Publication 926 - Household Employer'S Tax Guide - Internal Revenue Service - 2012 Page 15
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20Sample W-2 Form
Note: Although not shown, Mary also enters on Form W-2 the
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required state or local income tax information in boxes 15 through 20.
to file Copy A of Form W-2 electronically.
a Employee’s social security number
For Official Use Only
22222
Void
000-00-6789
OMB No. 1545-0008
b Employer identi cation number (EIN)
1 Wages, tips, other compensation
2
Federal income tax withheld
2300.00
12-3456789
c Employer’s name, address, and ZIP code
3
4
Social security wages
Social security tax withheld
2300.00
96.60
5
Medicare wages and tips
6
Medicare tax withheld
Mary Brown
2300.00
33.35
20 Gray Street
7
Social security tips
8
Allocated tips
Anyplace, CA 92665
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
Oak
C
Jane A.
o
d
e
13
Statutory
Retirement
Third-party
12b
employee
plan
sick pay
C
o
d
e
14 Other
12c
18 Pine Avenue
C
o
d
Anycity, CA 92666
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
Local income tax
20
State
State wages, tips, etc.
Local wages, tips, etc.
Locality name
W-2
2012
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.
X
(Check one)
(Check one)
c Total number of Forms W-2
d Establishment number
1 Wages, tips, other compensation
2 Federal income tax withheld
2300.00
e Employer identi cation number (EIN)
3 Social security wages
4 Social security tax withheld
12-3456789
2300.00
96.60
f Employer’s name
6 Medicare tax withheld
5 Medicare wages and tips
Mary Brown
2300.00
33.35
7 Social security tips
8 Allocated tips
20 Gray Street
10 Dependent care bene ts
9
Anyplace, CA 92665
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
18 Local wages, tips, etc.
19 Local income tax
16 State wages, tips, etc.
17 State income tax
Contact person
Telephone number
For Of cial Use Only
123-456-7890
Email address
Fax number
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.
Mary Brown
1/31/2013
Signature
Date
Title
W-3
2012
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–
• Do not round money amounts–show the cents portion.
• Type entries, if possible, using black ink.
• Enter all money amounts without the dollar sign and comma,
but with the decimal point (for example, 2300.00 not $2,300.00).
Publication 926 (March 2012)
Page 15
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