1 Year and Form being corrected

2 Employer's use

ooo

Oo OO

Oo O08 68 OO

9
Previously, at ‘De Pension Lega! Oet's Medicare Stat De- Pension Del d Medicare
3 Praviousty, Stat De Pension Legal Dele Medicare yaaysee | 4 Corrected Slat D2. Pension LegsDerd Medicare ypaystp | OMB No 1545-0008

Oo Expires 1-31.93

‘5 Employee's correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

8 Employer's state /.D. number

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

Incorrect on the last form you

Compiete 11 and/or 12 only if )
filed. Show incorrect item here.

11 Employee's incorrect SSN

12 Employee's name (:

correctly shown on previous form)

Item

(@) As Previously Reported

(b) Correct Information

(¢) Increase (decrease)

13 Social secunty wages

14 Social secunty tips

15 Social secuntty tax withheld

16 Wages, tips, other comp.

17 Federal income tax withheld

18 Allocated tips

19a

19b

19¢

CHANGES

20__ Gross annuity, etc. (W-2P)

21_Taxable amount (W-2P)

22_ State wages

23 _ State tax withheld

24 Local wages

25 Local tax withheld

Copy B tobe filled with employee's FEDERAL tax return

Form W-2c (Rev. 8.90) Statement of Corrected Income and Tax Amounts

rtment of the Treasury
Infarel Revenue Sece

1. Year and Form being corrected

2 Employer's use

9
2 RSG oe aie Se SET ae | 4 comer STG pea Ge mnaer | omnia ssi
oooood o O O8 0 Oo Expres 131-85

5 Employee's correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

'& Employer's state I.D. number

‘9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

‘Complete 11 and/or 12 only if
Incorrect on the last form you »
filed. Show incorrect item here.

11 Employee's incorrect SSN

12. Employee's name (as incorrectly shown on previous form)

(a) As Previously Reported

(b) Correct Information

(©) Increase (decrease)

13 Social secunty wages

34 Social secunty tips.

15 Social security tax withheld

16 _ Wages, tips, other comp.

17 Federal income tax withheld

18 Allocated tips

CHANGES

20 Gross annuity, etc. (W-2P)

21 Taxable amount (W-2P)

22 State wages

23. State tax withheld |

24 Local wages

25 _Localtaxwithheld

Copy B to be filled with employee's FEDERAL tax return
Department;

Form W-2c (Rev.8-90) Statement of Corrected Income and Tax Amounts

of the Treasury
Internal Revenue Service



Instructions for Preparing
Form W-2c

Paperwork Reduction Act Notice. —We ask for the
information on this form to carry out the Internal Revenue
Saws of the United States. You are required to gve us the
umformation. We need it to ensure that you are complying
with thase laws and to allow us to figure and collect the
Tight amount of tax,

‘The time needed to complete and file this form wit
vary depending on individual circumstances. The
estimated average time 1s 49 minutes. f you have
comments concerning the accuracy of this time estimate
or suggestions for making this form more simple, we
‘would be happy to hear {rom you. You can write to both
the Internal Revenue Service, Washingtun, DC 20224,
Attention: IRS Reports Clearance Officer, T.FP, and the
Giles of Management and Budget, Paperwork
Reduction Project (1545-0008), Washington, DC 20503.
DO NOT sen this tax form to either of thess offices.
Instead, see the instructions below for information on
where to file.

Purpose of Form.—-Form W-2c is used by an
employer (or other payer. in the case of Form
W-2P)to correct errors on previously filed
Forms W-2, W-2P. W-2AS, W-2CM, W-2GU. or
W-2VI, Use a separate Form W-3c, Transmittal
of Corrected Income and Tax Statements, to
transmit Forms W-2c for each type of form
shown in item 1,

Note: Section 218 filers (certain state and
local government employers) should follow the
instructions received from their State Social
Security Administrator in preparing corrections
for years before 1987.

HowTo ‘When making corrections for
more than one employee, you must use a Form
W-3c. A single Form W-2c may be submitted
without Form W-3c. If you are only correcting
‘the employees’ names or social security
numbers (SSN) on more than one Form W-2c,
do not file Form W-3c, Advise your employees
to correct their social security number and/or
‘ame an their original Form W-2.

