Fillable Example W-2 2015 Form W-2

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Example W-2 2015 Form W-2

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Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to the
official IRS form. Do not file copy A downloaded from this website with the SSA. The official
printed version of this IRS form is scannable, but the online version of it, printed from this
website, is not. A penalty may be imposed for filing forms that can’t be scanned. See the
penalties section in the current General Instructions for Forms W-2 and W-3 for more
information.
To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or
Order Information
Returns and Employer Returns Online, and we’ll mail you the scannable forms and other
products.
You may file Forms W-2 and W-3 electronically on the SSA’s website at
Employer
Reporting Instructions & Information. You can create fill-in versions of Forms W-2 and W-3
for filing with SSA. You may also print out copies for filing with state or local governments,
distribution to your employees, and for your records.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information about
printing these tax forms.
22222
Void
a Employee’s social security number
For Official Use Only
▶
OMB No. 1545-0008
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial
Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9 10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12
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12b
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Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax Statement
2015
Copy A For Social Security Administration — Send this entire page with
Form W-3 to the Social Security Administration; photocopies are not acceptable.
Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see the separate instructions.
Cat. No. 10134D
Do Not Cut, Fold, or Staple Forms on This Page
22222
a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans 12a
C
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12b
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12c
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Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax
Statement
2015
Department of the Treasury—Internal Revenue Service
Copy 1—For State, City, or Local Tax Department
a Employee’s social security number
OMB No. 1545-0008
Safe, accurate,
FAST! Use
Visit the IRS website at
www.irs.gov/efile
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages
4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9 10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12
C
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12b
C
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12c
C
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12d
C
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13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax
Statement
2015
Department of the Treasury—Internal Revenue Service
Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.
Notice to Employee
Do you have to file? Refer to the Form 1040 Instructions
to determine if you are required to file a tax return. Even if
you do not have to file a tax return, you may be eligible for
a refund if box 2 shows an amount or if you are eligible for
any credit.
Earned income credit (EIC). You may be able to take the
EIC for 2015 if your adjusted gross income (AGI) is less
than a certain amount. The amount of the credit is based
on income and family size. Workers without children could
qualify for a smaller credit. You and any qualifying children
must have valid social security numbers (SSNs). You
cannot take the EIC if your investment income is more than
the specified amount for 2015 or if income is earned for
services provided while you were an inmate at a penal
institution. For 2015 income limits and more information,
visit www.irs.gov/eitc. Also see Pub. 596, Earned Income
Credit. Any EIC that is more than your tax liability is
refunded to you, but only if you file a tax return.
Clergy and religious workers. If you are not subject to
social security and Medicare taxes, see Pub. 517, Social
Security and Other Information for Members of the Clergy
and Religious Workers.
Corrections. If your name, SSN, or address is incorrect,
correct Copies B, C, and 2 and ask your employer to
correct your employment record. Be sure to ask the
employer to file Form W-2c, Corrected Wage and Tax
Statement, with the Social Security Administration (SSA)
to correct any name, SSN, or money amount error
reported to the SSA on Form W-2. Be sure to get your
copies of Form W-2c from your employer for all
corrections made so you may file them with your tax
return. If your name and SSN are correct but are not the
same as shown on your social security card, you should
ask for a new card that displays your correct name at any
SSA office or by calling 1-800-772-1213. You also may
visit the SSA at www.socialsecurity.gov.
Cost of employer-sponsored health coverage (if such
cost is provided by the employer). The reporting in box
12, using code DD, of the cost of employer-sponsored
health coverage is for your information only. The amount
reported with code DD is not taxable.
Credit for excess taxes. If you had more than one
employer in 2015 and more than $7,347 in social security
and/or Tier 1 railroad retirement (RRTA) taxes were
withheld, you may be able to claim a credit for the excess
against your federal income tax. If you had more than one
railroad employer and more than $4,321.80 in Tier 2
RRTA tax was withheld, you also may be able to claim a
credit. See your Form 1040 or Form 1040A instructions
and Pub. 505, Tax Withholding and Estimated Tax.
(Also see Instructions for Employee on the back of Copy C.)
a Employee’s social security number
OMB No. 1545-0008
This information is being furnished to the Internal Revenue Service. If you
are required to file a tax return, a negligence penalty or other sanction
may be imposed on you if this income is taxable and you fail to report it.
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12
C
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12b
C
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12c
C
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12d
C
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13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax
Statement
2015
Department of the Treasury—Internal Revenue Service
Safe, accurate,
FAST! Use
Copy C—For EMPLOYEE’S RECORDS (See Notice to
Employee on the back of Copy B.)
Instructions for Employee (Also see Notice to Employee,
on the back of Copy B.)
Box 1. Enter this amount on the wages line of your tax return.
Box 2. Enter this amount on the federal income tax withheld line of your tax
return.
