Form W-2 Wage and Tax Statement

Please complete the form below by entering the information EXACTLY as it appears on your Form W-2.
Use the Tab key to move to the next field. Use the Submit button at the bottom of this form to send the information.
An asterisk ( * ) indicates a required field.

a Control Number

* your email address:

* Employer Identification Number:

Example: 12-3456789

1 Wages, Tips, Other Compensation

2 Federal Tax Withheld

* Employer's name:

Address:


City:
State: ZIP:

3 Social Security Wages

4 Social Security Tax Withheld

5 Medicare Wages and Tips

6 Medicare Tax Withheld

7 Social Security Tips

8 Allocated Tips

* Employee's social security number:

Example: 111-22-3333

9 Advance EIC Payment

10 Dependent Care Benefits

* Employee's name:

Address:


City:
State: ZIP:

11Nonqualified Plans

12a

13
 Stat Retire Sick

12b

14 Other

12c

12d

15 State/Employer ID

16 State Wages, Tips

 17 State Income Tax
 18 Local Wages, Tips
19 Local Income Tax
20 Locality Name

W-2 Wage and Tax Statement 2001

If you would like to give us any additional information at this time, which is NOT shown on your W-2, please enter it below. This could be information given in Box 14 that relates to Union Dues, etc.

*Click on the box when ready to send this form, then click Submit bar below: