Form 499r-2/w-2pr - Comprobante De Retencion - Withholding Statement - Puerto Rico Department Of The Treasury Page 2

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Formulario
INFORMACION PARA EL DEPARTAMENTO DE
GOBIERNO DE PUERTO RICO - GOVERNMENT OF PUERTO RICO
INFORMACION PARA EL SEGURO SOCIAL
499R-2/W-2PR
Form
HACIENDA
DEPARTAMENTO DE HACIENDA - DEPARTMENT OF THE TREASURY
Rev. 10.11
SOCIAL SECURITY INFORMATION
COMPROBANTE DE RETENCION - WITHHOLDING STATEMENT
DEPARTMENT OF THE TREASURY INFORMATION
091100
091100
091100
091100
091100
1.
Nombre - First Name
Núm. Seguro Social
3.
17.
Total Sueldos Seguro Social
7.
Sueldos - Wages
Social Security No.
Social Security Wages
8.
Comisiones - Commissions
Núm. de Ident. Patronal
4 .
Employer Ident. No. (EIN)
Apellido(s) - Surname(s)
18.
Seguro Social Retenido
9.
Concesiones - Allowances
Social Security Tax Withheld
5.
Fecha en que comenzó a recibir la
pensión - Date on which you started
Dirección Postal del Empleado - Employee's Mailing Address
to receive the pension
10.
Propinas - Tips
Día
Mes
Año
19.
Total Sueldos y Pro. Medicare
Day _____ Month _____ Year _____
Medicare Wages and Tips
11.
Total = 7 + 8 + 9 + 10
6.
Costo de Pensión o Anualidad
Cost of Pension or Annuity
12.
Gastos Reembolsados
Reimbursed Expenses
Costo de cubierta de salud auspiciada
6A.
2.
Nombre y Dirección Postal del Patrono
20.
Contrib. Medicare Retenida
por el patrono - Cost of employer-
Employer's Name and Mailing Address
Medicare Tax Withheld
sponsored health coverage
13.
Cont. Retenida - Tax Withheld
6B.
Donativos
14.
Fondo de Retiro Gubernamental
Charitable Contributions
21.
Propinas Seguro Social
Governmental Retirement Fund
Social Security Tips
Copia A - Copy A
15.
Aportaciones a Planes Cualific.
Envíe a: - Send to:
Número de Teléfono del Patrono
Contributions to CODA PLANS
Employer's Telephone Number
NEGOCIADO
22. Seguro Social no Retenido
Fecha Cese de Operaciones: Día
Mes
Año
DE PROCESAMIENTO DE
en Propinas - Uncollected
16.
Salarios bajo Ley Núm. 324 de 2004
Social Security Tax on Tips
Cease of Operations Date:
Day ______ Month ______ Year ______
PLANILLAS
Salaries under Act No. 324 of 2004
Número Control - Control Number
PO BOX 9022501
SAN JUAN PR 00902-2501
Contrib. Medicare no Retenida
23.
16A.
Aportaciones al Programa Ahorra y
Año:
en Propinas - Uncollected
Duplica tu Dinero - Contributions to the
2011
2011
2011
2011
2011
Year:
Medicare Tax on Tips
Save and Double your Money Program
Fecha de radicación: 31 de enero - Filing date: January 31
Instrucciones al dorso de Copia D - Instructions on back of Copy D
Conservación: Diez (10) años a partir de la fecha de radicación en el Negociado de Procesamiento de Planillas.
Retention: Ten (10) years from the filing date in the Returns Processing Bureau.

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