Free Form W-3c (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.

DO NOT CUT, FOLD, OR STAPLE
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a Tax year/Form corrected For Official Use Only OMB No. 1545-0008 c 941/941-SS Military 943 944/944-SS

/ W-

b Employer's name, address, and ZIP code

Kind of Payer
d Number of Forms W-2c e Employer's Federal EIN f Establishment number

CT-1

Hshld. emp.

Medicare govt. emp.

Third-party sick pay

g Employer's state ID number

Complete boxes h, i, or j only if incorrect on last form filed. Total of amounts previously reported as shown on enclosed Forms W-2c. 1 Wages, tips, other compensation

h

Employer's incorrect Federal EIN

i

Incorrect establishment number

j

Employer's incorrect state ID number

Total of corrected amounts as shown on enclosed Forms W-2c. 1 Wages, tips, other compensation

Total of amounts previously reported as shown on enclosed Forms W-2c. 2 Federal income tax withheld

Total of corrected amounts as shown on enclosed Forms W-2c. 2 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 payments

9

Advance EIC payments

10 Dependent care benefits

10 Dependent care benefits

11

Nonqualified plans

11

Nonqualified plans

12a-d (Coded items)

12a-d (Coded items)

14

Inc. tax W/H by 3rd party sick pay payer

14

Inc. tax W/H by 3rd party sick pay payer

16

State wages, tips, etc.

16

State wages, tips, etc.

17

State income tax

17 State income tax

18

Local wages, tips, etc.

18

Local wages, tips, etc.

19

Local income tax

19 Local income tax

Explain decreases here:

Has an adjustment been made on an employment tax return filed with the Internal Revenue Service? If "Yes," give date the return was filed

Yes

No

Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true, correct, and complete. Signature Contact person Title Telephone number Date For Official Use Only

(
Email address

) )
Department of the Treasury Internal Revenue Service

Fax number

(
Form

W-3c

(Rev. 2-2009)

Transmittal of Corrected Wage and Tax Statements Where To File

Purpose of Form
Use this form to transmit Copy A of Form(s) W-2c, Corrected Wage and Tax Statement (Rev. 2-2009). Make a copy of Form W-3c and keep it with Copy D (For Employer) of Forms W-2c for your records. File Form W-3c even if only one Form W-2c is being filed or if those Forms W-2c are being filed only to correct an employee's name and social security number (SSN), or the employer identification number (EIN). See the separate Instructions for Forms W-2c and W-3c for information on completing this form.

If you use the U.S. Postal Service, send Forms W-2c and W-3c to the following address: Social Security Administration Data Operations Center P.O. Box 3333 Wilkes-Barre, PA 18767-3333 If you use a carrier other than the U.S. Postal Service, send Forms W-2c and W-3c to the following address: Social Security Administration Data Operations Center Attn: W-2c Process 1150 E. Mountain Drive Wilkes-Barre, PA 18702-7997
Cat. No. 10164R

When To File
File this form and Copy A of Form(s) W-2c with the Social Security Administration as soon as possible after you discover an error on Forms W-2, W-2AS, W-2GU, W-2CM, W-2VI, or W-2c. Provide Copies B, C, and 2 of Form W-2c to your employees as soon as possible.

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