Form 2101 - W-2 Withholding Declaration
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MONTANA
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2101
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Rev 02 12
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W-2 Withholding Declaration
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Please print or type.
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Employee Name __________________________________________________________________
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Social Security Number
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-
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Mailing Address
_______________________________________________________________
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_______________________________________________________________
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_______________________________________________________________
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Employer Contact _________________________________________________________________
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Business Name ___________________________________________________________________
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Mailing Address
_______________________________________________________________
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_______________________________________________________________
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_______________________________________________________________
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Type of Business __________________________________________________________________
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Business Federal Employer Identifi cation Number (FEIN), if known
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Tax Year
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Y Y Y Y
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Total Wages Paid ................................................................................................... $ _______________
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Federal Income Tax Withheld (attach supporting documentation) ....................... $ _______________
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Montana Income Tax Withheld (attach supporting documentation) ...................... $ _______________
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I declare under penalty of false swearing that I was an employee of the employer identifi ed above and
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the employer, (mark
one box):
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did not furnish
refused to furnish
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to me a federal Form W-2 showing the Montana income tax that was withheld from my wages. The
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amount stated above as Montana income tax withheld was calculated as described in the documents
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I have attached to this form.
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________________________________________________________
____________________
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Signature of Taxpayer (required)
Date
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Questions? Please call us toll free at (866) 859-2254 (in Helena, 444-6900).
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*12CU0101*
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*12CU0101*
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