Whare To File.—Copy A of Form W-2e should
beled with the Social Security Administration
(SSA). See "Where To Fil

"in the instructions

Instructions for Preparing
Form W-2c

Paperwork Reduction Act Notice. —We ask for the
information on this form to carry out the Internai Revenue
aws of the United States. You are required to give us the
information, We need it to ensure that you are complying
with these laws and to allow us to figure and collect the
right amount of tax.

‘The time needed to complete and file this form will
‘ary depending on individual circumstances. The
(estimated average time is 49 minutes. Ifyou have
‘comments concerning the accuracy ofthis time estimate
‘or suggestions for making this farm more simple, we
would be happy to hear from you. You can write to both
the internal Revenue Service, Washington, DC 20224,
Attention: (RS Reports Clearance Officer, T:FP, and the
Office of Management and Budget, Paperwork
Reduction Project (1545-0008), Washington, DC 20503.
00 NOT send this tax form to sither of these offices.
Instead, see the instructions below for information on
where to file
Purpose of Form.—Form W-2c is used by an
employer (or other payer. in the case of Form
W-2P) to correct errors on previously filed
Forms W-2, W-2P. W-2AS, W-2CM, W-2GU, or
W-2VI. Use a separate Form W-3c, Transmittal
of Corrected income and Tax Statements, to
‘transmit Forms W-2c for each type of form
Shown in item 1.

Note: Section 218 filers (certain state and
focal government employers) shouid follow the
instructions received from their State Social
Security Administrator in preparing corrections
tor years before 1987.

How To Fi

When making corrections for
more than one employee, you must use a Form
W.3c. A single Form W-2c may be submitted
without Form W-3c. If you are only correcting
the employees’ names or social security
numbers (SSN) on more than one Form W-2c,
do nat file Form W-3c. Advise your emptoyees:
to correct their social security number and/or
name on their original Form W-2.

Where To File.—Copy A of Form W-2c should
be filed with the Social Security Administration
(SSA). See "Where To File” in the instructions

for Form W-3c. File the remaining cépies of
W.2c as noted on the bottom of each form.
How To Complete Form W-2c.—For
descriptions of individual items, see the
instructions for Forms W-2 and W-2P.
Complete items 1-10 as applicable. For items
11-25, complete only those items that are
being corrected. Otherwise, leave biank.

If any item shows a dollar change, and one of
the amounts is zero, enter “zero” or "0. Do
not leave blank. Negative amounts in column
(©) (decreases) must be shown in parentheses.

Form W-2c 1s six part form You may use
carbon paper to make copies. If using carbon
paper. please make sure all copies are legible.
Correcting More Than One Form W-2c for an
Employee.—if you are fing for an individual
who was issued more than one Form W-2
under the same employer identification
number (EIN) for the year being corrected, you
should take into account ali of the Forms W-2
when determining the amounts to be entered
on the Form W-2c.

EXAMPLE: Two Forms W-2 were filed for Mary
Smith for tax year 1988 under the same EIN
One form reported social security wages of
$30,000 and the second form reported social
security wages of $20,000. A Form W-2c filed
to change $30,000 to $25,000 should show
$30: in column (a) and $45,000 in column
(b).

you are correcting Medicare wage
payments, military, or reserve pay, you must
use a separate Form W-2c. Do rot combine
these payments with regular social security
wage payments.
Item 1—Year Being Corracted/Type of
Form, —Enter the year this Form W-2c is
correcting and the type of Form W-2 you are
correcting.
Item 2—Employer's use.—This is an optional
item that employers may use to identify
individual forms.
Itams 3 and 4.—Complete items 3 and 4 only
if you are making corrections to these items If
you ara, check the boxas in item 3 as they were
hacked on the original Form W-2. In tem 4,

for Form W-3c. File the remaining copies of
W-2c as noted on the bottom of each form.
How To Complete Form W-2c.—For
descriptions of individual items, see the
instructions for Forms W-2 and W-2P.
Complete items 1-10 as applicable. For items
11-25, complete anly those items that are
being corrected. Otherwise, eave bank,

If any stem shows a dollar change, and one of
the amounts is zero, enter “zero” or “0. Do
not leave biank. Negative amounts in column
(c) (decreases) must be shown in parentheses.

