Form 150-206-005 (Subtitute W-2) -Employee'S Substitute Wage And Tax Statement - Oregon Department Of Revenue
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1Date Received
EMPLOYEE’S SUBSTITUTE WAGE AND TAX STATEMENT
O R E G O N
D E PA R T M E N T
(SUBSTITUTE W-2)
O F R E V E N U E
Please provide the information requested below. Attach a copy of the IRS wage transcripts OR other W-2s for other years same
employer OR payroll check stubs as proof of state withholding claimed.
Business Name
Taxpayer’s Name
Owner’s Name
Telephone Number
Social Security Number
Business Address
Address
City
State
ZIP Code
City
State
ZIP Code
Wages Received
State Tax Withheld
Federal Tax Withheld
Period of Employment (Month, Day, Year)
From:
To:
Filing Status
Exemptions
Job Site Location
Explanation
DECLARATION
Under penalties for false swearing I declare that I have examined this document and to the best of my knowledge it is true, correct, and
complete. I authorize the Oregon Department of Revenue to use this information as a basis for action on my claim against the employer.
I understand that loss of withholding credit may result from subsequent findings or my failure to supply satisfactory proof or information.
Date
Taxpayer’s Signature
X
150-206-005 (Rev. 5-04) Web
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Parent category: Financial