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Virgin Islands Bureau of Internal Revenue
W-2VI / W-3SS/ 1099 / 1096 FORMS REQUEST
TAX YEAR ENDING 12/31/2014
1. EMPLOYER’S NAME
2. EMPLOYER IDENTIFICATION NO.
3. ADDRESS
4. NUMBER OF FORMS REQUESTED:
W-2VI ______ (each)
W-3SS _____ (each)
1099-MISC _____ (each)
1096 _____ (each)
TELEPHONE #: (_______)______-________
OTHER 1099 SERIES:
_________ (each) __________ (each)
5. NAME OF AUTHORIZED PERSON (Please Print)
6. SIGNATURE
Under penalty of perjury, I declare that I am the employer or authorized agent thereof, and the information contained in this request
for W-2VIs is accurate.
Purpose Complete and submit this form to the Virgin Islands Bureau of Internal Revenue to obtain blank forms W-2VI,
W-3SS, 1096 and 1099 Series to be completed by the employer, or authorized agent of the employer, and provided to the
employees and/or non-wage employees by January 31, 2015.
Instructions
Box 1. Print the name of the employer that will be issuing the forms requested. Include your d/b/a if applicable.
Box 2. Print/type the Employer Identification Number of the Employer in Box 1.
Box 3. Print/type the mailing address and telephone number of the Employer.
Box 4. Indicate next to the form type number of forms requested.
Box 5. Print/type the name of the Authorized Person requesting the forms for the Employer.
Box 6. Include the signature of the Authorized Person named in Box 5.
W-2V/W-3SS/ 1099/1096 Employer Request Form
Virgin Islands Bureau of Internal Revenue
12/14