Form It-102-1 - Affidavit Of West Virginia Income Taxes Withheld By Employer
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1IT-102-1
To be used only when taxpayer is unable to secure Form IT-102 or W-2.
Rev. 2/99
Read instructions on back of form.
WEST VIRGINIA INCOME TAX DIVISION
WAGES RECEIVED IN _________
WEST VIRGINIA
FROM EMPLOYER NAMED HEREIN
TAX WITHHELD
Affidavit of West Virginia Income Taxes Withheld
By Employer During the Calendar Year _________
NOTE: Prepare a separate affidavit for each employer
$
$
Type or Print Employer’s Name and Address
AFFIDAVIT: The undersigned being duly sworn states that the total
amount of wages received from the employer named and the West
Virginia income tax withheld by the employer as shown on this form
are correct for the calendar year _______ .
I further state that it was
not possible to obtain Form IT-102 or W-2 from this employer for the
reasons noted on the reverse of this form.
Type or Print Your Name and Address in Space Below
Signature of Employee
Signature of Officer Administering Oath
County
State
Date
IT-102-1
To be used only when taxpayer is unable to secure Form IT-102 or W-2.
Rev. 2/99
Read instructions on back of form.
WEST VIRGINIA INCOME TAX DIVISION
WAGES RECEIVED IN _________
WEST VIRGINIA
FROM EMPLOYER NAMED HEREIN
TAX WITHHELD
Affidavit of West Virginia Income Taxes Withheld
By Employer During the Calendar Year _________
NOTE: Prepare a separate affidavit for each employer
$
$
Type or Print Employer’s Name and Address
AFFIDAVIT: The undersigned being duly sworn states that the total
amount of wages received from the employer named and the West
Virginia income tax withheld by the employer as shown on this form
are correct for the calendar year _______ .
I further state that it was
not possible to obtain Form IT-102 or W-2 from this employer for the
reasons noted on the reverse of this form.
Type or Print Your Name and Address in Space Below
Signature of Employee
Signature of Officer Administering Oath
County
State
Date
IT-102-1
To be used only when taxpayer is unable to secure Form IT-102 or W-2.
Rev. 2/99
Read instructions on back of form.
WEST VIRGINIA INCOME TAX DIVISION
WAGES RECEIVED IN _________
WEST VIRGINIA
FROM EMPLOYER NAMED HEREIN
TAX WITHHELD
Affidavit of West Virginia Income Taxes Withheld
By Employer During the Calendar Year _________
NOTE: Prepare a separate affidavit for each employer
$
$
Type or Print Employer’s Name and Address
AFFIDAVIT: The undersigned being duly sworn states that the total
amount of wages received from the employer named and the West
Virginia income tax withheld by the employer as shown on this form
are correct for the calendar year _______ .
I further state that it was
not possible to obtain Form IT-102 or W-2 from this employer for the
reasons noted on the reverse of this form.
Type or Print Your Name and Address in Space Below
Signature of Employee
Signature of Officer Administering Oath
County
State
Date
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