a Employee’s social security number For Official Use Only ▶

22222 Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

Form W-2 Wage and Tax Statement

Copy A For Social Security Administration — Send this entire page with
2015 Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see the separate instructions.
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
 a Employee’s social security number
22222 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

W-2 Wage and Tax

2015
Department of the Treasury—Internal Revenue Service
Form Statement
Copy 1—For State, City, or Local Tax Department
 a Employee’s social security number Safe, accurate, Visit the IRS website at
OMB No. 1545-0008 FAST! Use www.irs.gov/efile

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
13 Statutory
employee
Retirement Third-party 12b
plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

W-2 Wage and Tax

2015
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.
Notice to Employee
Do you have to file? Refer to the Form 1040 Instructions to correct any name, SSN, or money amount error
to determine if you are required to file a tax return. Even if reported to the SSA on Form W-2. Be sure to get your
you do not have to file a tax return, you may be eligible for copies of Form W-2c from your employer for all
a refund if box 2 shows an amount or if you are eligible for corrections made so you may file them with your tax
any credit. return. If your name and SSN are correct but are not the
Earned income credit (EIC). You may be able to take the same as shown on your social security card, you should
EIC for 2015 if your adjusted gross income (AGI) is less ask for a new card that displays your correct name at any
than a certain amount. The amount of the credit is based SSA office or by calling 1-800-772-1213. You also may
on income and family size. Workers without children could visit the SSA at www.socialsecurity.gov.
qualify for a smaller credit. You and any qualifying children Cost of employer-sponsored health coverage (if such
must have valid social security numbers (SSNs). You cost is provided by the employer). The reporting in box
cannot take the EIC if your investment income is more than 12, using code DD, of the cost of employer-sponsored
the specified amount for 2015 or if income is earned for health coverage is for your information only. The amount
services provided while you were an inmate at a penal reported with code DD is not taxable.
institution. For 2015 income limits and more information, Credit for excess taxes. If you had more than one
visit www.irs.gov/eitc. Also see Pub. 596, Earned Income employer in 2015 and more than $7,347 in social security
Credit. Any EIC that is more than your tax liability is and/or Tier 1 railroad retirement (RRTA) taxes were
refunded to you, but only if you file a tax return. withheld, you may be able to claim a credit for the excess
Clergy and religious workers. If you are not subject to against your federal income tax. If you had more than one
social security and Medicare taxes, see Pub. 517, Social railroad employer and more than $4,321.80 in Tier 2
Security and Other Information for Members of the Clergy RRTA tax was withheld, you also may be able to claim a
and Religious Workers. credit. See your Form 1040 or Form 1040A instructions
Corrections. If your name, SSN, or address is incorrect, and Pub. 505, Tax Withholding and Estimated Tax.
correct Copies B, C, and 2 and ask your employer to (Also see Instructions for Employee on the back of Copy C.)
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)
 a Employee’s social security number This information is being furnished to the Internal Revenue Service. If you
OMB No. 1545-0008 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 (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

W-2
Department of the Treasury—Internal Revenue Service
Wage and Tax
Form Statement
Copy C—For EMPLOYEE’S RECORDS (See Notice to
2015 Safe, accurate,
FAST! Use

Employee on the back of Copy B.)