Form W-2c 1s a six part form. You may use
carbon paper to make copies. If using carbon
Daper. please make sure all copies are legible.
Correcting More Than One Form W-2c for an
Emptoyee.—it you are filing for an individual
who was issued more than one Form W-2
under the same employer identification
‘umber (EIN) for the year being corrected, you
should take into account aii of the Forms W-2
when determining the amounts to be entered
‘on the Form W-2c,

EXAMPLE: Two Forms W-2 were filed for Mary
‘Smith for tax year 1988 under the same EIN.
‘One form reported social security wages of
$30,000 and the second form reported social
security wages of $20,000. A Form W-2c fied
to change $30,000 to $25,000 should show
ie in column (a) and $45,000 in column
(b).

{if you are correcting Medicare wage
payments, military, or reserve pay, you must
use a separate Form W-2c. Do net combine
these payments with regular social security

wage payments.
Type of
nter the year this Form W-2c Is

correcting andthe type of Form W-2 you are
correcting.

Item 2—Employer’s use.—This is an optional
item that employers may use to identify
individual forms,

Items 3 and 4.—Complete items 3 and 4 only
i¥ you are making corrections to these items. I
you are, check the boxes in item 3.as they were
checked on’the original Form W-2.In item 4,

check the boxes as they should have been
checked. Any box checked in error on the
origina! should be left blank in item 4. For
example: you erroneously checked the pension
plan box on the original Form W-2, In item 3,
you would check the pension plan box. In item
4, the pension plan box should not be checked.

Item 6—Employer's SSA number.—This isa
number beginning with “69- that is assigned
to certain state or local government employers
for use for years before 1987. Also add the *L”
indicator, coverage group and/or PRU number,
if these have been assigned to you by SSA.
item 8—Emptoyer's state 1.0.
number.—You are not required to complete
this ttem. This number is assigned by the
individual states, You may want to complete
this item if you use copies of this form for your
state returns.

{tems 11 and 12.—Compiete items 11 and/or
12 only if you wish to correct an employee's
‘SSN or name. If the previously reported money
amounts were correct, you should not enier
them on Form W-2c.

Items 13-25—Changes:—Enter in Column
(a) the amount reported on the original Form
W-2. Enter in Column (b) the correct amount.
Enter in Column (c) the difference between
Columns (a) and (b). Show any decrease in
parentheses.

Hems 19a~19¢.—Use these lines to correct
the following, advance earned income credit
payments, taxabie fringe benefits, deferred
Compensation (including nonqualified plan and
section 457 distributions), dependent care
benatits, cost of group term ife insurance
coverage over $50,000, and distribution codes
shown in Box 24 of Form W-2P for years before
1991. Be sure to tabel each item.

Items 22~25—State or local data.—If your
ONLY changes to the original Form

W-2 are to state or local dats, DO NOT send
Form W-2c to SSA.

‘check the boxes as they should have been
checked. Any box checked in error on the
original should be left blank in item 4, For
‘example: you erroneously checked the pension
plan box on the original Form W-2. In item 3,
you would check the pension plan box, In item
4, the pension plan box should not be checked,
item 6—Employer's SSA number.—This is a
number beginning with "69-" that i

to certain state or local government employers
for use for years before 1987, Also add the
indicator. coverage group and/or PRU number,
if these have been assigned to you by SSA.
Item 8—Employer's state |.D.
fumber.—You are not required to complete
this item. This number is assigned by the
individual states. You may want to complete
this item if you use copies of this farm for your
state returns.

{tems 11 and 12.—Compiete items 11 and/or
12 only if you wish to correct an employee's
SSN or name. If the previously reported moriey
amounts were correct, you should not enter
them on Form W-2¢.

Items 13-25—Changes.—Enter in Column
(a) the amount reported on the original Form
W-2, Enter in Column (b) the catrect amount,
Enter in Column (c) the difference between
Columns (a) and (b). Show any decredse in
parentheses.

Items 19a-19¢.—Use these lines to correct
the following: advance earned income credit
payments, taxable fringe benefits, deferred
compensation (including nonqualified pian and
section 457 distributions), dependent care
benefits, cost of group life insurance
coverage over $50,000, and distribution codes
‘shown in Box 14 of Form W-2P for years before
1991, Be sure to label each item.

items 22-25—State or local data.—If your
ONLY changes to the original Form

W-2 are to state or local data, OO NOT send
Form W-2c to SSA.



