Federal Tax Forms for Businesses and Schedule EIC (Form 1040A or 1040) Advance Proof Copies

Transcription

1 Department of the Treasury Internal Revenue Servie Federal Tax Forms for Businesses and Shedule EIC (Form 00A or 00) Advane Proof Copies (Revised August ) IMPORTANT NOTICE Attahed are advane proof opies of Shedule EIC (Form 00A or 00) and the following major and Federal tax forms and shedules for usinesses: Form W-, Wage and Tax Statement () Form W-, Statements of Correted Inome and Tax Amounts (Rev. Nov. ) Form W-, Transmittal of Wage and Tax Statements () Form W-, Transmittal of Correted Inome and Tax Statements (Rev. Nov. ) Form, Employer s Quarterly Federal Tax Return (Rev. Jan. ) Form, Annual Return of Withheld Federal Inome Tax () Form -A, Annual Reord of Federal Tax Liaility (Jan. ) Form 0, U.S. Fiduiary Inome Tax Return () Shedule K- (Form 0) Benefiiary s Share of Inome, Dedutions, Credits, et. () Form 0, U.S. Partnership Return of Inome () Shedule K- (Form 0) Partner s Share of Inome, Credits, Dedutions, Et. () Form 0, U.S. Corporation Inome Tax Return () Form 0-A, U.S. Corporation Short-Form Inome Tax Return () Form 0S, U.S. Inome Tax Return for an S Corporation () Shedule K- (Form 0S) Shareholder s Share of Inome, Credits, Dedutions, et. () Please note these advane proofs are sujet to hange and OMB approval efore eing released for printing later this year. We have irled major hanges to the items in this pakage. If you have suggestions for improving any of these materials, please let us know y Otoer,. Write to: Tax Forms Coordinating Committee, Early Release, Internal Revenue Servie, Room, Constitution Ave., N.W., Washington, DC 0. Although we may e unale to give detailed responses to your omments, eah suggestion will e arefully onsidered efore final versions are issued. If you need additional opies of this pakage, you may all either 0--0 (not a toll-free numer) or -00--TAX-FORM (-00--). You may also write to: Internal Revenue Servie, P.O. Box, Rihmond, VA -. Puliation 0-A (Rev. August ) Cat. No. 0V

2 SCHEDULE EIC (Form 00A or 00) Department of the Treasury Internal Revenue Servie Name(s) shown on return Earned Inome Credit Attah to Form 00A or 00. See Instrutions for Shedule EIC. OMB No. -00 Attahment Sequene No. Your soial seurity numer Want the IRS to figure the redit for you? Just fill in this page. We ll do the rest. General Information To take You must have worked and earned less than $,00, and this redit Your adjusted gross inome (Form 00A, line, or Form 00, line ) must e less than $,00, and Your filing status an e any status exept married filing a separate return, and You must have at least one qualifying hild (see oxes elow), and You annot e a qualifying hild yourself. A qualifying hild is a hild who: Do you have at least one qualifying hild? is your: was (at the end of ): who: son daughter adopted hild grandhild stephild or foster hild No Yes A N D Information Aout Your Qualifying Child or Children under age or under age and a full-time student or any age and permanently and totally disaled August A N D lived with you in the U.S. for more than half of * (or all of if a foster hild*) *If the hild didn t live with you for the required time (for example, was orn in ), see the Exeption on page (00A) or page EIC- (00). You annot take the redit. Enter NO next to line of Form 00A (or line of Form 00). Go to line. But if the hild was married or is also a qualifying hild of another person (other than your spouse if filing a joint return), first see page (00A) or page EIC- (00). If more than two qualifying hildren, see page (00A) or page EIC- (00). (a) Child s name (first, initial, and last name) () Child s year of irth For a hild orn efore, hek if hild was (e) If hild was orn () a student under age at end of (d) disaled (see ooklet) efore, enter the hild s soial seurity numer (f) Child s relationship to you (for example, son, grandhild, et.) (g) Numer of months hild lived with you in the U.S. in Caution: Other Information If a hild you listed aove was orn in and you hose to laim the redit or exlusion for hild are expenses for this hild on Shedule (Form 00A) or Form (Form 00), hek here Do you want the IRS to figure the redit for you? Yes No Fill in lines and ; and enter the amount from Form 00A, line, or Form 00, line, here. $ Go to page on the ak now. Enter any nontaxale earned inome (see page (00A) or page EIC- (00)) suh as military housing and susistene or ontriutions to a 0(k) plan. Also, list type and amount here. Enter the total amount you paid in for health insurane that overed at least one qualifying hild. See instrutions If you want the IRS to figure the redit for you: S T O P Attah this shedule to your return. If filing Form 00A, print EIC on the line next to line. If filing Form 00, print EIC on the dotted line next to line. For Paperwork Redution At Notie, see Form 00A or 00 instrutions. Cat. No. M Shedule EIC (Form 00A or 00)

