Year/Form corrected OMB No. 1545-0008 For Official

Use Only ©

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

For Privacy Act/Paperwork Reduction Act Notice, see separate instructions. Copy A For Social Security Administration

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Cat. No. 61437D

Corrected Name

Do NOT Cut, Staple, or Separate Forms on This Page – Do NOT Cut, Staple, or Separate Forms on This Page

a Void

b c

i

/ W-2

Hshld.

emp.
Year/Form corrected OMB No. 1545-0008

/ W-2

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

Copy 1 For State, City, or Local Tax Department

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Corrected Name

a Void

b c

i Hshld.

emp.
Year/Form corrected OMB No. 1545-0008

/ W-2

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

Copy B To Be Filed With Employee’s FEDERAL Tax Return

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Corrected Name

a Void

b c

i Hshld.

emp.
Year/Form corrected OMB No. 1545-0008

/ W-2

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

Copy C For Employee’s Records

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Corrected Name

a Void

b c

i Hshld.

emp.
Notice to Employee

This is a corrected Form W-2, Wage and Tax

Statement, (or Form W-2AS, W-2CM, W-2GU, or

W-2VI) for the tax year shown in box a. If you

have filed an income tax return for the year

shown, you may have to file an amended return.

Compare amounts on this form with those

reported on your income tax return. If the

corrected amounts change your U.S. income tax,

file Form 1040X, Amended U.S. Individual

Income Tax Return, with Copy B of this Form

W-2c to amend the return you already filed.

If boxes h or i have any checkboxes marked,

box h will show the original information and box i

will show the corrected information.

For more information, contact your nearest

Internal Revenue Service office. Employees in

American Samoa, Commonwealth of the Northern

Mariana Islands, Guam, or the U.S. Virgin Islands

should contact their local taxing authority for

more information. If you have not filed your return for the year

shown in box a, attach Copy B of the original

Form W-2 you received from your employer and

Copy B of this Form W-2c to your return when

you file it.
Year/Form corrected OMB No. 1545-0008

/ W-2

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

Copy 2 To Be Filed With Employee’s State, City, or Local Income Tax Return

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Corrected Name

a Void

b c

i Hshld.

emp.
Year/Form corrected OMB No. 1545-0008

/ W-2

Employee’s name, address, and ZIP code Employer’s name, address, and ZIP code

d Employee’s correct SSN e Employer’s SSA number f Employer’s Federal EIN g Employer’s state I.D. number

69-

Complete k and/or l only if

incorrect on the last form you

filed. Show incorrect item here.

k Employee’s incorrect SSN l Employee’s name (as incorrectly shown on previous form) ©

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Def’d.

comp.

Legal

rep.

Pension

plan

DeceasedStat.

emp.

Previously

reported

h Corrected © j Hshld.

emp. © Employer’s use

Form W-2 box (a) As previously reported (b) Correct information (c) Increase (decrease)

1

2 Federal income tax withheld

Wages, tips, other comp.

3

4 Social security tax withheld

Social security wages

Social security tips

5 Medicare wages and tips

6

7

Medicare tax withheld

8

CHANGES

Allocated tips

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Local income tax

Copy D For Employer

Department of the Treasury Form W-2c Internal Revenue Service (Rev. 1-99) Corrected Wage and Tax Statement

Corrected Name

a Void

b c

i Hshld.

emp.

For Privacy Act/Paperwork Reduction Act Notice, see separate instructions.
Employer’s, Please Note—

Specific information needed to complete Form

W-2c is given in the separate Instructions for

Forms W-2c and W-3c (January 1999). You can

order those instructions and additional forms by

calling 1-800-TAX-FORM (1-800-829-3676). You

can also get forms and instructions from the

IRS’s Internet Web Site at www.irs.ustreas.gov.