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26 U.S.C. § 7204
Employee's Withholding Statement, Form W-2
Furnishing False and Fraudulent StatementIN THE DISTRICT COURT OF THE UNITED STATES FOR THE ____________ DISTRICT OF ____________
UNITED STATES OF AMERICA
v.
_______________________
)
)
)
)
)No. __________________
26 U.S.C., § 7204The United States Attorney charges:
That on or about the _____ day of __________, 19___, in the ___________ District of __________, [Defendant's Name],1 a resident of [City], [State], who during the calendar year 19___ employed [Name of Employee], a resident of [City], [State], and who was required under the Internal Revenue laws to deduct and withhold federal income taxes and Federal Insurance Contributions Act taxes with respect to the wages of [Name of Employee] and to furnish him [her] on or before January 31, 19___, with a written statement showing the amount of wages paid and taxes deducted and withheld during the calendar year 19___, did willfully furnish a false and fraudulent statement to said employee showing that the total wages paid were $_________ and that the income taxes deducted and withheld were $_________ and that the Federal Insurance Contributions Act taxes deducted and withheld were $______________, whereas, as [Defendant's Name] then and there well knew and believed, the total wages paid were $_________, and the income taxes deducted and withheld were $_________ and the Federal Insurance Contributions Act taxes deducted and withheld were $_________.
In violation of Title 26, United States Code, Section 7204.
________________________
United States Attorney
NOTES1. If the employer is a corporation, refer to language at Forms - 25 as a guide in charging appropriate corporate officers with furnishing a false and fraudulent withholding statement on behalf of the corporation.
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Uploaded April 1998