3 Shedule EIC (Form 00A or 00) Figure Your Basi Credit Enter the amount from line of Form 00A or Form 00. If you reeived a taxale sholarship or fellowship grant, see instrutions Enter any nontaxale earned inome (see page (00A) or page EIC- (00)) suh as military housing and susistene or ontriutions to a 0(k) plan. Also, list type and amount here. Form 00 Filers Only: If you were self-employed or used Sh. C or C-EZ as a statutory employee, enter the amount from the worksheet on page EIC- Earned inome. Add lines,, and. If $,00 or more, you annot take the redit. Enter NO next to line of Form 00A (or line of Form 00) Use line aove to find your redit in TABLE A on pages and 0 (00A) or pages EIC- and (00). Enter here 0 Adjusted gross inome. Enter the amount from Form 00A, line, or Form 00, line Is line $,00 or more? YES. Use line to find your redit in TABLE A on pages and 0 (00A) or pages EIC- and (00). Enter here August NO. Go to line. Basi redit: If you answered YES to line 0, enter the smaller of line or line 0. If you answered NO to line 0, enter the amount from line. Next: To take the health insurane redit, fill in lines. To take the extra redit for a hild orn in, fill in lines. Otherwise, go to line 0 now. Figure Your Health Insurane Credit Use line aove to find your redit in TABLE B on page (00A) or page EIC- (00). Enter here Is line aove $,00 or more? 0 Page YES. Use line to find your redit in TABLE B on page (00A) or page EIC- (00). Enter here NO. Go to line. If you answered YES to line, enter the smaller of line or line. If you answered NO to line, enter the amount from line. Enter the total amount you paid in for health insurane that overed at least one qualifying hild. See instrutions Health insurane redit. Enter the smaller of line or line Figure Your Extra Credit for Child Born in Take this redit only if you did not take the redit or exlusion for hild are expenses on Shedule or Form for the same hild. TIP: You an take oth the asi redit and the extra redit for your hild orn in. Use line aove to find your redit in TABLE C on page (00A) or page EIC- (00). Enter here Is line aove $,00 or more? YES. Use line to find your redit in TABLE C on page (00A) or page EIC- (00). Enter here NO. Go to line. Extra redit for hild orn in : If you answered YES to line, enter the smaller of line or line. If you answered NO to line, enter the amount from line. Figure Your Total Earned Inome Credit 0 Add lines,, and. Enter the total here and on Form 00A, line (or on Form 00, line ). This is your total earned inome redit 0 Want the earned inome redit added to your take-home pay in? To see if you an, get Form W- from your TIP: employer or y alling the IRS at

4 a d e f Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name (first, middle initial, last) Employee s address and ZIP ode Void For Offiial Use Only OMB No August Statutory employee Wages, tips, other ompensation Soial seurity wages Advane EIC payment Deeased Pension plan Legal rep. 0 emp. Federal inome tax withheld Soial seurity tax withheld Alloated tips Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Mediare wages and tips Soial seurity tips Nonqualified plans See Instrs. for ox Mediare tax withheld Dependent are enefits Benefits inluded in ox Other Form W- Wage and Tax Statement Copy A For Soial Seurity Administration Cat. No. 0D Department of the Treasury Internal Revenue Servie For Paperwork Redution At Notie, see separate instrutions. Do NOT Cut or Separate Forms on This Page

5 a d e Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name, address, and ZIP ode OMB No August Statutory employee Wages, tips, other ompensation Soial seurity wages Mediare wages and tips Soial seurity tips Advane EIC payment Nonqualified plans Deeased Pension plan Legal rep. 0 emp. Federal inome tax withheld Soial seurity tax withheld Mediare tax withheld Alloated tips Dependent are enefits Benefits inluded in ox Other Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Form W- Wage and Tax Statement Copy For State, City, or Loal Tax Department Department of the Treasury Internal Revenue Servie

6 a d e Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name, address, and ZIP ode OMB No August Statutory employee Wages, tips, other ompensation Soial seurity wages Mediare wages and tips Soial seurity tips Advane EIC payment Nonqualified plans Deeased Pension plan Legal rep. 0 See Instrs. for ox emp. Federal inome tax withheld Soial seurity tax withheld Mediare tax withheld Alloated tips Dependent are enefits Benefits inluded in ox Other Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Form W- Copy B To Be Filed With Employee s FEDERAL Tax Return Department of the Treasury Internal Revenue Servie Wage and Tax Statement This information is eing furnished to the Internal Revenue Servie.

7 a d e Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name, address, and ZIP ode OMB No August This information is eing furnished to the Internal Revenue Servie. If you are required to file a tax return, a negligene penalty or other santion may e imposed on you if this inome is taxale and you fail to report it. Statutory employee Wages, tips, other ompensation Soial seurity wages Advane EIC payment Deeased Pension plan Legal rep. 0 emp. Federal inome tax withheld Soial seurity tax withheld Alloated tips Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Mediare wages and tips Soial seurity tips Nonqualified plans See Instrs. for ox Mediare tax withheld Dependent are enefits Benefits inluded in ox Other Form W- Wage and Tax Statement Copy C For EMPLOYEE S RECORDS (See Notie on ak.) Department of the Treasury Internal Revenue Servie

