Form W-2 - Withholding Declaration - Montana Department Of Revenue - 2011

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Clear Form

MonTana

2101

Rev 03 11

W-2 Withholding Declaration

Please print or type.

Employee Name __________________________________________________________________

Social Security Number

Mailing Address

_______________________________________________________________

Employer Name ___________________________________________________________________

Business Name ___________________________________________________________________

Mailing Address

_______________________________________________________________

Type of Business __________________________________________________________________

Federal Employer Identification Number (FEIN), if known

Tax Year

Y Y Y Y

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 identified above and

the employer,



(mark

one box)

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).

If you file your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you file electronically, you

represent that you have retained the required documents in your tax records and will provide them upon the department’s request.

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