Montana Form 2101 - W-2 Withholding Declaration
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1MONTANA
Clear Form
2101
Rev 02 12
W-2 Withholding Declaration
Please print or type.
Employee Name __________________________________________________________________
Social Security Number
-
-
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Employer Contact _________________________________________________________________
Business Name ___________________________________________________________________
Mailing Address
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Type of Business __________________________________________________________________
Business Federal Employer Identifi cation 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 identifi ed above and
X
the employer, (mark
one box):
did not furnish
refused to furnish
to me a 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).
*12CU0101*
*12CU0101*
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Parent category: Financial