8 Notie to Employee: Refund. Even if you do not have to file a tax return, you should file to get a refund if ox shows Federal inome tax withheld, or if you an take the earned inome redit. Earned Inome Credit. You must file a tax return if any amount is shown in ox. For, if your inome is less than $XX,XXX, you may qualify for an earned inome redit (EIC). If you have one or more qualifying hildren, you may qualify for an EIC up to $X,XXX. Beginning in, if you are age to, annot e laimed as a dependent y someone else, and reside in the United States for more than months, you may qualify for the EIC. Any EIC that is more than your tax liaility is refunded to you, ut ONLY if you file a tax return. For example, if you have no tax liaility and qualify for a $00 EIC, you an get $00, ut only if you file a tax return. If you have one qualifying hild, you may get as muh as $X,XXX of the EIC in advane y ompleting Form W-. The instrutions for Forms 00 and 00A, and Pu., explain the EIC in detail. You an get forms, instrutions, and puliations y alling toll-free -00-TAX-FORM (-). Corretions. If your name, soial seurity numer, or address is inorret, orret Copies B, C, and and ask your employer to orret your employment reord. Be sure to ask the employer to file Form W-, Statement of Correted Inome and Tax Amounts, with the Soial Seurity Administration (SSA) to orret any name, amount, or numer error reported to the SSA on Copy A of the Form W-. If your name and numer are orret ut are not the same as shown on your soial seurity ard, you should ask for a new ard at any Soial Seurity offie. Credit for Exess Taxes. If more than one employer paid you wages during and more than the maximum soial seurity employee tax, railroad retirement (RRTA) tax, or omined soial seurity and RRTA tax was withheld, you may laim the exess as a redit against your Federal inome tax. See your inome tax return instrutions. Box. Enter this amount on the wages line of your tax return. Box. Enter this amount on the Federal inome tax withheld line of your tax return. Box. This amount is not inluded in oxes,, or. For information on how to report tips on your tax return, see the instrutions for Form 00, 00A, or 00EZ. Box. Enter this amount on the advane earned inome redit payment line of your tax return. Box 0. This amount is the total dependent are enefits your employer paid to you (or inurred on your ehalf). Any amount over $,000 has een inluded in ox. Part or all of this amount may e taxale unless you omplete Shedule of Form 00A or Form. See the instrutions for Forms 00 and 00A. August Box. Any amount in ox is a distriution made to you from a nonqualified deferred ompensation or setion plan. This amount is inluded in ox and/or oxes and. Box. This amount is inluded in ox. If there is an amount in ox, you may e ale to dedut expenses that are related to fringe enefits; see the instrutions for your tax return. Box. Any amount in ox should e oded (letter). The following list explains the odes. You may need this information to omplete your tax return. A Unolleted soial seurity tax on tips (see Total tax in Form 00 instrutions) B Unolleted Mediare tax on tips (see Total tax in Form 00 instrutions) C Cost of group-term life insurane overage over $0,000 D Eletive deferrals to a setion 0(k) ash or deferred arrangement E Eletive deferrals to a setion 0() salary redution agreement F Eletive deferrals to a setion 0(k)() salary redution SEP G Eletive and noneletive deferrals to a setion () deferred ompensation plan H Eletive deferrals to a setion 0()()(D) tax-exempt organization plan (see Form 00 instrutions for how to dedut) J Sik pay not inludile as inome K Tax on exess golden parahute payments L Nontaxale part of employee usiness expense reimursements M Unolleted soial seurity tax on ost of group-term life insurane overage over $0,000 (former employees only) (see Form 00 instrutions) N Unolleted Mediare tax on ost of group-term life insurane overage over $0,000 (former employees only) (see Form 00 instrutions) Box. If the Pension plan ox is marked, speial limits may apply to the amount of IRA ontriutions you may dedut. If the Deferred ompensation ox is marked, the eletive deferrals in ox (for all employers, and for all suh plans to whih you elong) are generally limited to $,. Eletive deferrals for setion 0() ontrats are limited to $,00 ($,00 in limited irumstanes, see Pu. ). The limit for setion () plans is $,00. Amounts over that must e inluded in inome. See instrutions for Form 00. Caution: The eletive deferral dollar limitation of $, is sujet to hange for.

9 a d e Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name, address, and ZIP ode OMB No August Statutory employee Wages, tips, other ompensation Soial seurity wages Advane EIC payment Deeased Pension plan Legal rep. 0 emp. Federal inome tax withheld Soial seurity tax withheld Alloated tips Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Mediare wages and tips Soial seurity tips Nonqualified plans Mediare tax withheld Dependent are enefits Benefits inluded in ox Other Form W- Wage and Tax Statement Copy To Be Filed With Employee s State, City, or Loal Inome Tax Return Department of the Treasury Internal Revenue Servie

10 a d e Control numer Employer s identifiation numer Employer s name, address, and ZIP ode Employee s soial seurity numer Employee s name, address, and ZIP ode OMB No August Statutory employee Wages, tips, other ompensation Soial seurity wages Mediare wages and tips Soial seurity tips Advane EIC payment Nonqualified plans Deeased Pension plan Legal rep. 0 See Instrs. for Form W- emp. Federal inome tax withheld Soial seurity tax withheld Mediare tax withheld Alloated tips Dependent are enefits Benefits inluded in ox Other Sutotal Deferred ompensation State Employer s state I.D. No. State wages, tips, et. State inome tax Loality name 0 Loal wages, tips, et. Loal inome tax Form W- Copy D For Employer Wage and Tax Statement Department of the Treasury Internal Revenue Servie For Paperwork Redution At Notie, see separate instrutions.

11 Cat. No. D a d h Please do not staple. CHANGES Year/Form orreted Void OMB No For Offiial / Use Only Employee s name, address, and ZIP ode Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax e k Employer s SSA numer Legal rep. Employee s inorret SSN (a) As previously reported Employer s name, address, and ZIP ode August f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. See ak of Copy D for instrutions and the Paperwork Redution At Notie. Form W- (Rev. -) Correted Def d. omp. IRA/SEP i g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information Statement of Correted Inome and Tax Amounts Correted j Employer s use () Inrease (derease) Copy A For Soial Seurity Administration Department of the Treasury Internal Revenue Servie Do NOT Cut or Separate Forms on This Page

12 a Year/Form orreted Void OMB No / Employee s name, address, and ZIP ode Correted Employer s name, address, and ZIP ode Correted d h CHANGES Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax Form W- (Rev. -) e k Employer s SSA numer Legal rep. Def d. omp. IRA/SEP i Employee s inorret SSN (a) As previously reported f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. August g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information Statement of Correted Inome and Tax Amounts j Employer s use () Inrease (derease) Copy For State, City, or Loal Tax Department Department of the Treasury Internal Revenue Servie

