massachusetts, Michigan, Minnesota,

Internal Revenue Service

isn’t required to, provide the name and EIN of the employer. If it is

Montana, Nebraska, New Hampshire,

IRS SSA CAWR

providing this information, and if it has contracts with more than one

New Jersey, New York, North Carolina,

Philadelphia, PA 19255-0533

employer, it must file a separate Form 8922 for the wages and taxes

North Dakota, Ohio, Oregon,

related to each employer. Alternatively, it may file a separate Form

Pennsylvania, Rhode Island, South

8922 for the wages and taxes related to each employer for which it is

Carolina, South Dakota, Vermont, Virginia,

West Virginia, Wisconsin, Wyoming

8922

Form

Cat. No. 37734T

Department of the Treasury - Internal Revenue Service

Form 8922 - Third-Party Sick Pay Recap - 2017

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