Instructions for Employee (Also see Notice to Employee, 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
on the back of Copy B.) D, E, F, and S) and designated Roth contributions (codes AA, BB, and EE)
Box 1. Enter this amount on the wages line of your tax return. under all plans are generally limited to a total of $18,000 ($12,500 if you only
Box 2. Enter this amount on the federal income tax withheld line of your tax have SIMPLE plans; $21,000 for section 403(b) plans if you qualify for the
return. 15-year rule explained in Pub. 571). Deferrals under code G are limited to
$18,000. Deferrals under code H are limited to $7,000.
Box 5. You may be required to report this amount on Form 8959, Additional However, if you were at least age 50 in 2015, your employer may have
Medicare Tax. See the Form 1040 instructions to determine if you are allowed an additional deferral of up to $6,000 ($3,000 for section 401(k)(11)
required to complete Form 8959. and 408(p) SIMPLE plans). This additional deferral amount is not subject to
Box 6. This amount includes the 1.45% Medicare Tax withheld on all the overall limit on elective deferrals. For code G, the limit on elective
Medicare wages and tips shown in Box 5, as well as the 0.9% Additional deferrals may be higher for the last 3 years before you reach retirement age.
Medicare Tax on any of those Medicare wages and tips above $200,000. Contact your plan administrator for more information. Amounts in excess of
Box 8. This amount is not included in boxes 1, 3, 5, or 7. For information on the overall elective deferral limit must be included in income. See the
how to report tips on your tax return, see your Form 1040 instructions. “Wages, Salaries, Tips, etc.” line instructions for Form 1040.
You must file Form 4137, Social Security and Medicare Tax on Unreported Note. If a year follows code D through H, S, Y, AA, BB, or EE, you made a
Tip Income, with your income tax return to report at least the allocated tip make-up pension contribution for a prior year(s) when you were in military
amount unless you can prove that you received a smaller amount. If you have service. To figure whether you made excess deferrals, consider these
records that show the actual amount of tips you received, report that amount amounts for the year shown, not the current year. If no year is shown, the
even if it is more or less than the allocated tips. On Form 4137 you will contributions are for the current year.
calculate the social security and Medicare tax owed on the allocated tips
shown on your Form(s) W-2 that you must report as income and on other tips A—Uncollected social security or RRTA tax on tips. Include this tax on Form
you did not report to your employer. By filing Form 4137, your social security 1040. See “Other Taxes” in the Form 1040 instructions.
tips will be credited to your social security record (used to figure your
benefits). B—Uncollected Medicare tax on tips. Include this tax on Form 1040. See
“Other Taxes” in the Form 1040 instructions.
Box 10. This amount includes the total dependent care benefits that your
employer paid to you or incurred on your behalf (including amounts from a C—Taxable cost of group-term life insurance over $50,000 (included in boxes
section 125 (cafeteria) plan). Any amount over $5,000 is also included in box 1, 3 (up to social security wage base), and 5)
1. Complete Form 2441, Child and Dependent Care Expenses, to compute
any taxable and nontaxable amounts. 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
Box 11. This amount is (a) reported in box 1 if it is a distribution made to you section 401(k) arrangement.
from a nonqualified deferred compensation or nongovernmental section
457(b) plan or (b) included in box 3 and/or 5 if it is a prior year deferral under E—Elective deferrals under a section 403(b) salary reduction agreement
a nonqualified or section 457(b) plan that became taxable for social security
and Medicare taxes this year because there is no longer a substantial risk of (continued on back of Copy 2)
forfeiture of your right to the deferred amount. This box should not be used if
you had a deferral and a distribution in the same calendar year. If you made a
deferral and received a distribution in the same calendar year, and you are or
will be age 62 by the end of the calendar year, your employer should file
Form SSA-131, Employer Report of Special Wage Payments, with the Social
Security Administration and give you a copy.
 a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