13 a Year/Form orreted Void OMB No / Employee s name, address, and ZIP ode Correted Employer s name, address, and ZIP ode Correted d h CHANGES Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax Form W- (Rev. -) e k Employer s SSA numer Legal rep. Def d. omp. IRA/SEP i Employee s inorret SSN (a) As previously reported f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. August g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information Statement of Correted Inome and Tax Amounts j Employer s use () Inrease (derease) Copy B To Be Filed With Employee s FEDERAL Tax Return Department of the Treasury Internal Revenue Servie

14 a Year/Form orreted Void OMB No / Employee s name, address, and ZIP ode Correted Employer s name, address, and ZIP ode Correted d h CHANGES Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax Form W- (Rev. -) e k Employer s SSA numer Legal rep. Def d. omp. IRA/SEP i Employee s inorret SSN (a) As previously reported f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. August g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information Statement of Correted Inome and Tax Amounts j Employer s use () Inrease (derease) Copy C For Employee s Reords Department of the Treasury Internal Revenue Servie

15 a Year/Form orreted Void OMB No / Employee s name, address, and ZIP ode Correted Employer s name, address, and ZIP ode Correted d h CHANGES Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax Form W- (Rev. -) e k Employer s SSA numer Legal rep. Def d. omp. IRA/SEP i Employee s inorret SSN (a) As previously reported f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. August g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information j Employer s use () Inrease (derease) Copy To Be Filed With Employee s State, City, or Loal Inome Tax Return Department of the Treasury Internal Revenue Servie Statement of Correted Inome and Tax Amounts

16 a Year/Form orreted Void OMB No / Employee s name, address, and ZIP ode Correted Employer s name, address, and ZIP ode Correted d h CHANGES Employee s orret SSN Previously reported Complete k and/or l only if inorret on the last form you filed. Show inorret item here. Stat. emp. Deeased Deeased Form W- ox Wages, tips, other omp. Pension plan Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax 0 Loal wages, tips, et. Loal inome tax Form W- (Rev. -) e k Employer s SSA numer Legal rep. Def d. omp. IRA/SEP i Employee s inorret SSN (a) As previously reported f Correted l Employer s Federal EIN Stat. emp. - Pension plan Legal rep. August g Employer s state I.D. numer Def d. omp. IRA/SEP Employee s name (as inorretly shown on previous form) () Corret information Statement of Correted Inome and Tax Amounts j Employer s use () Inrease (derease) Copy D For Employer Department of the Treasury Internal Revenue Servie

17 DO NOT STAPLE a Control numer Total numer d Estalishment numer of statements f g h Kind of Payer Employer s name e Employer s address and ZIP ode Other EIN used this year CT- Military Employer s identifiation numer For Offiial Use Only OMB No Mediare govt. emp. August Wages, tips, other ompensation Soial seurity wages Mediare wages and tips Soial seurity tips Advane EIC payments Nonqualified plans 0 Alloated tips Adjusted total soial seurity wages and tips Adjusted total Mediare wages and tips Inome tax withheld y third-party payer Federal inome tax withheld Soial seurity tax withheld Mediare tax withheld Dependent are enefits Deferred ompensation i Employer s state I.D. No. Under penalties of perjury, I delare that I have examined this return and aompanying douments, and, to the est of my knowledge and elief, they are true, orret, and omplete. Signature Telephone numer Please return this entire page with Copy A of Forms W- to the Soial Seurity Administration address for your state as listed elow. Household employers filing Forms W- for household employees should send the forms to the Aluquerque Data Operations Center. You may order forms y alling -00-TAX-FORM (-00--). Title Form W- Transmittal of Wage and Tax Statements General Instrutions Where To File If your legal residene, prinipal plae of usiness, offie, or ageny is loated in ( ) Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Minnesota, Missouri, Montana, Neraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wisonsin, Wyoming Alaama, Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Mississippi, New Mexio, Oklahoma, South Carolina, Tennessee, Texas Connetiut, Delaware, Distrit of Columia, Indiana, Kentuky, Maine, Maryland, Massahusetts, Mihigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia If you have no legal residene or prinipal plae of usiness in any state Use this address Soial Seurity Administration Data Operations Center Salinas, CA Soial Seurity Administration Data Operations Center Aluquerque, NM 0 Soial Seurity Administration Data Operations Center Wilkes-Barre, PA Soial Seurity Administration Data Operations Center Wilkes-Barre, PA Cat. No. 0Y Date Department of the Treasury Internal Revenue Servie Note: Extra postage may e neessary if the report you send ontains more than a few pages or if the envelope is larger than letter size. Paperwork Redution At Notie We ask for the information on this form to arry out the Internal Revenue laws of the United States. You are required to give us the information. We need it to ensure that you are omplying with these laws and to allow us to figure and ollet the right amount of tax. The time needed to omplete and file this form will vary depending on individual irumstanes. The estimated average time is minutes. If you have omments onerning the auray of this time estimate or suggestions for making this form more simple, we would e happy to hear from you. You an write to oth the Internal Revenue Servie, Attention: Reports Clearane Offier, T:FP, Washington, DC 0; and the Offie of Management and Budget, Paperwork Redution Projet (-000), Washington, DC 00. Do NOT send the form to either of these offies. Instead, see Where To File. Items To Note Change to Kind of Payer Box. The /E lael was hanged to eause Form E, Quarterly Return of Withheld Federal Inome Tax and Mediare Tax, is osolete for payments made after Deemer,. New Form, Annual Return of Withheld Federal Inome Tax, is used to report inome tax withholding on pensions, annuities, IRAs, gamling winnings, and akup withholding shown on Forms 0 and W-G. State and loal government employers must file Form. See Cirular E, Employer s Tax Guide, for details. Information Reporting Call Site. The IRS operates a entralized all site to answer questions aout reporting on Forms W-, W-, 0 and other information returns. If you have questions related to reporting on information returns, you may all (0) -00 (not a toll-free numer). Purpose of Form. This form (Copy A) is a transmittal for Copy A of Forms W-. Page (Your Copy) should e kept for your reords along with Copy D of Form W-.