1 Year and Form being corrected 2 Employer's use

97

Previously, Sat De Penson Lagat bef d Medicare
3 Reported” emp. ceased plan” rep. comp "emp. RA/SEP

OO O60 6 0 0

4 Correctad» St3t

De- Pension Legal Def'¢ Medicare
emp ceased plan rep. comp emp

O00 00 0

IRA/SEP | OMBNo 1545-0008
o Expires 1-31-93

5 Employee's correct SSN 6 Employer's SSA number

7 Employer's Federal E1N

8 Employer's state! D. number

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

11 E ree's i ‘SSN
fa, 12 ont mployee's incorrect SS

Complete 11 and/or 12 only if
Incorreet dn the y
rect item here.

filed. Show i

12. Employee's name (as incorrectly shown on previous form)

tram (a) As Previously Reported

(0) Correct Information

(c) Increase. (decrease)

13 Socialsecunty wages

14 Social security'tips

15° Social security tak withheld

16 Wages, tips, other tomp

17 _Federal income tax withheld

18 Allocated tips

19a

19d

19

CHANGES

20 Gross annuity, etc. (W-2P)

21__Taxable amount (W-2P)

22. State wages

23 State tax withheld

24 Local wages

25__Local tax withheld

Copy C for oc employee's records

Form W-2c¢ (Rev.8-90) Statement of Corrected Income and Tax Amounts

iment of the Treasury
Intgra’ Revenue Sees

1 Year and Form being corrected
19 /

2 Employer's use

Previously, Stat ‘De- Pension Legal Oef'd Medicare
3 Reported”TM emp ceased “plan” rep. comp emp. IRA/SEP

0 OO O

4 Corrected» Stat:

De. Pension Legal Defd Meduare
mp. ceased plan” rep comp. emp

OO 0 O00 0

IRA/SEP | OMB No, 1545-0008
o Expires 1-31-93

5 Employee's correct SSN 6 Employer's SSA number

7 Employer's Federal EIN

& Employer's state ILD number

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

Complete 1 anda I2onlyif "
21 ef Zonly » 11 Employee's incorrect SSN

fies, Show Incorrect itery here.

12 Employee's name (as incorrectly shown on previous form)

Item (@) As Previously Reported

(b) Correct information

(©) Increase (decr

13 Social security wages

14 Sotial security tips

15 Social sécurity tax withheld

16 Wages, tips; other comp.

17 _Federal income tax withheld

18 Allocated tips

198

19

CHANGES

19¢

20 Gross annuity, etc (W-2P)

21__ Taxable amount (W-2P)

22 State wages _

23. State tax withheld

24 Local wages

25 _Local tax withheld

Copy C for employee's records.

Form W-2c (Rev. 8.99) Statement of Corrected Income and Tax Amounts





Year and Form being corrected

19 /

2 Employer's use

3 Previously, Stat De.

Reported "emp. ceased plan

Pension Legal Dera Medicare
SD comp. emp IRASEP

O oO O 0

& Corrected Stat Oe:
"9

Pension LegalDefe
ceased plan rep. comp.

O 00 OO OO

Meaicare
lecicare payseP

‘OMB No. 1545-0008
oO Expires 1-31-93

@

Employee's correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

8 Employer’s state I.D. number

9 Employee's name, address, and ZIP code

10 Employer's name, address, and Z'P code

‘Complete 11 and/or 12 only if
incorrect on the last form you »
filed. Show incorrect item here.

11 Employee's incorrect SSN

12 Employee's name (as incorrectly shown on previous form)

Item

(a) As Previously Reported

(>) Correct Information

(©) Increase (decrease)

13 Social security wages

14 Social security tips

15 Social security tax withheld

16 Wages, tips, other comp.

17 _ Federal income tax withheld

18 Allocated tips

19a

19b

19¢

CHANGES

20 _ Gross annurty, etc. (W-2P)

21 Taxable amount (W-2P)

22_State wages

23 State tax withheld

24 Local wages

25 _Local tax withheld

Form W-2¢ (Rev.8-90) Statement of Corrected Income and Tax Amounts

Copy D for employer
Deparnet of he Hans
Internal Revenue Seren

1 Year anc Form being corrected 2 Employer's use
19 /
Previously, Stat De Pension Tegal Del'd Medicare rractedp Stat De Pension LogalDetd Medicare
3 Reported” emp. cease plan rep. comp "emp RA/SEP | 4 Correctedy oo ooasey Tian” rep. comp. emp. A/SEP | OMB No. 1545-0008
OO O00 0 G6 oo | Bees 1-31-93
5 Employee's correct SSN 6 Employer's SSA number 7 Employer's Federal EIN 8 Employer's state !.D. number

©

Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

‘Complete 11 and/or 12 only if
Incorrect on the last form you >
filed. Show Incorrect item here.

