Form W-2vi - U.s. Virgin Islands Wage And Tax Statement - 2012 Page 2

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a Employee’s social security number
For Official Use Only
Void
22222
OMB No. 1545-0008
b Employer identification number (EIN)
1 Wages, tips, other compensation
2 VI income tax withheld
c Employer’s name, address, and ZIP code
3 Social security wages
4 Social security tax withheld
5 Medicare wages and tips
6 Medicare tax withheld
7 Social security tips
8
d Control number
9
10
e Employee’s first name and initial
11 Nonqualified plans
12a See instructions for box 12
Last name
Suff.
C
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
C
o
d
e
14 Other
12c
C
o
d
e
12d
C
o
f Employee’s address and ZIP code
d
e
W-2VI
U.S. Virgin Islands
2012
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
Form
For Privacy Act and Paperwork Reduction Act
Notice, see the separate instructions.
Copy A For Social Security Administration — Send this entire page with Copy A of
Form W-3SS to the Social Security Administration; photocopies are not acceptable.
Cat. No. 49977C
Do Not Cut, Fold, or Staple Forms on This Page

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