18 a Control numer OMB No Kind of Payer Total numer d Estalishment numer of statements f g h Employer s name e Employer s address and ZIP ode Other EIN used this year CT- Military Employer s identifiation numer Mediare govt. emp. August Wages, tips, other ompensation Soial seurity wages Mediare wages and tips Soial seurity tips Advane EIC payments Nonqualified plans 0 Federal inome tax withheld Soial seurity tax withheld Mediare tax withheld Alloated tips Adjusted total soial seurity wages and tips Adjusted total Mediare wages and tips Inome tax withheld y third-party payer Dependent are enefits Deferred ompensation i Employer s state I.D. No. Form W- Transmittal of Wage and Tax Statements Department of the Treasury Internal Revenue Servie Note: Amounts reported on related employment tax forms (W-,,, or ) should agree with the amounts reported on Form W-. If there are differenes, you may e ontated y the IRS. You should retain your reoniliation for future referene. See Reoniling Forms W-, W-, and on page. Sustitute Forms. Employers filing privately printed Forms W- must file Forms W- that are the same width as Form W-. The forms must meet the requirements in Pu.. Who Must File. Employers and other payers must file Form W- to send Copy A of Forms W-. Use Form W- for the urrent year. A transmitter or sender (inluding a servie ureau, paying agent, or disursing agent) may sign Form W- for the employer or payer only if the sender:. Is authorized to sign y an ageny agreement (either oral, written, or implied) that is valid under state law; and. Writes For (name of payer) next to the signature. If an authorized sender signs for the payer, the payer is still responsile for filing, when due, a orret and omplete Form W- and related Forms W-, and is sujet to any penalties that result from not omplying with these requirements. Be sure the payer s name and employer identifiation numer (EIN) on Forms W- and W- are the same as those used on the Form,, or filed y or for the payer. A household employer is not required to file a Form W- if filing a single Form W-. If you uy or sell a usiness during the year, see Rev. Pro. -, - C.B., for details on who should file the employment tax returns. Page When To File. File Form W-, with Copy A of Forms W-, y Feruary,. You may e penalized if you do not inlude the orret information on the return or if you file the return late. Extension To File. You may request an extension of time to file y sending Form 0, Request for Extension of Time To File Information Returns, to the address shown on that form. You must request the extension efore the due date of the returns for your request to e onsidered. See Form 0 for more details. Magneti Media Reporting. If you file 0 or more Forms W-, you must report on magneti media. You may e harged a penalty if you fail to file on magneti media when required. If you are filing Forms W- using magneti media, you will need Form, Transmitter Report and Summary of Magneti Media, and you may also need Form -A, Continuation Sheet for Form... If you file on magneti media, do not file the same returns on paper. You an get magneti media reporting speifiations y ontating any of the Soial Seurity Magneti Media Coordinators. Call -00-SSA- for a phone numer of the oordinator in your area, or you may also write to the Soial Seurity Administration, Attn: Resumittal Group, -E-0 NB, Metro West, P.O. Box, Baltimore, MD. Using a personal omputer and a modem, you an get information on magneti media filing from eletroni Bulletin Board System (BBS) through either the SSA-BBS or the IRP-BBS(IRS). You an aess the SSA-BBS y dialing (0) - or the IRP-BBS(IRS) y dialing (0) -. A waiver an e requested on Form 0, Request for Waiver From Filing Information Returns on Magneti Media. This form must e sumitted to the IRS days efore the due date of the return. Get Form 0 for filing information. Shipping and Mailing. If you file more than one type of employment tax form, please group Forms W- of the same type and send them in separate groups. See the speifi instrutions for ox. Please do not staple or tape Form W- to the related Forms W-. These forms are mahine read, and staple holes or tears ause the mahine to jam. If you have a large numer of Forms W- to send with one Form W-, you may send them in separate pakages. Show your name and EIN on eah pakage. Numer them in order ( of, of, et.) and plae Form W- in pakage. Show the numer of pakages at the ottom of Form W- elow the title. If you mail them, you must send them First-Class. Making Corretions. Use Form W-, Transmittal of Correted Inome and Tax Statements, to make orretions to a previously filed Form W-. Speifi Instrutions This form is imaged and harater reognized y mahines, so please type entries if possile. Send the whole first page of Form W- with Copy A of Forms W-. Make all dollar entries without the dollar sign and omma ut with the deimal point ( ). The following instrutions are for oxes on the form. If any entry does not apply to you, leave it lank. Household employers, see the instrutions for Form. Thirdparty payers of sik pay, see Pu., Sik Pay Reporting. Box a Control numer. This is an optional ox whih you may use for numering the whole transmittal.

