Form 8922

2016

Third-Party 

Sick Pay 

Recap

OMB No. 1545-0123

8888 CORRECTED

FILER’S name, street address, city or town, province or state, country, ZIP 

or foreign postal code, and telephone no.

OTHER PARTY’S name (see instructions before entering)

OTHER PARTY’S employer identification number (see instructions before 

entering)

Filer is an (check one):

 Employer

 Insurer/Agent

FILER’S employer identification number

1 Sick pay subject to federal 

income tax

$

2 Federal income tax withheld 

from sick pay

$

3 Sick pay subject to social 

security tax

$

4 Social security tax withheld 

from sick pay

$

5 Sick pay subject to 

Medicare tax

$

6 Medicare tax withheld from 

sick pay

$

Instructions for Form 8922

Section references are to the Internal Revenue Code unless otherwise 

noted.

Future Developments

For the latest information about developments related to Form 8922 

and its instructions, such as legislation enacted after they were 

published, go to www.irs.gov/form8922.

General Instructions

▲!

CAUTION

Don’t send this form to the Social Security Administration. 

This form is processed solely by the IRS for third-party sick 

pay reporting.

Purpose of Form

Form 8922 is filed to reconcile employment tax returns (for example, 

Form 941) with Forms W-2 when third-party sick pay is paid. For more 

information, see Sick Pay Reporting in Pub. 15-A.

Who Must File 

Generally, if the liability for the employer’s share of social security tax 

and Medicare tax is reported on the employer’s employment tax 

return, Form 8922 must be filed by:

• The employer, if sick pay is reported on Forms W-2 under the name 

and EIN of the insurer or agent.

• The insurer or agent, if sick pay is reported on Forms W-2 under the 

name and EIN of the employer.

For more information on who must file Form 8922, see Pub. 15-A.

When To File

File Form 8922 by February 28, 2017. 

Where To File

Send Form 8922 to the following:

If your principal business, office, 

or agency is located in

Use the following 

▲

address

▲

Alabama, Alaska, Arizona, Arkansas, 

Colorado, Florida, Georgia, Hawaii, 

Kansas, Louisiana, Mississippi, Missouri, 

Nevada, New Mexico, Oklahoma, 

Tennessee, Texas, Utah, Washington

Internal Revenue Service 

Memphis Service Center 

P.O. Box 87 Mail Stop 814D6 

Memphis, TN 38101-0087

California, Connecticut, Delaware, District 

of Columbia, Idaho, Illinois, Indiana, Iowa, 

Kentucky, Maine, Maryland, 

Massachusetts, Michigan, Minnesota, 

Montana, Nebraska, New Hampshire, 

New Jersey, New York, North Carolina, 

North Dakota, Ohio, Oregon, 

Pennsylvania, Rhode Island, South 

Carolina, South Dakota, Vermont, Virginia, 

West Virginia, Wisconsin, Wyoming

Internal Revenue Service 

IRS SSA CAWR 

Philadelphia, PA 19255-0533

If your principal place of business is outside the United States, file 

with the Internal Revenue Service, IRS SSA CAWR, Philadelphia, PA 

19255-0533.

Private delivery services. Private delivery services can’t deliver to the 

addresses shown above. If you choose to use a private delivery 

service, send Form 8922 to the address shown below based on the 

location of your principal business, office, or agency.

Internal Revenue Service 

Mail Stop 4-G08 151 

2970 Market St 

Philadelphia, PA 19104

Internal Revenue Service 

5333 Getwell Rd Stop 814 D6 

Memphis, TN 38118

The list of private delivery services that are designated by the IRS are 

provided in Pub. 15. 

Substitute Forms

The IRS accepts quality substitute tax forms that are consistent with 

the official forms and have no adverse impact on our processing. The 

official Form 8922 is the standard for substitute forms. Because a 

substitute form is a variation from the official form, you should know 

the requirements of the official form for the year of use before you 

create a substitute version. For details on the requirements for 

substitute forms, see Pub. 1167.

Specific Instructions

Check box for employer or insurer/agent. Check the appropriate 

box to state whether you’re the employer or the insurer/agent filing 

Form 8922.