Box 5. You may be required to report this amount on Form 8959, Additional
Medicare Tax. See the Form 1040 instructions to determine if you are
required to complete Form 8959.
Box 6. This amount includes the 1.45% Medicare Tax withheld on all
Medicare wages and tips shown in Box 5, as well as the 0.9% Additional
Medicare Tax on any of those Medicare wages and tips above $200,000.
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on
how to report tips on your tax return, see your Form 1040 instructions.
You must file Form 4137, Social Security and Medicare Tax on Unreported
Tip Income, with your income tax return to report at least the allocated tip
amount unless you can prove that you received a smaller amount. If you have
records that show the actual amount of tips you received, report that amount
even if it is more or less than the allocated tips. On Form 4137 you will
calculate the social security and Medicare tax owed on the allocated tips
shown on your Form(s) W-2 that you must report as income and on other tips
you did not report to your employer. By filing Form 4137, your social security
tips will be credited to your social security record (used to figure your
benefits).
Box 10. This amount includes the total dependent care benefits that your
employer paid to you or incurred on your behalf (including amounts from a
section 125 (cafeteria) plan). Any amount over $5,000 is also included in box
1. Complete Form 2441, Child and Dependent Care Expenses, to compute
any taxable and nontaxable amounts.
Box 11. This amount is (a) reported in box 1 if it is a distribution made to you
from a nonqualified deferred compensation or nongovernmental section
457(b) plan or (b) included in box 3 and/or 5 if it is a prior year deferral under
a nonqualified or section 457(b) plan that became taxable for social security
and Medicare taxes this year because there is no longer a substantial risk of
forfeiture of your right to the deferred amount. This box should not be used if
you had a deferral and a distribution in the same calendar year. If you made a
deferral and received a distribution in the same calendar year, and you are or
will be age 62 by the end of the calendar year, your employer should file
Form SSA-131, Employer Report of Special Wage Payments, with the Social
Security Administration and give you a copy.
Box 12. The following list explains the codes shown in box 12. You may
need this information to complete your tax return. Elective deferrals (codes
D, E, F, and S) and designated Roth contributions (codes AA, BB, and EE)
under all plans are generally limited to a total of $18,000 ($12,500 if you only
have SIMPLE plans; $21,000 for section 403(b) plans if you qualify for the
15-year rule explained in Pub. 571). Deferrals under code G are limited to
$18,000. Deferrals under code H are limited to $7,000.
However, if you were at least age 50 in 2015, your employer may have
allowed an additional deferral of up to $6,000 ($3,000 for section 401(k)(11)
and 408(p) SIMPLE plans). This additional deferral amount is not subject to
the overall limit on elective deferrals. For code G, the limit on elective
deferrals may be higher for the last 3 years before you reach retirement age.
Contact your plan administrator for more information. Amounts in excess of
the overall elective deferral limit must be included in income. See the
“Wages, Salaries, Tips, etc.” line instructions for Form 1040.
Note. If a year follows code D through H, S, Y, AA, BB, or EE, you made a
make-up pension contribution for a prior year(s) when you were in military
service. To figure whether you made excess deferrals, consider these
amounts for the year shown, not the current year. If no year is shown, the
contributions are for the current year.
A—Uncollected social security or RRTA tax on tips. Include this tax on Form
1040. See “Other Taxes” in the Form 1040 instructions.
B—Uncollected Medicare tax on tips. Include this tax on Form 1040. See
“Other Taxes” in the Form 1040 instructions.
C—Taxable cost of group-term life insurance over $50,000 (included in boxes
1, 3 (up to social security wage base), and 5)
D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also
includes deferrals under a SIMPLE retirement account that is part of a
section 401(k) arrangement.
E—Elective deferrals under a section 403(b) salary reduction agreement
(continued on back of Copy 2)
a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans 12a
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12c
C
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12d
C
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13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax
Statement
2015
Department of the Treasury—Internal Revenue Service
Copy 2—To Be Filed With Employee’s State, City, or Local
Income Tax Return
Instructions for Employee (continued from back of
Copy C)
F—Elective deferrals under a section 408(k)(6) salary reduction SEP
G—Elective deferrals and employer contributions (including nonelective
deferrals) to a section 457(b) deferred compensation plan
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization
plan. See “Adjusted Gross Income” in the Form 1040 instructions for
how to deduct.
J—Nontaxable sick pay (information only, not included in boxes 1, 3, or
5)
K—20% excise tax on excess golden parachute payments. See “Other
Taxes” in the Form 1040 instructions.
L—Substantiated employee business expense reimbursements
(nontaxable)
M—Uncollected social security or RRTA tax on taxable cost of group-
term life insurance over $50,000 (former employees only). See “Other
Taxes” in the Form 1040 instructions.