19 Box Kind of Payer. Mark the hekox that applies to you. Mark only one ox. If you have more than one type, send eah with a separate Form W-.. Mark this ox if you file Form, Employer s Quarterly Federal Tax Return, and no other ategory applies. Military. Mark this ox if you are a military employer sending Forms W- for memers of the uniformed servies.. Mark this ox if you file Form, Employer s Annual Tax Return for Agriultural Employees, and you are sending forms for agriultural employees. For nonagriultural employees, send their Forms W- with a separate Form W-. CT-. Mark this ox if you are a railroad employer sending Forms W- for employees overed under the Railroad Retirement Tax At (RRTA). Do NOT show employee RRTA tax in oxes through. These oxes are ONLY for soial seurity and Mediare information. If you also have employees who are sujet to soial seurity and Mediare taxes, send eah group s Forms W- with a separate Form W-. Mark the ox of the Form W- used to send the Forms W- for employees sujet to soial seurity and Mediare taxes.. Mark this ox if you are a household employer sending Forms W- for household employees. If you also have employees who are not household employees, send eah group s Forms W- with a separate Form W-. Mediare government employee. Mark this ox if you are a U.S., state, or loal ageny filing Forms W- for employees sujet only to the.% Mediare tax. See Government Employers in the Instrutions for Form W- for additional information. Box Total numer of statements. Show the numer of ompleted individual Forms W- you are transmitting. Do not ount void or sutotal statements. Box d Estalishment numer. You may use this ox to identify separate estalishments in your usiness. You may use any four-digit numer to identify them. You may file a separate Form W-, with Forms W-, for eah estalishment even if they all have the same EIN; or you may use a single Form W- for all Forms W-. Box e Employer s identifiation numer. Enter the nine-digit numer assigned to you y the IRS. The numer should e the same as shown on your Form,, or and in the following format: Do not use an earlier owner s EIN. See Box h elow. If availale, use the lael sent to you with Pu. that shows your name, address, and EIN. Plae the lael at the top of ox f in the spae provided. Use of the lael speeds proessing. Make any neessary orretions on the lael. If you do not have an EIN when filing your Form W-, enter Applied For in ox e, not your soial seurity numer. Box f Employer s name. This entry should e the same as that shown on your Form,, or. If availale, use the lael sent to you with Pu.. Box g Employer s address and ZIP ode. If availale, use the lael sent to you with Pu.. Make any neessary orretions on the lael. See Box e. Box h Other EIN used this year. If you have used an EIN (inluding a prior owner s EIN) on Form,, or sumitted for that is different from the EIN reported on Form W- in ox e, enter the other EIN used. Box i Employer s state I.D. numer. This numer is assigned y individual states where your usiness is loated. You may want to omplete this ox if you use opies of this form for your state returns. If reporting for two states, keep eah I.D. numer separated y the roken line. Boxes through 0 Enter the totals reported in oxes through 0 on Forms W- eing transmitted. Box Nonqualified plans. Enter the total amount of nonqualified plan and setion plan distriutions reported in ox on Forms W-. Do not show a ode. Box Deferred ompensation. Enter the total of the amounts with odes D-H reported in ox on Forms W-. The amounts you should report are for 0(k), 0(), 0(k)(), (), and 0()()(D) plans. Do not inlude setion (f) plans. Do not list eah plan separately. Report these amounts as one lump sum on Form W- without a ode. Box Adjusted total soial seurity wages and tips. The amount reported in this ox in most ases should e the total soial seurity wages and soial seurity tips reported to the IRS on your Forms,, or for. To get to the adjusted total of soial seurity wages and soial seurity tips, you must take into aount any urrent year adjustments in soial seurity wages and tips shown on Form (or ),, or. Do not inlude prior year adjustments in the adjusted total for the urrent year. If this amount does not math the total of the amounts shown in oxes and, you should determine why there is a disrepany and keep reord of it. See Reoniling Forms W-, W-, and. August Box Adjusted total Mediare wages and tips. Generally, the amounts reported in this ox should agree with the total Mediare wages and tips reported to the IRS on Forms,, or for. See Box aove for more information. If this amount does not math the amount shown in ox, Mediare wages and tips, you should determine why and keep reord of it. Box Inome tax withheld y third-party payer. Complete this ox if you have employees who had inome tax withheld on third-party payments of sik pay. Show the total inome tax withheld y third-party payers on payments to all your employees. Although this tax is inluded in the ox total, it must e separately shown here. Sik Pay. Sik pay paid to an employee y a third-party, suh as an insurane ompany or trust, requires speial treatment at year-end eause the IRS reoniles an entity s Forms with the Forms W- and W- filed. If the third-party payer does not notify the employer aout sik pay payments, the third-party payer should prepare Forms W- and W- with respet to the employee. See Pu.. Reoniling Forms W-, W-, and When there are disrepanies etween amounts reported on Forms filed with the IRS and Forms W- and W- filed with the SSA, we must ontat you to resolve the disrepanies. This osts time and money, oth for the Government and for you the employer. To eliminate errors that an ause disrepanies. Report onuses as wages and as soial seurity and Mediare wages on Forms W- and.. Report oth soial seurity and Mediare wages and taxes separately on Forms W-, W-, and.. Report soial seurity taxes on Form W- in the ox for soial seurity tax withheld, not as soial seurity wages.. Report Mediare taxes on Form W- in the ox for Mediare tax withheld, not as Mediare wages.. Make sure soial seurity and Mediare wage amounts for eah employee do not exeed the annual soial seurity and Mediare wage ases.. Do not report nonash wages not sujet to soial seurity or Mediare taxes as soial seurity or Mediare wages. To redue the disrepanies etween amounts reported on Forms W-, W-, and Form. Be sure the amounts on Form W- are the total amounts from Forms W-.. Reonile Form W- with your four quarterly Forms y omparing amounts reported for Soial seurity wages, soial seurity tips, and Mediare wages and tips. The amounts may not math if, for example, you made adjustments for the urrent year on Form. In this ase, the amounts reported in oxes and of Form W- should inlude Form adjustments only for the urrent year (i.e., if the Form adjustments inlude amounts for a prior year, do not report those adjustments on the urrent year Forms W- and W-). Soial seurity taxes and Mediare taxes. The amounts shown on the four quarterly Forms inluding urrent year adjustments should e approximately twie the amounts shown on Form W-. Advane earned inome redit. Amounts reported on Forms W-, W-, and may not math for valid reasons. If they do not math, you should determine that the reasons are valid. Keep your reoniliation in ase there are inquiries from the IRS or the SSA. Page