11 Employee's incorrect SSN

12 Employee's name (as incorrectly shown on previous form)

Item.

(a) As Previously Reported

(b) Correct Information

(€) Increase (decrease)

13, Social security wages

14 Social security tips

15 Social secutity tax withheld

16 Wages, tips, other comp.

17 Federal income tax withheld

18 Allocated tips

198

CHANGES

19¢

20 Gross annutty, etc. (W-2P)

21._Taxable amount (W-2P)

22 State wages

23 State tax withheld

24 Local wages

25 _Local tax withheld

Form W-2c (Rev. 8.90) Statement of Corrected Income and Tax Amounts



1 Year and Form being corrected

9 oy

2 Employer's use

For Officiat
Use Only >

3 Previously, Stat.
Reported ” emp.

oO Oo 0 O

De- Pension Legal Def'd Medicare
ceased plan” rep. comp. emp. 'RA/SEP

oO

‘Stat.
4 Corrected Stat

ceased plan rep. comp. emp.

OO DO a

De Pension Legal Ded Medicare pa/sep

(OMB No, 1545-0008
o Expires 131-93

5 Employee's correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

‘8 Employer's state .D. number

Please do not staple

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

Complete 11 and/or 12 only if
Incorrect onihe ast iormyou
filed. Show incorrect item here.

11 Employees incorrect SSN

12. Employee's name (as incorrectly shown on previous form)

tem

(2) As Previously Reported

(b) Correct Information

(¢) Increase (decrease)

13. Social security wages

14 Social security tips

15. Sociat security tax withheld

16 Wages, tips, other comp.

17 _ Federal income tax withheld

18 Allocated tips

19a

19

CHANGES

19

20 _Gross annuity, etc. (W-2P)

21_Taxable amount (W-2P)

22_State wages

23 _ State tax withheld

24 Local wages

25 _Local tax withheld

‘See back of Copy D for instructions and the Paperwork Reduction Act Notice,

Form W-2¢ (Rev.8-90) Statement of Corrected Income and Tax Amounts

Copy A for Social Security Administration

Department of the Treasury
Internal Revenue Service

1 Year and Form being corrected
19 f

2 Employer's use

For Official
Use Only >

3 Previous, Stat De
Reported P emp ceased plan rep

Pension Legal Ded Medicare
Cord Medicare RayseP

ia

4 Corrected» Sta

Bit De: Person Loge! Dat Medicare
emp ceased plan rep comp,

O 0 O08 OO

imaysep | OMB No. 1545-0008
o Expires 1-31-93,

5 Empioyee’s correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

8 Employer's state ILD. number

Please do not staple

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

Complete 11 and/or 12 only if
Compre Taser ani
filed. Show Incorrect item here.

11 Employee's incorrect SSN

12 Employee's name (as incorrectly shown on previous form)

Item

(a) As Previously Reported

(b) Correct Information

(c) Increase (decrease)

security wages

secunty tips

15. Social secunty tax withheld

16 Wages, tips, other comp.

[17 Federal income tax withheld

18 Allocated tips
19a

19

CHANGES

19¢

20 Gross annuity, ete. (W-2P)

21__Taxable amount (W-2P)

22 State wages

23 _ State taxwithheld

| 24 Local wages

25 Local tax withheld

‘See back of Copy D for instructions and the Paperwork Reduction Act Notice.

Form W-2c (Rev.8.99) Statement of Corrected Income and Tax Amounts

Copy A for Social Security Administration

nt ofthe Treasury
Ievernal Revenue Sernce



Notice to Employee

This is a corrected version of the Form W-2 shown in
Box 1 on the front of this form. If you have already
filed an income tax return for the year shown in Box
1, you may-have to file an amended income tax return
for that year Compare information reported on this
form with amounts reported on your income tax
return; If the corrected amounts change your income
tax liability, file Form 1040X and attach a copy of this
Form W-2c to amend your previously filed return.

