Publication 957 - Reporting Back Pay And Special Wage Payments To The Social Security Administration Page 13

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Table 5. Sample—Paper Listing for Reporting Special Wage Payments to Several Employees
Report of Special Wage Payments
Tax Year:
Page
of
A. Employer Name:
EIN:
Address:
Contact Name:
Phone: (
)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1) B. Employee Name: (Last)
(First)
(MI)
C. SSN:
D. SWP:$
E. Type:
Other:
2) B. Employee Name: (Last)
(First)
(MI)
C. SSN:
D. SWP:$
E. Type:
Other:
3) B. Employee Name: (Last)
(First)
(MI)
C. SSN:
D. SWP:$
E. Type:
Other:
4) B. Employee Name: (Last)
(First)
(MI)
C. SSN:
D. SWP:$
E. Type:
Other:
5) B. Employee Name: (Last)
(First)
(MI)
C. SSN:
D. SWP:$
E. Type:
Other:
INSTRUCTIONS:
Enter tax year and page number.
A. Employer name, employer identification number (EIN), address, the name of a contact person, and a phone
number where the contact person can be reached during normal business hours.
B. Employee’s name.
C. Employee’s social security number (SSN).
D. Total amount of special wage payments made to the employee.
E. Type of special wage payment from the following list: (1) Vacation Pay, (2) Sick Pay, (3) Severance Pay,
(4) Bonus, (5) Deferred Compensation, (6) Stock Options, and (7) Other—Please explain.
Do not use a paper listing for nonqualified deferred compensation and section 457 plan deferrals and
payments that could not be reported in block 11 of Form W-2. (Get Form SSA-131.)
Publication 957 (May 2010)
Page 13

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