20 Please do not staple. a Year/Form orreted OMB No For Offiial / Use Only Employer s name, address, and ZIP ode Correted d e Numer of Forms W- Estalishment numer Employer s Federal EIN f Kind of payer / E Complete i only if inorret on the last form you filed. Show the inorret item here. i CT- Military Employer s inorret Federal EIN Mediare gov t. emp. j Se. g Inorret estalishment numer Employer s state I.D. numer h Employer s SSA no. (see instrutions) k Employer s inorret SSA numer CHANGES Form W- ox Wages, tips, and other ompensation Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax (a) Total of amounts entered in olumn (a) on attahed Forms W- () Total of orret information reported on attahed Forms W- August () Inrease (derease) 0 Loal wages, tips, et. Loal inome tax Explain dereases here Has an adjustment een made on an employment tax return filed with the Internal Revenue Servie? If Yes, give date the return was filed Under penalties of perjury, I delare that I have examined this return, inluding aompanying douments, and to the est of my knowledge and elief, it is true, orret, and omplete. Yes No Signature ( ) Telephone numer Title Form W- (Rev. -) Transmittal of Correted Inome and Tax Statements For Paperwork Redution At Notie, see other side. Cat. No. 0R Date Department of the Treasury Internal Revenue Servie

21 a Year/Form orreted OMB No / Employer s name, address, and ZIP ode Correted d Numer of Forms W- Estalishment numer e Employer s Federal EIN f Kind of payer / E Complete i only if inorret on the last form you filed. Show the inorret item here. i CT- Military Employer s inorret Federal EIN Mediare gov t. emp. j Se. g Inorret estalishment numer Employer s state I.D. numer h Employer s SSA no. (see instrutions) k Employer s inorret SSA numer CHANGES Form W- ox Wages, tips, and other ompensation Federal inome tax withheld Soial seurity wages Soial seurity tax withheld Mediare wages and tips Mediare tax withheld Soial seurity tips Alloated tips State wages, tips, et. State inome tax (a) Total of amounts entered in olumn (a) on attahed Forms W- () Total of orret information reported on attahed Forms W- August () Inrease (derease) 0 Loal wages, tips, et. Loal inome tax Explain dereases here Has an adjustment een made on an employment tax return filed with the Internal Revenue Servie? If Yes, give date the return was filed Yes No Form W- (Rev. -) Transmittal of Correted Inome and Tax Statements Department of the Treasury Internal Revenue Servie

22 Form (Rev. January ) Department of the Treasury Internal Revenue Servie Enter state ode for state in whih deposits made (see page of instrutions). If address is different from prior return, hek here IRS Use Employer s Quarterly Federal Tax Return See separate instrutions for information on ompleting this return. Name (as distinguished from trade name) Trade name, if any Address (numer and street) Please type or print. Date quarter ended Employer identifiation numer August If you do not have to file returns in the future, hek here and enter date final wages paid If you are a seasonal employer, see Seasonal employers on page and hek here (see instrutions) Numer of employees (exept household) employed in the pay period that inludes Marh th Total wages and tips sujet to withholding, plus other ompensation Total inome tax withheld from wages, tips, and sik pay Adjustment of withheld inome tax for preeding quarters of alendar year City, state, and ZIP ode OMB No. -00 T FF FD FP I T Adjusted total of inome tax withheld (line as adjusted y line see instrutions) a Taxale soial seurity wages $.% (.) = Taxale soial seurity tips $.% (.) = Taxale Mediare wages and tips $.% (.0) = Total soial seurity and Mediare taxes (add lines a,, and ). Chek here if wages are not sujet to soial seurity and/or Mediare tax Adjustment of soial seurity and Mediare taxes (see instrutions for required explanation) Sik Pay $ ± Frations of Cents $ ± Other $ = 0 Adjusted total of soial seurity and Mediare taxes (line as adjusted y line see instrutions) a 0 Total taxes (add lines and 0) Advane earned inome redit (EIC) payments made to employees, if any Net taxes (sutrat line from line ). This should equal line, olumn (d) elow (or line D of Shedule B (Form )) Total deposits for quarter, inluding overpayment applied from a prior quarter Balane due (sutrat line from line ). Pay to Internal Revenue Servie Overpayment, if line is more than line, enter exess here $ and hek if to e: Applied to next return OR Refunded. Monthly depositors: Complete line, olumns (a) through (d) and hek here Semiweekly depositors: Complete Shedule B and hek here All filers: If line is less than $00, you need not omplete line or Shedule B. Monthly Summary of Federal Tax Liaility. (a) First month liaility () Seond month liaility () Third month liaility (d) Total liaility for quarter Sign Here Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Print Your Signature Name and Title Date For Paperwork Redution At Notie, see page of separate instrutions. Cat. No. 00Z Form (Rev. -)