If you have not yet filed an income tax return for
the year shown in Box 1, attach a copy of the original
Form W-2 that you received from your employer,
along with a copy of this Form W-2c to your return.

If Boxes 3 or 4 have any checkboxes marked, Box 3
will show how it was reported originally and Box.4 will
show the corrections. If there are-any corrections that
will change your tax liability, file Form 1040x.

For more information, contact your nearest Internal
Revenue office. Employees in American Samoa,
Guam, Commonwealth of the Northern Mariana
Istands, or the Virgin Istands should contact their local
taxing authority for more information.

Notice to Employee

This is a corrected version of the Form W-2 shown in
Box 1 on the front of this form. If you have already
filed an income tax return for the year shown in Box
1, you may have to file an amended ihcome tax return
for that year Compare information reported on this
form with amounts reported on your income tax
return. If the corrected amounts change your income
tax liability, file Form 1040X and attach a copy of this
Form W-2c to amend your previously filed return.

If you have not yet filed an income tax return for
the year shown in Box 1, attach a copy of the original
Form W-2 that you received from your employer,
along with a copy of this Form W-2c to your return.

If Boxes 3 or 4 have any checkboxes marked, Box 3
will show how it was repérted.originally and Box 4 will
show.the corrections. If there are any corrections that
‘will change your tax liability, file Form 1040X.

For more information, contact your nearest Internal
Revenue office. Employees in American Samoa,
Guam, Commonwealth of the Northern Mariana
Islands, or the Virgin Islands,should contact their local
taxing-authority for more information.




1 Year and Form being corrected
19 /

2 |

3 Prom, Sot De Pension Usgat Der d: Mecrare pa/seP 4 Corrected Sat aiid Ver ero RAYSEP | OMB No. 1545-0008
OOOO O80 0 O00 O00 0 OO | Bishis

5 Employee's correct SSN

6 Employer's SSA number

7 Employer's Federal EIN

8 Employer's state ILD. number

9 Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

‘Complete 11 and/or 12 only if
Incerrect onine ast formyeu
filed. Show Incorrect item here.

11 Employee's incorrect SSN

12. Empioyee’s name (as incorrectly shown on previous form)

Item

(a) As Previously Reported

(b) Correct Information (©) Increase (decrease)

13 Social security wages

14 Social security tips

15 Social secunty tax withheld

16 Wages, tips, other comp.

17 Federal income tax withheld

18 Allocated tsps

19a

19>

CHANGES

19¢

20 Gross annuity, etc. (W-2P)

21 Taxable amount (W-2P)

22 _ State wages

23 State tax withheld

24 Local wages

25 Local tax withheld

Form W-2¢ (Rev.8.90) Statement of Corrected Income and Tax Amounts

Copy 1 for state, ety, or local tax department
Department of the Treasury
torernal Revenue Service

‘5 Employee's correct SSN

6 Employer's SSA number
69-

1 Year and Form being corrected 2 Employersuse
19. t
3 Report” ome. ooned pan fek) came. Namp' WASEP | 4 Corrected oo Glan” op: can emg RNSEP | OMB Mo 15455008
Oaoo 8 O ia] ou O OD _ | Sowestais
8

‘Employer's state 1.D. number

(3) Employee's name, address, and ZIP code

10 Employer's name, address, and ZIP code

Paella be trig helt rape 11 Employee's Incorrect SSN 12 Employee's name (2s incorrectty shown on previous form)
filed. Show incorrect item here. _
Item {a) As Previously Reported (6) Correct Information {6} Increase (decrease)

13 _ Social security wages

14 Social security tips

15 Social security tax withheld

16 Wages, tips, other comp.

17 _Federal income tax withheld

18 Allocated tips

19b

19¢

CHANGES

20 Gross annuity, etc. (W-2P)

21 Taxable amount (W-2P)

22 _ State wages

23 State tax withheld

24 Local wages

25 Local tax withheld

Copy 1 for state, city, or local tax department
Department ofthe Treasury

Form W-2¢ (Rev.8.90) Statement of Corrected Income and Tax Amounts tntoensl Bower