Form W-2c - Corrected Wage And Tax Statement Page 7
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9For Official Use Only
44444
OMB No. 1545-0008
a
Employer’s name, address, and ZIP code
c
Tax year/Form corrected
d
Employee’s correct SSN
/ W-2
e
Corrected SSN and/or name (Check this box and complete boxes f and/or
g if incorrect on form previously filed.)
Complete boxes f and/or g only if incorrect on form previously filed
f
Employee’s previously reported SSN
g
Employee’s previously reported name
b
Employer’s Federal EIN
h
Employee’s first name and initial
Last name
Suff.
Note: Only complete money fields that are being corrected
(exception: for corrections involving MQGE, see the Instructions
for Forms W-2c and W-3c, boxes 5 and 6).
Employee’s address and ZIP code
i
Previously reported
Correct information
Previously reported
Correct information
1
Wages, tips, other compensation
1
Wages, tips, other compensation
2
Federal income tax withheld
2
Federal income tax withheld
3
Social security wages
3
Social security wages
4
Social security tax withheld
4
Social security tax withheld
5
Medicare wages and tips
5
Medicare wages and tips
6
Medicare tax withheld
6
Medicare tax withheld
7
Social security tips
7
Social security tips
8
Allocated tips
8
Allocated tips
9
Advance EIC payment
9 Advance EIC payment
10
Dependent care benefits
10
Dependent care benefits
11
Nonqualified plans
11 Nonqualified plans
12a
See instructions for box 12
12a
See instructions for box 12
C
C
o
o
d
d
e
e
13
Statutory
Retirement
Third-party
13
Statutory
Retirement
Third-party
12b
12b
employee
plan
sick pay
employee
plan
sick pay
C
C
o
o
d
d
e
e
14 Other (see instructions)
14 Other (see instructions)
12c
12c
C
C
o
o
d
d
e
e
12d
12d
C
C
o
o
d
d
e
e
State Correction Information
Previously reported
Correct information
Previously reported
Correct information
15
State
15 State
15 State
15 State
Employer’s state ID number
Employer’s state ID number
Employer’s state ID number
Employer’s state ID number
16
State wages, tips, etc.
16 State wages, tips, etc.
16
State wages, tips, etc.
16
State wages, tips, etc.
17
State income tax
17 State income tax
17
State income tax
17
State income tax
Locality Correction Information
Previously reported
Correct information
Previously reported
Correct information
18
Local wages, tips, etc.
18 Local wages, tips, etc.
18
Local wages, tips, etc.
18
Local wages, tips, etc.
19
Local income tax
19 Local income tax
19
Local income tax
19
Local income tax
20
Locality name
20 Locality name
20
Locality name
20
Locality name
Copy 2—To Be Filed with Employee’s State, City, or Local Income Tax Return
Department of the Treasury
W-2c
Corrected Wage and Tax Statement
Form
(Rev. 2-2009)
Internal Revenue Service
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