23 Form Department of the Treasury Internal Revenue Servie Enter state ode for state in whih deposits made (See page of instrutions). If address is different from prior return, hek here IRS Use Annual Return of Withheld Federal Inome Tax See Cirular E for more information onerning inome tax withholding. Name (as distinguished from trade name) Trade name, if any Address (numer and street) Please type or print. Taxpayer identifiation numer August City, state, and ZIP ode OMB No. -00 IRS USE ONLY T FF FD FP I T If you do not have to file returns in the future, hek here Date final payments paid Federal inome tax withheld from pensions, annuities, gamling, et. Bakup withholding (see instrutions) Total taxes (add lines and ) Total deposits for from your reords Balane due (sutrat line from line ). Pay to the Internal Revenue Servie A B C D E If line is less than line, enter overpayment here $ and hek if to e: Applied to next return OR Refunded Monthly Summary of Federal Tax Liaility. If line is less than $00, you need not omplete this setion day, do not omplete the lines A-M elow. Instead, attah Form -A and hek here (see instrutions) (line ). If you are a monthly depositor, summarize your monthly tax liaility elow. If you are a semiweekly The total tax liaility for the year (line M) should depositor or have aumulated $00,000 or more on any equal total taxes (line ) aove. January Feruary Marh April May Sign Here Tax liaility for month F G July H I J K L M Total liaility for year (add lines A through L) Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Signature June August Septemer Otoer Print Your Name and Title Tax liaility for month Novemer Deemer Date Tax liaility for month For Paperwork Redution At Notie, see page. Cat. No. B Form ()

24 Form -A (January ) Department of the Treasury Internal Revenue Servie Annual Reord of Federal Tax Liaility OMB No. xxxx-xxxx Expires x-xx-xx Name as shown on Form Taxpayer identifiation numer January tax liaility Feruary tax liaility August (a) Total for month () Total for month April tax liaility May tax liaility (d) Total for month (e) Total for month Marh tax liaility 0 0 () Total for month June tax liaility (f) Total for month 0 0 Cat. No. M Form -A (-)

25 Form -A (-) July tax liaility August tax liaility August (g) Total for month (h) Total for month Otoer tax liaility Novemer tax liaility (j) Total for month (k) Total for month Septemer tax liaility 0 0 (i) Total for month Deemer tax liaility 0 (l) Total for month 0 0 (m) Total liaility for year (add lines (a) through (l). This should equal line on Form Page

26 Department of the Treasury Internal Revenue Servie 0 U.S. Fiduiary Inome Tax Return For the alendar year or fisal year eginning,, and ending, Form OMB No. -00 A Type of Entity Name of estate or trust (grantor type trust, see instrutions) C Employer identifiation numer Inome Dedutions Please attah hek or money order here Tax and Payments Deedent s estate Simple trust Complex trust Grantor type trust Bankrupty estate Chpt. Bankrupty estate Chpt. Please Sign Here Paid Preparer s Use Only Name and title of fiduiary Numer, street, and room or suite no. (If a P.O. ox, see page of instrutions.) August D E Nonexempt haritale and splitinterest trusts, hek appliale oxes (see instrutions): Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Delaration of preparer (other than fiduiary) is ased on all information of whih preparer has any knowledge. Signature of fiduiary or offier representing fiduiary Preparer s signature Firm s name (or yours if self-employed) and address For Paperwork Redution At Notie, see page of the separate instrutions. Date Date EIN of fiduiary (see instrutions) Chek if selfemployed E.I. No. ZIP ode Date entity reated Pooled inome fund Desried in setion (a)() B Numer of Shedules K- attahed (see City, state, and ZIP ode Not a private foundation instrutions) Desried in setion (a)() F Chek G Pooled mortgage aount (see instrutions) appliale Initial return Final return Amended return oxes: Change in Fiduiary s Name Address Bought Sold Date: Interest inome Dividends Business inome or (loss) (attah Shedule C or C-EZ (Form 00)) Capital gain or (loss) (attah Shedule D (Form 0)) Rents, royalties, partnerships, other estates and trusts, et. (attah Shedule E (Form 00)) Farm inome or (loss) (attah Shedule F (Form 00)) Ordinary gain or (loss) (attah Form ) Other inome (state nature of inome) Total inome (omine lines through ) 0 Interest. (Chek if Form is attahed ) 0 Taxes Fiduiary fees Charitale dedution (from Shedule A, line ) Attorney, aountant, and return preparer fees a Other dedutions NOT sujet to the % floor (attah shedule) a Allowale misellaneous itemized dedutions sujet to the % floor Total (add lines 0 through ) Adjusted total inome or (loss) (sutrat line from line ). Enter here and on Shedule B, line Inome distriution dedution (from Shedule B, line ) (see instrutions) (attah Shedules K- (Form 0)) Estate tax dedution (inluding ertain generation-skipping taxes) (attah omputation) 0 Exemption 0 Total dedutions (add lines through 0) Taxale inome of fiduiary (sutrat line from line ) Total tax (from Shedule G, line ) Payments: a estimated tax payments and amount applied from return a Estimated tax payments alloated to enefiiaries (from Form 0-T) Sutrat line from line a d Tax paid with extension of time to file: Form Form Form 00 d e Federal inome tax withheld e Credits: f Form ; g Form ; h Other ; Total i Total payments (add lines through e, and i) Penalty for underpayment of estimated tax (see instrutions) Tax Due. If line is smaller than the total of lines and, enter amount owed Overpayment. If line is larger than the total of lines and, enter amount overpaid Amount of line to e: a Credited to estimated tax ; Refunded Preparer s soial seurity no. Cat. No. 0H Form 0 ()