Attention: 

You may file Forms W-2 and W-3 electronically on the SSA’s Employer 

W-2 Filing Instructions and Information web page, which is also accessible 

at www.socialsecurity.gov/employer. 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.

Note: Copy A of this form is provided for informational purposes only. Copy A appears in 

red, similar to the official IRS form. The official printed version of this IRS form is scannable, 

but the online version of it, printed from this website, is not. Do not print and file Copy A 

downloaded from this website with the SSA; 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, available at www.irs.gov/w2, for more information.

Please note that Copy B and other copies of this form, which appear in black, may be 

downloaded, filled in, and printed and used to satisfy the requirement to provide the 

information to the recipient.

To order official IRS information returns such as Forms W-2 and W-3, which include a 

scannable Copy A for filing, go to IRS’ Online Ordering for Information Returns and 

Employer Returns page, or visit www.irs.gov/orderforms and click on Employer and 

Information returns. We’ll mail you the scannable forms and any other products you order.

See IRS Publications 1141, 1167, and 1179 for more 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 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

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12b

C

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12c

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12d

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13 Statutory 

employee

Retirement 

plan

Third-party 

sick pay

14 Other

Form W-2AS American Samoa 

Wage and Tax Statement 2021

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

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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

Form W-2AS American Samoa 

Wage and Tax Statement 2021 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 

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12b

C

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12c

C

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12d

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13 Statutory 

employee

Retirement 

plan

Third-party 

sick pay

14 Other

Form W-2AS American Samoa 

Wage and Tax Statement 2021

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 2021 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 selfemployment tax) for 2022, you may have to make estimated tax payments to the 

U.S. Internal Revenue Service. Use Form 1040-ES, Estimated Tax for Individuals.

Employee’s social security number (SSN). For your protection, this form may 

show only the last four digits of your SSN. However, your employer has reported 

your complete SSN to the American Samoa Tax Office and the SSA.

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 employersponsored 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 2021 

and more than $8,853.60 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 box 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 2021, 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

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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

Form W-2AS American Samoa 

Wage and Tax Statement 2021

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 makeup 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 the 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 the 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 2021

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 2021 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 January 31, 2022, furnish Copies B and C to 

each person who was your employee during 2021. Mail or 

electronically file Copy A of Form(s) W-2AS and W-3SS with the 

SSA by January 31, 2022. 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 2021 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.