Attention:

This form is provided for informational purposes and should not be reproduced on personal computer printers by individual

printed using special paper, special inks, and within precise specifications.

taxpayers for filing. The printed version of this form is "machine readable" form. As such, it must be designed as a

Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.

The printed version of the form may be obtained by calling 1-800-TAX-FORM (1-800-829-3676). Be sure to order using the IRS form or publication number.

a Control number

22222

Void

For Official Use Only

OMB No. 1545-0008

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

$

$

c Employer’s name, address, and ZIP code

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

$

$

e	Employee’s first name and initial

Last name

12a See instructions for box 12

eodC

$

12b

eodC

$

f Employee’s address and ZIP code

14 Other

12c

eodC

$

12d

deoC

$

15 StateEmployer’s state ID number

16State wages, tips, etc.

17 State income tax

18 Local wages, tips, etc.

19 Local income tax

20 Locality name

$

$

$

$

$

$

$

$

W- 2

Wage and Tax

2

3

Department of the Treasury—Internal Revenue Service

Form

Statement

(99)

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Copy A For Social Security Administration—Send this entire page with Form W-3 to the Social Security Administration; photocopies are not acceptable.

Cat. No. 10134D

Do Not Cut, Fold, or Staple Forms on This Page

—

Do Not Cut, Fold, or Staple Forms on This Page

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3Social security wages		4	Social security tax withheld
$	
$				
5	Medicare wages and tips		6	Medicare tax withheld		
$				$			
7Social security tips		8	Allocated tips		
$		$		

11Nonqualified plans		
$				
13 Statutory	Retirement	Third-party	
	employee	plan	sick pay	
	□	□	□	

a Control number

22222

OMB No. 1545-0008

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

		

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

e	Employee’s first name and initial

Last name

f Employee’s address and ZIP code

14 Other

12c

eodC

12d

eodC

W- 2

Wage and Tax

2

0

0

3

Department of the Treasury—Internal Revenue Service

Form

Statement

Copy 1 For State, City, or Local Tax Department

3Social security wages

4	Social security tax withheld

5	Medicare wages and tips

6	Medicare tax withheld

7Social security tips

8	Allocated tips

11Nonqualified plans

employee

plan

sick pay

Third-party

13 Statutory

Retirement

	12a		
	eodC		
	12b		
	eodC		

15	StateEmployer’s state ID number	16State wages, tips, etc.	17 State income tax	18 Local wages, tips, etc.	19 Local income tax	20 Locality name	

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□

a Control number

Safe, accurate,

Visit the IRS Web Site

OMB No. 1545-0008

FAST! Use

at www.irs.gov.

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

		

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

e	Employee’s first name and initial

Last name

f Employee’s address and ZIP code

14 Other

W- 2

Wage and Tax

2

0

0

3

Department of the Treasury—Internal Revenue Service

Form

Statement

Copy B To Be Filed with Employee’s FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service.

3Social security wages

4	Social security tax withheld

5	Medicare wages and tips

6	Medicare tax withheld

7Social security tips

8	Allocated tips

11Nonqualified plans

employee

plan

sick pay

Third-party

13 Statutory

Retirement

	12a See instructions for box 12	
	eodC		
	12b		
	eodC		

12c		
eodC		
12d		
eodC		

15	StateEmployer’s state ID number	16State wages, tips, etc.	17 State income tax	18 Local wages, tips, etc.	19 Local income tax	20 Locality name	

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Notice to Employee

Clergy and religious workers. If you are not subject to social security and Medicare taxes, see Pub. 517, Social Security and Other Information for Members of the Clergy and Religious Workers.

Refund. Even if you do not have to file a tax return, you should file to get a refund if box 2 shows Federal income tax withheld, or if you can take the earned income credit.

Earned income credit (EIC). You must file a tax return if any amount is shown in box 9.

Corrections. If your name, SSN, or address is incorrect, correct Copies B, C, and 2 and ask your employer to correct your employment record. Be sure to ask the employer to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security Administration (SSA) to correct any name, SSN, or money amount error reported to the SSA on Form W-2. If your name and SSN are correct but are not the same as shown on your social security card, you should ask for a new card at any SSA office or call 1-800-772-1213.

