Free Form W-2c (Rev. February 2009) - Federal

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to the official IRS form. Do not file copy A downloaded from this website with the SSA. The official printed version of this IRS form is scannable, but the online version of it, printed from this website, is not. A penalty of $50 per information return may be imposed for filing forms that cannot be scanned. To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order Information Returns and Employer Returns Online, and we'll mail you the scannable forms and other products.

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 SSA. You may also print out copies for filing with state or local governments, distribution to your employees, and for your records. See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms.

Comp Specialist: This form needs to have a 2/3" head margin when the PDF is cropped.

DO NOT CUT, FOLD, OR STAPLE THIS FORM 44444
For Official Use Only OMB No. 1545-0008 c Tax year/Form corrected d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

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

Copy A--For Social Security Administration
Cat. No. 61437D Department of the Treasury Internal Revenue Service

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

44444

For Official Use Only OMB No. 1545-0008 c Tax year/Form corrected d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

Copy 1--State, City, or Local Tax Department Form

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

44444

For Official Use Only OMB No. 1545-0008

Safe, accurate, FAST! Use c Tax year/Form corrected

Visit the IRS website at www.irs.gov. d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

Copy B--To Be Filed with Employee's FEDERAL Tax Return Form

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

44444

For Official Use Only OMB No. 1545-0008

Safe, accurate, FAST! Use c Tax year/Form corrected

Visit the IRS website at www.irs.gov. d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

Copy C--For EMPLOYEE's RECORDS Form

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

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 c. 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 you have not filed your return for the year shown in box c, 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.

44444

For Official Use Only OMB No. 1545-0008 c Tax year/Form corrected d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

Copy 2--To Be Filed with Employee's State, City, or Local Income Tax Return Form

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

44444

For Official Use Only OMB No. 1545-0008 c Tax year/Form corrected d Employee's correct SSN

a Employer's name, address, and ZIP code

/ W-2 e Corrected SSN and/or name (Check this box and complete boxes f and/or

g if incorrect on form previously filed.) Complete boxes f and/or g only if incorrect on form previously filed
f Employee's previously reported SSN

b Employer's Federal EIN

g Employee's previously reported name

h Employee's first name and initial

Last name

Suff.

Note: Only complete money fields that are being corrected (exception: for corrections involving MQGE, see the Instructions for Forms W-2c and W-3c, boxes 5 and 6). Previously reported Correct information
1 Wages, tips, other compensation 1 Wages, tips, other compensation

i 2

Employee's address and ZIP code

Previously reported
Federal income tax withheld 2

Correct information
Federal income tax withheld

3

Social 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

7

Social security tips

7

Social security tips

8

Allocated tips

8

Allocated tips

9

Advance EIC payment

9

Advance EIC payment

10

Dependent care benefits

10

Dependent care benefits

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

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a See instructions for box 12
C o d e

12a See instructions for box 12
C o d e

12b
C o d e

12b
C o d e

14 Other (see instructions)

14

Other (see instructions)

12c
C o d e

12c
C o d e

12d
C o d e

12d
C o d e

Previously reported
15 State

Correct information
15 State

State Correction Information Previously reported
15 State

Correct information
15 State

Employer's state ID number 16 State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc. 16

Employer's state ID number State wages, tips, etc.

17 State income tax

17

State income tax

17

State income tax

17

State income tax

Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

Locality Correction Information Previously reported
18 Local wages, tips, etc. 18

Correct information
Local wages, tips, etc.

19 Local income tax

19

Local income tax

19

Local income tax

19

Local income tax

20 Locality name

20

Locality name

20

Locality name

20

Locality name

Copy D--For Employer Form

W-2c

(Rev. 2-2009)

Corrected Wage and Tax Statement

Department of the Treasury Internal Revenue Service

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. Electronic filing of Form W-2c is preferred. For information on how to file electronically, go to the Social Security Administration website at www.socialsecurity.gov/employer.