N—Uncollected Medicare tax on taxable cost of group-term life
insurance over $50,000 (former employees only). See “Other Taxes” in
the Form 1040 instructions.
P—Excludable moving expense reimbursements paid directly to
employee (not included in boxes 1, 3, or 5)
Q—Nontaxable combat pay. See the instructions for Form 1040 or Form
1040A for details on reporting this amount.
R—Employer contributions to your Archer MSA. Report on Form 8853,
Archer MSAs and Long-Term Care Insurance Contracts.
S—Employee salary reduction contributions under a section 408(p)
SIMPLE plan (not included in box 1)
T—Adoption benefits (not included in box 1). Complete Form 8839,
Qualified Adoption Expenses, to compute any taxable and nontaxable
amounts.
V—Income from exercise of nonstatutory stock option(s) (included in
boxes 1, 3 (up to social security wage base), and 5). See Pub. 525 and
instructions for Schedule D (Form 1040) for reporting requirements.
W—Employer contributions (including amounts the employee elected to
contribute using a section 125 (cafeteria) plan) to your health savings
account. Report on Form 8889, Health Savings Accounts (HSAs).
Y—Deferrals under a section 409A nonqualified deferred compensation
plan
Z—Income under a nonqualified deferred compensation plan that fails
to satisfy section 409A. This amount is also included in box 1. It is
subject to an additional 20% tax plus interest. See “Other Taxes” in the
Form 1040 instructions.
AA—Designated Roth contributions under a section 401(k) plan
BB—Designated Roth contributions under a section 403(b) plan
DD—Cost of employer-sponsored health coverage. The amount
reported with Code DD is not taxable.
EE—Designated Roth contributions under a governmental section
457(b) plan. This amount does not apply to contributions under a tax-
exempt organization section 457(b) plan.
Box 13. If the “Retirement plan” box is checked, special limits may
apply to the amount of traditional IRA contributions you may deduct.
See Pub. 590, Individual Retirement Arrangements (IRAs).
Box 14. Employers may use this box to report information such as state
disability insurance taxes withheld, union dues, uniform payments,
health insurance premiums deducted, nontaxable income, educational
assistance payments, or a member of the clergy's parsonage allowance
and utilities. Railroad employers use this box to report railroad
retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax and
Additional Medicare Tax. Include tips reported by the employee to the
employer in railroad retirement (RRTA) compensation.
Note. Keep Copy C of Form W-2 for at least 3 years after the due date
for filing your income tax return. However, to help protect your social
security benefits, keep Copy C until you begin receiving social security
benefits, just in case there is a question about your work record and/or
earnings in a particular year.
Void
a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)
c Employer’s name, address, and ZIP code
d Control number
e Employee’s first name and initial Last name Suff.
f Employee’s address and ZIP code
1 Wages, tips, other compensation
2 Federal income tax withheld
3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8 Allocated tips
9
10 Dependent care benefits
11 Nonqualified plans 12a See instructions for box 12
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12b
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Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20
Locality name
Form
W-2
Wage and Tax
Statement
2015
Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see separate instructions.
Copy D — For Employer
Employers, Please Note—
Specific information needed to complete Form W-2 is available
in a separate booklet titled the 2015 General Instructions for
Forms W-2 and W-3. You can order those instructions and
additional forms by calling 1-800-TAX-FORM (1-800-829-3676).
You also can get forms and instructions at IRS.gov.
Caution. Do not send the SSA Forms W-2 and W-3 that you
have printed from IRS.gov. The SSA is unable to process these
forms. Instead, you can create and submit them online. See
E-filing, later.
Due dates. By February 1, 2016, furnish Copies B, C, and 2 to
each person who was your employee during 2015. By February
29, 2016, send Copy A of Form(s) W-2 and W-3 to the SSA.
However, if you file electronically, the due date is March 31,
2016. See the separate instructions.
Need help? If you have questions about reporting on Form W-2,
call the information reporting customer service site toll free at
1-866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD
equipment for persons who are deaf, hard of hearing, or have a
speech disability, call 304-579-4827 (not toll free). The hours of
operation are 8:30 a.m. to 4:30 p.m. Eastern time.
E-filing. If you file 250 or more Form(s) W-2, you must file
electronically. Even if you are not required to file electronically,
doing so can save you time and effort. Employers may now use
the SSA's W-2 Online service to create, save, print, and submit
up to 50 Form(s) W-2 at a time over the Internet. When you e-file
with the SSA, no separate Form W-3 filing is required. An
electronic Form W-3 will be created for you by the W-2 Online
service. For information, visit the SSA's Employer W-2 Filing
Instructions & Information website at www.socialsecurity.gov/
employer.
Future developments. Information about any future
developments affecting Form W-2 and its instructions (such as
legislation enacted after we release them) will be posted at
www.irs.gov/w2.
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