Instructions For Schedule H (Form 1040) - Household Employment Taxes - 2007 Page 9
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11Note: Although not shown, Susan also enters on Form W-2 the
Visit the SSA website at to file
required state or local income tax information in boxes 15 through 20.
Copy A of Form W-2 electronically.
a
Employee’s social security number
For Official Use Only
22222
Void
000-00-4567
OMB No. 1545-0008
b
Employer identification number (EIN)
1
Wages, tips, other compensation
2
Federal income tax withheld
2475.95
00-1234567
c
Employer’s name, address, and ZIP code
3
Social security wages
4
Social security tax withheld
Susan Green
2300.00
142.60
16 Gray Street
5
Medicare wages and tips
6
Medicare tax withheld
2300.00
33.35
Anyplace, CA 92665
7
Social security tips
8
Allocated tips
d
Control number
9
Advance EIC payment
10
Dependent care benefits
e
Employee’s first name and initial
Last name
Suff.
11
Nonqualified plans
12a
See instructions for box 12
C
Helen R.
Maple
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
19 Pine Avenue
C
o
d
Anycity, CA 92666
e
14
Other
12c
C
o
d
e
12d
C
o
d
e
f
Employee’s address and ZIP code
15
Employer’s state ID number
16
State wages, tips, etc.
17
State income tax
18
Local wages, tips, etc.
19
Local income tax
20
Locality name
State
2
0 7
0
Wage and Tax
W-2
Department of the Treasury—Internal Revenue Service
Statement
Form
For Privacy Act and Paperwork Reduction
Act Notice, see back of Copy D.
Copy A For Social Security Administration — Send this entire page with
Form W-3 to the Social Security Administration; photocopies are not acceptable.
Cat. No. 10134D
a
Control number
For Official Use Only
33333
OMB No. 1545-0008
b
941
Military
943
944
1
Wages, tips, other compensation
2
Federal income tax withheld
2475.95
Kind
Hshld.
Medicare
Third-party
of
3
Social security wages
4
Social security tax withheld
CT-1
emp.
govt. emp.
sick pay
Payer
2300.00
142.60
X
c
Total number of Forms W-2
d Establishment number
5
Medicare wages and tips
6
Medicare tax withheld
2300.00
33.35
e
Employer identification number (EIN)
7
Social security tips
8
Allocated tips
00-1234567
f
Employer’s name
9
Advance EIC payments
10
Dependent care benefits
Susan Green
11
Nonqualified plans
12
Deferred compensation
16 Gray Street
Anyplace, CA 92665
13
For third-party sick pay use only
14
Income tax withheld by payer of third-party sick pay
g
Employer’s address and ZIP code
h
Other EIN used this year
15
State
Employer’s state ID number
16 State wages, tips, etc.
17
State income tax
18 Local wages, tips, etc.
19
Local income tax
Contact person
Telephone number
For Official Use Only
123
456-7890
(
)
Email address
Fax number
(
)
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.
1/29/08
Signature
Title
Date
2 0
0 7
W-3
Department of the Treasury
Transmittal of Wage and Tax Statements
Form
Internal Revenue Service
● Do not round money amounts—show the cents portion.
Note: When you fill in Forms W-2 and W-3, please—
● Type or print entries, if possible, using black ink.
● Enter all money amounts without the dollar sign and comma,
but with the decimal point (for example, 2475.95 not $2,475.95).
H-9
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