You may be able to take the EIC for 2003 if: (a) you do not have a qualifying child and you earned less than $11,230 ($12,230 if married filing jointly), (b) you have one qualifying child and you earned less than $29,666 ($30,666 if married filing jointly), or (c) you have more than one qualifying child and you earned less than $33,692 ($34,692 if married filing jointly). You and any qualifying children must have valid social security numbers (SSNs). You cannot claim the EIC if your investment income is more than $2,600. Any EIC that is more than your tax liability is refunded to you, but only if you file a tax return. If you have at least one qualifying child, you may get as much as $1,528 of the EIC in advance by completing Form W-5, Earned Income Credit Advance Payment Certificate, and giving it to your employer.

Credit for excess taxes. If you had more than one employer in 2003 and more than $5,394.00 in social security and/or Tier 1 railroad retirement (RRTA) taxes were withheld, you may be able to claim a credit for the excess against your Federal income tax. If you had more than one railroad employer and more than $3,160.50 in Tier 2 RRTA tax was withheld, you also may be able to claim a credit. See your Form 1040 or 1040A instructions and Pub. 505, Tax Withholding and Estimated Tax.

(Also see Instructions on back of Copy C.)

a Control number

OMB No. 1545-0008

This information is being furnished to the Internal Revenue Service. If you are required to file a tax return, a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it.

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

		

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

e	Employee’s first name and initial

Last name

f Employee’s address and ZIP code

14 Other

W- 2

Wage and Tax

2

0

0

3

Department of the Treasury—Internal Revenue Service

Form

Statement

Safe, accurate,

Copy C For EMPLOYEE’S RECORDS. (See Notice to Employee on back of Copy B).

FAST! Use

3Social security wages

4	Social security tax withheld

5	Medicare wages and tips

6	Medicare tax withheld

7Social security tips

8	Allocated tips

11Nonqualified plans

employee

plan

sick pay

Third-party

13 Statutory

Retirement

	12a See instructions for box 12	
	eodC		
	12b		
	eodC		

12c		
eodC		
12d		
eodC		

15	StateEmployer’s state ID number	16State wages, tips, etc.	17 State income tax	18 Local wages, tips, etc.	19 Local income tax	20 Locality name	

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Instructions (Also see Notice to Employee on back of Copy B.)

D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also includes deferrals under a SIMPLE retirement account that is part of a section

Box 1. Enter this amount on the wages line of your tax return.

Box 2. Enter this amount on the Federal income tax withheld line of your tax return.

401(k) arrangement.

E—Elective deferrals under a section 403(b) salary reduction agreement

Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on how to report tips on your tax return, see your Form 1040 instructions.

F—Elective deferrals under a section 408(k)(6) salary reduction SEP

Box 9. Enter this amount on the advance earned income credit payments line of your Form 1040 or 1040A.

G—Elective deferrals and employer contributions (including nonelective deferrals)

to a section 457(b) deferred compensation plan

Box 10. This amount is the total dependent care benefits your employer paid to you or incurred on your behalf (including amounts from a section 125 (cafeteria plans)). Any amount over $5,000 also is included in box 1. You must complete Schedule 2 (Form 1040A) or Form 2441, Child and Dependent Care Expenses, to compute any taxable and nontaxable amounts.

H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan (see  Adjusted Gross Income in the Form 1040 instructions for how to deduct)

J—Nontaxable sick pay (not included in boxes 1, 3, or 5)

K—20% excise tax on excess golden parachute payments (see Total Tax in

the Form 1040 instructions)

Box 11. This amount is: (a) reported in box 1 if it is a distribution made to you from a nonqualified deferred compensation or nongovernmental section 457 plan or (b) included in box 3 and/or 5 if it is a prior year deferral under a nonqualified or section 457 plan that became taxable for social security and Medicare taxes this year because there is no longer a substantial risk of forfeiture of your right to

L—Substantiated employee business expense reimbursements (nontaxable) M—Uncollected social security or RRTA tax on taxable cost of group-term life insurance over $50,000 (former employees only) (see Total Tax in the Form

1040 instructions)

the deferred amount.

