Fillable Form It-2102.6 - Certificate Of Income Tax Withheld

IT-2102.6

New York State Department of Taxation and Finance

Certificate of Income Tax Withheld

(with instructions)

If every effort to get a federal Form W-2, Wage and Tax Statement,

Enter any other information, such as the employer identification

from your employer has failed, file this certificate with this year’s tax

number (EIN), that will help the Tax Department locate your

return, for this employer. If you were unable to get a federal Form

employer, or if you prefer, submit a copy of your payroll stub:

W-2 from more than one employer, file a separate certificate for

each employer. Complete this form, sign, and submit it with your

return.

Explain why you were unable to obtain a federal Form W-2 from

your employer:

Privacy notification

The Commissioner of Taxation and Finance may collect and maintain

personal information pursuant to the New York State Tax Law, including but

not limited to, sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096,

1142, and 1415 of that Law; and may require disclosure of social security

numbers pursuant to 42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities and,

when authorized by law, for certain tax offset and exchange of tax information

Enter your employer’s present name and address if different from

programs as well as for any other lawful purpose.

that entered on the certificate:

Information concerning quarterly wages paid to employees is provided to

certain state agencies for purposes of fraud prevention, support enforcement,

evaluation of the effectiveness of certain employment and training programs

and other purposes authorized by law.

Failure to provide the required information may subject you to civil or criminal

penalties, or both, under the Tax Law.

This information is maintained by the Manager of Document Management,

NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone

(518) 457-5181.

Do not detach.

IT-2102.6

Certificate of Income Tax Withheld

New York State • New York City • Yonkers

Employee’s first name and initial

Last name

Your social security number

Mailing address (number and street or rural route)

Apt no.

City, village, or post office

State

ZIP code

Use this form only

when you are unable to

Employer’s name

obtain federal Form W-2

from your employer.

Address (number and street or rural route)

City, village, or post office

State

ZIP code

Whole dollars only

1 Total wages before any deductions .....................................................................................................

2 New York State income tax withheld ....................................................................................................

3 New York City income tax withheld ......................................................................................................

4 Yonkers income tax withheld ...............................................................................................................

I certify that the total amount of wages paid and New York State, New York City, and Yonkers tax withheld by the employer shown on this form are, to the

best of my knowledge, correct. I further state that it was not possible to obtain federal Form W-2 from the employer for the reason noted above.

Employee signature

Date

110001140094

Form It-2102.6 - Certificate Of Income Tax Withheld - 2014

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