Fillable Form 22222: a Employees social security number 3 (IRS)

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Form 22222: a Employees social security number 3 (IRS)

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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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 Samoa 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
9 10
11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
12b
C
o
d
e
12c
C
o
d
e
12d
C
o
d
e
13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
Form W-2AS
American Samoa
Wage and Tax Statement
2020
Copy A—For Social Security Administration. Send this entire page with Copy A of
Form W-3SS 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. 10140H
Do Not Cut, Fold, or Staple Forms on This Page
22222
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 Samoa 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
9 10
11 Nonqualified plans 12a
C
o
d
e
12b
C
o
d
e
12c
C
o
d
e
12d
C
o
d
e
13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
Form W-2AS
American Samoa
Wage and Tax Statement
2020
Department of the Treasury—Internal Revenue Service
Copy 1—For American Samoa Treasurer
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 Samoa 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
9 10
11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
12b
C
o
d
e
12c
C
o
d
e
12d
C
o
d
e
13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
Form W-2AS
American Samoa
Wage and Tax Statement
2020
Copy B—To Be Filed With Employee’s American Samoa Tax Return
Department of the Treasury—Internal Revenue Service
This information is being furnished to
the American Samoa Tax Office,
Government of American Samoa.
Notice to Employee
Do you have to file? Refer to the Instructions for Forms 1040 and 1040-SR to
determine if you are required to file a tax return. Even if you don’t 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.
Copies B and C; corrections. File Copy B of this form with your 2020 American
Samoa income tax return. Keep Copy C for your records. If your name, social
security number (SSN), or address is incorrect, correct Copies B and C and ask
your employer to correct your employment record. Be sure to ask your employer
to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security
Administration (SSA) to correct any name, amount, or SSN error reported to the
SSA. 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.
Estimated tax. If you expect to owe $1,000 or more in tax (including self-
employment tax) for 2021, you may have to make estimated tax payments to the
U.S. Internal Revenue Service. Use Form 1040-ES, Estimated Tax for Individuals.
Clergy and religious workers. If you aren’t subject to social security and
Medicare taxes, see Pub. 517, Social Security and Other Information for Members
of the Clergy and Religious Workers.
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 social security tax. If you had more than one employer in 2020
and more than $8,537.40 in social security tax was withheld, you can have the
excess refunded by filing Form 843, Claim for Refund and Request for Abatement,
with the Department of the Treasury, Internal Revenue Service Center, Austin, TX
73301-0215, USA. However, if you are required to file Form 1040 or 1040-SR with the
United States, you must claim the excess tax as a credit on Form 1040 or 1040-SR.
Unreported tip income. 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 with adequate records 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. Use
Form 4137 to figure the social security and Medicare tax owed on tips you didn’t
report to your employer. Enter this amount on the wages line of your tax return.
(Form 1040-SS filers, see the instructions for Form 1040-SS, Part I, line 6.) By filing
this form, your social security tips will be credited to your social security record
(used to figure your benefits).
(See also the Instructions for Employee on this page and the back of Copy C.)
Instructions for Employee
(See also Notice to Employee on this page.)
Box 5. You may be required to report this amount on Form 8959, Additional
Medicare Tax. See the Instructions for Forms 1040 and 1040-SR 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 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 shouldn’t 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 $19,500 ($13,500 if you have only SIMPLE plans;
$22,500 for section 403(b) plans if you qualify for the 15-year rule explained in
Pub. 571). Deferrals under code G are limited to $19,500. Deferrals under code H
are limited to $7,000.
However, if you were at least age 50 in 2020, your employer may have allowed
an additional deferral of up to $6,500 ($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 your
tax return.
(continued on back of Copy C)
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 Samoa 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
9 10
11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
12b
C
o
d
e
12c
C
o
d
e
12d
C
o
d
e
13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
Form W-2AS
American Samoa
Wage and Tax Statement
2020
Copy C—For EMPLOYEE’S RECORDS
(See Notice to Employee on the back of Copy B.)
Department of the Treasury—Internal Revenue Service
This information is being furnished to
the American Samoa Tax Office,
Government of American Samoa.
Instructions for Employee (continued from back of
Copy B)
Box 12 (continued)
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 tax on tips. Report on U.S. Form 1040 or 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
B—Uncollected Medicare tax on tips. Report on U.S. Form 1040 or 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
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
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. (You
may be able to deduct.)
J—Nontaxable sick pay (information only, not included in box 1, 3, or 5)
M—Uncollected social security tax on taxable cost of group-term life insurance
over $50,000 (former employees only). Report on U.S. Form 1040 or 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
N—Uncollected Medicare tax on taxable cost of group-term life insurance over
$50,000 (former employees only). Report on U.S. Form 1040 or 1040-SR. Report
on Form 1040-SS if not required to file Form 1040 or 1040-SR.
P—Excludable moving expense reimbursements paid directly to a member of the
U.S. Armed Forces (not included in box 1, 3, or 5)
Q—Nontaxable combat pay. See your tax return instructions 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 figure 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, Taxable and Nontaxable
Income, for reporting requirements.
W—Employer contributions (including amounts the employee elected to contribute
using a section 125 (cafeteria) plan) to your health savings account (HSA). 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 instructions for your tax return.
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.
FF—Permitted benefits under a qualified small employer health reimbursement
arrangement
GG—Income from qualified equity grants under section 83(i)
HH—Aggregate deferrals under section 83(i) elections as of the close of the
calendar year
Box 13. If the “Retirement plan” box is checked, special limits may apply to the
amount of traditional IRA contributions that you may deduct. See Pub. 590-A,
Contributions to Individual Retirement Arrangements (IRAs).
Note: Keep Copy C of Form W-2AS 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 Samoa 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
9 10
11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
12b
C
o
d
e
12c
C
o
d
e
12d
C
o
d
e
13
Statutory
employee
Retirement
plan
Third-party
sick pay
14 Other
Form W-2AS
American Samoa
Wage and Tax Statement
2020
Copy D—For Employer
Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction Act
Notice, see the separate instructions.
Employers, Please Note—
Specific information needed to complete Form W-2AS is
available in a separate booklet titled the 2020 General
Instructions for Forms W-2 and W-3. You can order these
instructions and additional forms at www.irs.gov/OrderForms.
Caution: Do not send the SSA Forms W-2AS and W-3SS 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, 2021, furnish Copies B and C to
each person who was your employee during 2020. Mail or
electronically file Copy A of Form(s) W-2AS and W-3SS with the
SSA by February 1, 2021. See the separate instructions.
Need help? If you have questions about reporting on Form
W-2AS, call the information reporting customer service site at
866-455-7438 (not toll free from American Samoa) 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).
E-filing. See the 2020 General Instructions for Forms W-2 and
W-3 for information on when you’re required to file electronically.
Even if you aren’t 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-2AS at a time over the Internet. When you e-file with
the SSA, no separate Form W-3SS filing is required. An
electronic Form W-3SS 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.SSA.gov/employer or
contact your Employer Services Liaison Officer (ESLO) at
510-970-8247 (not toll free) or SF.CA.RO.CDPS.ESLO@ssa.gov.
Future developments. Information about any future
developments affecting Form W-2AS and its instructions (such
as legislation enacted after we release them) will be posted at
www.irs.gov/FormW2AS.
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Form 22222: a Employees social security number 3 (IRS)

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Completed 28 January 2021

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