Instructions For Schedule H (Form 1040) - Household Employment Taxes - 2017 Page 12
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13Note. Although not shown, Susan also enters on Form W-2
Visit the SSA website at to le Copy A
and Form W-3 the required state or local income tax informa-
.
of Form W-2 electronically
tion (boxes 15-20 on Form W-2; boxes 15-19 on Form W-3).
a Employee’s social security number
For Official Use Only
22222
Void
000-00-4567
OMB No. 1545-0008
b Employer identi cation 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
2300.00
142.60
Susan Green
5 Medicare wages and tips
6 Medicare tax withheld
16 Gray Street
2300.00
33.35
Anyplace, CA 92665
7 Social security tips
8 Allocated tips
d Control number
9 Veri cation code
10 Dependent care bene ts
e Employee’s rst name and initial
11 Nonquali ed plans
12a See instructions for box 12
Last name
Suff.
Maple
Helen R.
C
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
C
o
d
e
19 Pine Avenue
14 Other
12c
C
o
Anycity, CA 92666
d
e
12d
C
o
d
e
f Employee’s address and ZIP code
15
Employer’s state ID number
16
17 State income tax
18
19
20
State wages, tips, etc.
Local wages, tips, etc.
Local income tax
Locality name
State
W-2
2017
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
For Privacy Act and Paperwork Reduction
Form
Act Notice, see the separate instructions.
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
944
None apply
501c non-govt.
Third-party
sick pay
Kind
Kind
of
of
(Check if
Hshld.
Medicare
State/local
Payer
Employer
applicable)
CT-1
emp.
govt. emp.
non-501c
State/local 501c
Federal govt.
(Check one)
(Check one)
c Total number of Forms W-2
d Establishment number
1 Wages, tips, other compensation
2 Federal income tax withheld
1
2475.95
e Employer identi cation number (EIN)
3 Social security wages
4 Social security tax withheld
00-1234567
2300.00
142.60
f Employer’s name
6 Medicare tax withheld
5 Medicare wages and tips
Susan Green
2300.00
33.35
7 Social security tips
8 Allocated tips
16 Gray Street
10 Dependent care bene ts
9
Anyplace, CA 92665
11 Nonquali ed plans
12a Deferred compensation
g Employer’s address and ZIP code
h Other EIN used this year
13 For third-party sick pay use only
12b
15 State
Employer’s state ID number
14 Income tax withheld by payer of third-party sick pay
16 State wages, tips, etc.
17 State income tax
18 Local wages, tips, etc.
19 Local income tax
Employer's contact person
Employer's telephone number
For Of cial Use Only
(123) 456-7890
Employer's fax number
Employer's email address
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.
1/30/18
Signature
Date
Title
W-3
2017
Transmittal of Wage and Tax Statements
Department of the Treasury
Form
Internal Revenue Service
Note. When you fill in Forms W-2 and W-3, please:
• Show the cents portion of the money amounts.
• Type entries 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); and
H-12
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