Fillable Form 8922 - Third-Party Sick Pay Recap

CORRECTED

8888

FILER'S name, street address, city or town, province or state, country, ZIP

Filer is an (check one):

OMB No. 1545-0123

Third-Party

or foreign postal code, and telephone no.

2015

Employer

Sick Pay

Recap

Insurer/Agent

8922

Form

FILER'S employer identification number

1 Sick pay subject to federal

2 Federal income tax withheld

OTHER PARTY'S name (see instructions before entering)

income tax

from sick pay

3 Sick pay subject to social

4 Social security tax withheld

security tax

from sick pay

OTHER PARTY'S employer identification number (see instructions before

5 Sick pay subject to

6 Medicare tax withheld from

entering)

Medicare tax

sick pay

Instructions for Form 8922

California, Connecticut, Delaware,

District of Columbia, Idaho, Illinois,

Section references are to the Internal Revenue Code unless otherwise

Indiana, Iowa, Kentucky, Maine,

noted.

Maryland, Massachusetts, Michigan,

Minnesota, Montana, Nebraska, New

Internal Revenue Service

Future Developments

Hampshire, New Jersey, New York,

IRS SSA CAWR

For the latest information about developments related to Form 8922

North Carolina, North Dakota, Ohio,

Philadelphia, PA 19255-0533

Oregon, Pennsylvania, Rhode Island,

and its instructions, such as legislation enacted after they were

South Carolina, South Dakota, Vermont,

published, go to

Virginia, West Virginia, Wisconsin,

General Instructions

Wyoming

If your principal place of business is outside the United States, file

Do not send this form to the Social Security

▲

with the Internal Revenue Service, IRS SSA CAWR, Philadelphia, PA

Administration. This form is processed solely by the IRS

19255-0533.

for third-party sick pay reporting.

CAUTION

Substitute Forms

Purpose of Form

The IRS accepts quality substitute tax forms that are consistent with

Form 8922 is filed to reconcile employment tax returns (for example,

the official forms and have no adverse impact on our processing. The

Form 941) with Forms W-2 when third-party sick pay is paid. For more

official Form 8922 is the standard for substitute forms. Because a

information, see Sick Pay Reporting in Pub. 15-A.

substitute form is a variation from the official form, you should know

the requirements of the official form for the year of use before you

Who Must File

create a substitute version. For details on the requirements for

Generally, if the liability for the employer’s share of social security tax

substitute forms, see Pub. 1167.

and Medicare tax is reported on the employer’s employment tax

Specific Instructions

return, Form 8922 must be filed by:

• The employer, if sick pay is reported on Forms W-2 under the name

Check box for employer or insurer/agent. Check the appropriate

and EIN of the insurer or agent.

box to state whether you are the employer or the insurer/agent filing

Form 8922.

• The insurer or agent, if sick pay is reported on Forms W-2 under the

name and EIN of the employer.

Filer's name. If the Employer box is checked, the employer for whom

the sick pay was paid by the insurer or agent will complete the

For more information on who must file Form 8922, see Pub. 15-A.

information with the employer's name, address, and phone number.

When To File

If the Insurer/Agent box is checked, the insurer or agent who paid

File Form 8922 by February 29, 2016.

the sick pay will complete the information with the insurer/agent's

name, address, and phone number.

Where To File

Filer's EIN. If the employer box is checked, enter the EIN of the

Send Form 8922 to the following:

employer.

If your principal business, office,

Use the following

If the Insurer/Agent box is checked, enter the EIN of the insurer or

or agency is located in

address

agent.

Other party's name and EIN. If the Employer box is checked, the

employer must provide the name and EIN of the insurer or agent. If the

Alabama, Alaska, Arizona, Arkansas,

employer has contracts with more than one insurer or agent, the

Colorado, Florida, Georgia, Hawaii,

Internal Revenue Service

Kansas, Louisiana, Mississippi, Missouri,

employer must file a separate Form 8922 for the wages and taxes

Memphis Service Center

Nevada, New Mexico, Oklahoma,

P.O. Box 87 Mail Stop 814D6

related to each contract.

Tennessee, Texas, Utah, Washington

Memphis, TN 38101-0087

If the Insurer/Agent box is checked, the insurer or agent may, but is

not required to, provide the name and EIN of the employer. If it is

providing this information, and if it has contracts with more than one

employer, it must file a separate Form 8922 for the wages and taxes

related to each employer. Alternatively, it may file a separate Form

8922 for the wages and taxes related to each employer for which it is

8922

Form

Cat. No. 37734T

IRS.gov/form8922

Department of the Treasury - Internal Revenue Service

Form 8922 - Third-Party Sick Pay Recap - 2015

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