Attention:

This form is provided for informational purposes only. Copy A appears in red, similar to the official printed IRS form. But do not file Copy A downloaded from this website with the SSA. A penalty of $50 per information return may be imposed for filing such forms that cannot be scanned.

To order official IRS forms, call 1-800-TAX-FORMS (1-800-829- 3 676) or order online at Forms and Publications By U.S. Mail.

You may file Forms W-2 and W-3 electronically on the SSA’s website at Employer Reporting Instructions & Information. You can create fill-in versions of Forms W-2 and W-3 for filing with the SSA. You may also print out copies for filing with state or local governments, distribution to your employees, and for your records.

W-2 / W-3 Cover page

DO NOT CUT, FOLD, OR STAPLE THIS FORM

aTax year/Form corrected

/ W-2

44444

For Official Use Only

OMB No. 1545-0008

b Employee’s correct SSN

cCorrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form W-2c (Rev. 1-2006)

Copy A—For Social Security Administration

Corrected Wage and Tax Statement

Cat. No. 61437D

Department of the Treasury Internal Revenue Service

1Wages, tips, other compensation

1	Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4Social security tax withheld

4	Social security tax withheld

5	Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Cdoe		Code		

State Correction Information	

aTax year/Form corrected

/ W-2

44444

OMB No. 1545-0008

b Employee’s correct SSN

cCorrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

Copy 1—State, City, or Local Tax Department

Form W-2c (Rev. 1-2006)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

1	Wages, tips, other compensation

1	Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4	Social security tax withheld

4	Social security tax withheld

5	Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Cdoe		Code		

State Correction Information	

a Tax year/Form corrected

/ W-2

OMB No. 1545-0008

Safe, accurate,

Visit the IRS website

FAST! Use

at www.irs.gov.

b Employee’s correct SSN

c Corrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

Copy B—To Be Filed with Employee’s FEDERAL Tax Return

Form W-2c (Rev. 1-2006)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

1	Wages, tips, other compensation

1Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4	Social security tax withheld

4	Social security tax withheld

5Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Cdoe		Code		

State Correction Information	

a Tax year/Form corrected

/ W-2

OMB No. 1545-0008

Safe, accurate,

Visit the IRS website

FAST! Use

at www.irs.gov.

b Employee’s correct SSN

c Corrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

Copy C—For EMPLOYEE’s RECORDS

Form W-2c (Rev. 1-2006)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

1	Wages, tips, other compensation

1Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4	Social security tax withheld

4	Social security tax withheld

5Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Cdoe		Code		

State Correction Information	

Notice to Employee

This is a corrected Form W-2, Wage and Tax Statement, (or Form W-2AS, W-2CM, W-2GU, W-2VI or W-2c) 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 1 040X, Amended U.S. Individual Income Tax Return, with Copy B of this Form W-2c to amend the return you already filed.

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.

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.

aTax year/Form corrected

/ W-2

OMB No. 1545-0008

b Employee’s correct SSN

cCorrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

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

Form W-2c (Rev. 1-2006)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

1	Wages, tips, other compensation

1	Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4	Social security tax withheld

4	Social security tax withheld

5	Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Cdoe		Code		

State Correction Information	

a Tax year/Form corrected

/ W-2

OMB No. 1545-0008

b Employee’s correct SSN

cCorrected SSN and/or

name (if checked, enter

incorrect SSN and/or name

in box h and/or box i)

d Employer’s Federal EIN

e Employee’s first name and initial

Last name

Suff.

g Employer’s name, address, and ZIP code

f Employee’s address and ZIP code

if incorrect on last form filed.

Complete boxes h and/or i only

h Employee’s incorrect SSN

i Employee’s name (as incorrectly shown on previous form)

Note: Only complete money fields that are being corrected (except MQGE).

14 Other (see instructions)

14 Other (see instructions)

Previously reported	Correct information	Previously reported	Correct information	

				

Locality Correction Information

				

Copy D—For Employer

Form W-2c (Rev. 1-2006)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

1	Wages, tips, other compensation

1	Wages, tips, other compensation

2	Federal income tax withheld

2	Federal income tax withheld

3Social security wages

3	Social security wages

4Social security tax withheld

4	Social security tax withheld

5Medicare wages and tips

5	Medicare wages and tips

6	Medicare tax withheld

6	Medicare tax withheld

7Social security tips

7	Social security tips

8Allocated tips

8	Allocated tips

9Advance EIC payment

9 Advance EIC payment

10Dependent care benefits

10	Dependent care benefits

11Nonqualified plans

11	Nonqualified plans

15 State

15 State

15 State

15 State

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

Employer’s state ID number

16State wages, tips, etc.

16	State wages, tips, etc.

16State wages, tips, etc.

16	State wages, tips, etc.

17State income tax

17	State income tax

17	State income tax

17	State income tax

18Local wages, tips, etc.

18	Local wages, tips, etc.

18Local wages, tips, etc.

18	Local wages, tips, etc.

19Local income tax

19	Local income tax

19	Local income tax

19	Local income tax

20Locality name

20	Locality name

20	Locality name

20	Locality name

□

Previously reported	Correct information	Previously reported	Correct information	

				

		12aSee instructions for box 12	12a See instructions for box 12	
		Cdoe		Code		
13	Statutory	Retirement	Third-party	13 Statutory	Retirement	Third-party	12b		12b		
employee	plan	sick pay	employee	plan	sick pay					
						Cdoe		Code		
□	□	□	□	□	□					

12c		12c		
Cdoe		Code		
12d		12d		
Code		Code		

State Correction Information	

Employers, Please Note:

Specific information needed to complete Form W-2c is given in the separate Instructions for Forms W-2c and W-3c. 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 website at www.irs.gov.