N—Uncollected Medicare tax on taxable cost of group-term life insurance over $50,000 (former employees only) (see Total Tax in the Form 1040 instructions) P—Excludable moving expense reimbursements paid directly to employee (not

Box 12. The following list explains the codes shown in box 12. You may need this information to complete your tax return. Elective deferrals (codes D, E, F, G, H, and S) under all plans are generally limited to $12,000 ($15,000 for section 403(b) plans, if you qualify for the 15-year rule explained in Pub. 571). However, if you were at least age 50 in 2003, your employer may have allowed an additional deferral of up to $2,000 ($1,000 for section 401(k)(1 1) and 408(p) SIMPLE plans). This additional deferral amount is not subject to the overall limit on elective deferrals. For code G, the limit on elective deferrals may be higher for the last 3 years before you reach retirement age. Contact your plan administrator for more information. Amounts in excess of the overall elective deferral limit must be included in income. See the Wages, Salaries, Tips, etc. line instructions for

included in boxes 1, 3, or 5)

R—Employer contributions to your Archer (MSA) (see Form 8853, Archer MSAs and Long-Term Care Insurance Contracts)

S—Employee salary reduction contributions under a section 408(p) SIMPLE (not included in box 1)

T—Adoption benefits (not included in box 1). You must complete Form 8839, Qualified Adoption Expenses, to compute any taxable and nontaxable amounts.

V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3 (up to social security wage base), and 5)

Form 1040.

Note: If a year follows code D, E, F, G, H, or S, you made a make-up pension contribution for a prior year(s) when you were in military service. To figure whether you made excess deferrals, consider these amounts for the year shown, not the current

Box 13. If the Retirement plan box is checked, special limits may apply to the

amount of traditional IRA contributions you may deduct.

year. If no year is shown, the contributions are for the current year.

Note: Keep Copy C of Form W-2 for at least 3 years after the due date for filing your income tax return. However, to help protect your social security benefits, keep Copy C until you begin receiving social security benefits, just in case there is a question about your work record and/or earnings in a particular year. Review the information shown on your annual (for workers over 25) Social Security Statement.

A—Uncollected social security or RRTA tax on tips (Include this tax on Form

1040. See Total Tax in the Form 1040 instructions.)

B—Uncollected Medicare tax on tips (Include this tax on Form 1040. See Total Tax in the Form 1040 instructions.)

C—Taxable cost of group-term life insurance over $50,000 (included in boxes 1, 3 (up to social security wage base), and 5)

a Control number

OMB No. 1545-0008

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

		

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

e	Employee’s first name and initial

Last name

f Employee’s address and ZIP code

14 Other

W- 2

Wage and Tax

2

0

0

3

Department of the Treasury—Internal Revenue Service

Form

Statement

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

3Social security wages

4	Social security tax withheld

5	Medicare wages and tips

6	Medicare tax withheld

7Social security tips

8	Allocated tips

11Nonqualified plans

employee

plan

sick pay

Third-party

13 Statutory

Retirement

	12a		
	eodC		
	12b		
	eodC		

12c		
eodC		
12d		
eodC		

15	StateEmployer’s state ID number	16State wages, tips, etc.	17 State income tax	18 Local wages, tips, etc.	19 Local income tax	20 Locality name	

□
□
□

a Control number

Void

OMB No. 1545-0008

b Employer identification number

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

		

d	Employee’s social security number

9Advance EIC payment

10 Dependent care benefits

e	Employee’s first name and initial

Last name

f Employee’s address and ZIP code

14 Other

W- 2

Wage and Tax

2

0

0

3

Department of the Treasury—Internal Revenue Service

Form

Statement

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Copy D For Employer.

3Social security wages

4	Social security tax withheld

5	Medicare wages and tips

6	Medicare tax withheld

7Social security tips

8	Allocated tips

11Nonqualified plans

employee

plan

sick pay

Third-party

13 Statutory

Retirement

□

	12a See instructions for box 12	
	eodC		
	12b		
	eodC		

12c		
eodC		
12d		
eodC		

15	StateEmployer’s state ID number	16State wages, tips, etc.	17 State income tax	18 Local wages, tips, etc.	19 Local income tax	20 Locality name	

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Employers, Please Note

Specific information needed to complete Form W-2 is given in a separate booklet titled 2003 Instructions for Forms W-2 and W-3. 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 Web Site at www.irs.gov.

Due dates. Furnish Copies B, C, and 2 to the employee generally by February 2, 2004.

File Copy A with the SSA generally by March 1, 2004. Send all Copies A with Form W-3,

Transmittal of Wage and Tax Statements.

However, if you file electronically (not by magnetic media), the due date is March 31, 2004.

Caution: Because the SSA processes paper forms
by machine, you cannot file with the SSA Forms
W-2 and W-3 that you print from the IRS Web Site.

Instead, visit the SSA Web Site at

www.ssa.gov/employer to see if you can file “fill-in” versions of Forms W-2 and W-3.