Filer’s name. If the Employer box is checked, the employer for whom 

the sick pay was paid by the insurer or agent will complete the 

information with the employer’s name, address, and phone number.

If the Insurer/Agent box is checked, the insurer or agent who paid 

the sick pay will complete the information with the insurer/agent’s 

name, address, and phone number.

Filer’s EIN. If the employer box is checked, enter the EIN of the 

employer.

If the Insurer/Agent box is checked, enter the EIN of the insurer or 

agent.

Other party’s name and EIN. If the Employer box is checked, the 

employer must provide the name and EIN of the insurer or agent. If the 

employer has contracts with more than one insurer or agent, the 

employer must file a separate Form 8922 for the wages and taxes 

related to each contract.

If the Insurer/Agent box is checked, the insurer or agent may, but 

isn’t required to, provide the name and EIN of the employer. If it is 

providing this information, and if it has contracts with more than one 

employer, it must file a separate Form 8922 for the wages and taxes 

related to each employer. Alternatively, it may file a separate Form 

8922 for the wages and taxes related to each employer for which it is 

Form 8922 Cat. No. 37734T IRS.gov/form8922 Department of the Treasury - Internal Revenue Service
Form 8922 (2016) Page 2 

supplying the name and EIN, and then file one Form 8922 for the 

wages and taxes related to the employers for which it isn’t supplying 

the name and EIN.

Box 1. Enter the total amount of sick pay subject to federal income 

tax.

Box 2. Enter the total amount of federal income tax withheld from the 

sick pay.

Box 3. Enter the total amount of sick pay subject to social security 

tax.

Box 4. Enter the total amount of social security tax withheld from the 

sick pay.

Box 5. Enter the total amount of sick pay subject to Medicare tax.

Box 6. Enter the total amount of the Medicare tax (including Additional 

Medicare Tax) withheld from the sick pay.

Corrected Form 8922. If you filed Form 8922 with the IRS and later 

discover that you made an error on it, you must correct it as soon as 

possible. Complete all entries on Form 8922 when making a 

correction. Enter an “X” in the “CORRECTED” checkbox only when 

correcting a Form 8922 previously filed with the IRS.

Recordkeeping. Keep all records of employment taxes for at least 4 

years. These should be available for IRS review.

Privacy Act and Paperwork Reduction Act Notice. We ask for the 

information on this form to carry out the Internal Revenue laws of the 

United States. We need it to figure and collect the right amount of tax. 

Section 6051 and its regulations require you to furnish wage and tax 

statements to employees, the Social Security Administration, and the 

Internal Revenue Service. Section 6109 requires you to provide your 

identification number. Failure to provide this information in a timely 

manner or providing false or fraudulent information may subject you to 

penalties. 

Generally, tax returns and return information are confidential, as 

required by section 6103. However, section 6103 allows or requires 

the Internal Revenue Service to disclose or give the information shown 

on your return to others as described in the Code. For example, we 

may disclose your tax information to the Department of Justice for 

civil and/or criminal litigation, and to cities, states, the District of 

Columbia, and U.S. commonwealths and possessions for use in 

administering their tax laws. We may also disclose this information to 

other countries under a tax treaty, to federal and state agencies to 

enforce federal nontax criminal laws, or to federal law enforcement 

and intelligence agencies to combat terrorism.

You aren’t required to provide the information requested on a form 

that is subject to the Paperwork Reduction Act unless the form 

displays a valid OMB control number. Books or records relating to a 

form or its instructions must be retained as long as their contents may 

become material in the administration of any Internal Revenue law.

The time needed to complete and file this form will vary depending 

on individual circumstances. The estimated burden for business 

taxpayers filing this form is approved under OMB control number 

1545-0123 and is included in the estimates shown in the instructions 

for their business income tax return.

If you have comments concerning the accuracy of these time 

estimates or suggestions for making Form 8922 simpler, we would be 

happy to hear from you. You can send us comments from 

www.irs.gov/formspubs. Click on More Information and then click on 

Give us feedback. Or you can send your comments to Internal 

Revenue Service, Tax Forms and Publications Division, 1111 

Constitution Avenue, NW, IR-6526, Washington, DC 20224. Don’t 

send Form 8922 to this address. Instead, see Where To File, earlier.