Instructions For Schedule H (Form 1040) - 2016 Page 11
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9
10
11
12Note: Although not shown, Susan also enters on Form W-2 the
Visit the SSA website at to
required state or local income tax information in boxes 15
.
file Copy A of Form W-2 electronically
through 20.
a Employee’s social security number
For Official Use Only
22222
Void
OMB No. 1545-0008
000-00-4567
b Employer identi cation 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
2300.00
142.60
Susan Green
5 Medicare wages and tips
6 Medicare tax withheld
16 Gray Street
2300.00
33.35
Anyplace, CA 92665
7 Social security tips
8 Allocated tips
d Control number
9
10 Dependent care bene ts
e Employee’s rst name and initial
Last name
Suff.
11 Nonquali ed plans
12a See instructions for box 12
C
Maple
Helen R.
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
19 Pine Avenue
C
o
d
e
Anycity, CA 92666
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
17 State income tax
18
19
20
State wages, tips, etc.
Local wages, tips, etc.
Local income tax
Locality name
State
W-2
2016
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
For Privacy Act and Paperwork Reduction
Form
Act Notice, see the separate instructions.
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
None apply
501c non-govt.
Third-party
sick pay
Kind
Kind
of
of
(Check if
Hshld.
Medicare
State/local
Payer
Employer
applicable)
CT-1
emp.
govt. emp.
non-501c
State/local 501c
Federal govt.
(Check one)
(Check one)
c Total number of Forms W-2
d
Establishment number
1 Wages, tips, other compensation
2 Federal income tax withheld
2475.95
e Employer identi cation number (EIN)
3 Social security wages
4 Social security tax withheld
00-1234567
2300.00
142.60
f Employer’s name
5 Medicare wages and tips
6 Medicare tax withheld
Susan Green
2300.00
33.35
7 Social security tips
8 Allocated tips
16 Gray Street
10 Dependent care bene ts
Anyplace, CA 92665
9
11 Nonquali ed plans
12a Deferred compensation
g Employer’s address and ZIP code
h Other EIN used this year
13 For third-party sick pay use only
12b
15 State
Employer’s state ID number
14 Income tax withheld by payer of third-party sick pay
16 State wages, tips, etc.
17 State income tax
18 Local wages, tips, etc.
19 Local income tax
Employer's contact person
Employer's telephone number
For Of cial Use Only
(123) 456-7890
Employer's fax number
Employer's email address
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.
1/30/17
Signature
Date
Title
W-3
2016
Transmittal of Wage and Tax Statements
Department of the Treasury
Form
Internal Revenue Service
Note: When you fill in Forms W-2 and W-3, please—
• Don’t round money amounts—show the cents portion.
• Type entries 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-11
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