W-2 Wage and Tax

2015
Department of the Treasury—Internal Revenue Service
Form Statement
Copy 2—To Be Filed With Employee’s State, City, or Local
Income Tax Return
Instructions for Employee (continued from back of V—Income from exercise of nonstatutory stock option(s) (included in
Copy C) boxes 1, 3 (up to social security wage base), and 5). See Pub. 525 and
instructions for Schedule D (Form 1040) for reporting requirements.
F—Elective deferrals under a section 408(k)(6) salary reduction SEP W—Employer contributions (including amounts the employee elected to
G—Elective deferrals and employer contributions (including nonelective contribute using a section 125 (cafeteria) plan) to your health savings
deferrals) to a section 457(b) deferred compensation plan account. Report on Form 8889, Health Savings Accounts (HSAs).
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization Y—Deferrals under a section 409A nonqualified deferred compensation
plan. See “Adjusted Gross Income” in the Form 1040 instructions for plan
how to deduct. Z—Income under a nonqualified deferred compensation plan that fails
J—Nontaxable sick pay (information only, not included in boxes 1, 3, or to satisfy section 409A. This amount is also included in box 1. It is
5) subject to an additional 20% tax plus interest. See “Other Taxes” in the
Form 1040 instructions.
K—20% excise tax on excess golden parachute payments. See “Other
Taxes” in the Form 1040 instructions. AA—Designated Roth contributions under a section 401(k) plan
L—Substantiated employee business expense reimbursements BB—Designated Roth contributions under a section 403(b) plan
(nontaxable) DD—Cost of employer-sponsored health coverage. The amount
M—Uncollected social security or RRTA tax on taxable cost of group- reported with Code DD is not taxable.
term life insurance over $50,000 (former employees only). See “Other EE—Designated Roth contributions under a governmental section
Taxes” in the Form 1040 instructions. 457(b) plan. This amount does not apply to contributions under a tax-
N—Uncollected Medicare tax on taxable cost of group-term life exempt organization section 457(b) plan.
insurance over $50,000 (former employees only). See “Other Taxes” in Box 13. If the “Retirement plan” box is checked, special limits may
the Form 1040 instructions. apply to the amount of traditional IRA contributions you may deduct.
P—Excludable moving expense reimbursements paid directly to See Pub. 590, Individual Retirement Arrangements (IRAs).
employee (not included in boxes 1, 3, or 5) Box 14. Employers may use this box to report information such as state
Q—Nontaxable combat pay. See the instructions for Form 1040 or Form disability insurance taxes withheld, union dues, uniform payments,
1040A for details on reporting this amount. health insurance premiums deducted, nontaxable income, educational
assistance payments, or a member of the clergy's parsonage allowance
R—Employer contributions to your Archer MSA. Report on Form 8853,
and utilities. Railroad employers use this box to report railroad
Archer MSAs and Long-Term Care Insurance Contracts.
retirement (RRTA) compensation, Tier 1 tax, Tier 2 tax, Medicare tax and
S—Employee salary reduction contributions under a section 408(p) Additional Medicare Tax. Include tips reported by the employee to the
SIMPLE plan (not included in box 1) employer in railroad retirement (RRTA) compensation.
T—Adoption benefits (not included in box 1). Complete Form 8839, Note. Keep Copy C of Form W-2 for at least 3 years after the due date
Qualified Adoption Expenses, to compute any taxable and nontaxable for filing your income tax return. However, to help protect your social
amounts. 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.
 a Employee’s social security number
Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
13 Statutory Retirement Third-party 12b
employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

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

W-2 Wage and Tax

2015
Department of the Treasury—Internal Revenue Service
Form Statement For Privacy Act and Paperwork Reduction
Act Notice, see separate instructions.
Copy D — For Employer
Employers, Please Note—
Specific information needed to complete Form W-2 is available Need help? If you have questions about reporting on Form W-2,
in a separate booklet titled the 2015 General Instructions for call the information reporting customer service site toll free at
Forms W-2 and W-3. You can order those instructions and 1-866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD
additional forms by calling 1-800-TAX-FORM (1-800-829-3676). equipment for persons who are deaf, hard of hearing, or have a
You also can get forms and instructions at IRS.gov. speech disability, call 304-579-4827 (not toll free). The hours of
operation are 8:30 a.m. to 4:30 p.m. Eastern time.
Caution. Do not send the SSA Forms W-2 and W-3 that you
have printed from IRS.gov. The SSA is unable to process these E-filing. If you file 250 or more Form(s) W-2, you must file
forms. Instead, you can create and submit them online. See electronically. Even if you are not required to file electronically,
E-filing, later. doing so can save you time and effort. Employers may now use
the SSA's W-2 Online service to create, save, print, and submit
Due dates. By February 1, 2016, furnish Copies B, C, and 2 to
up to 50 Form(s) W-2 at a time over the Internet. When you e-file
each person who was your employee during 2015. By February
with the SSA, no separate Form W-3 filing is required. An
29, 2016, send Copy A of Form(s) W-2 and W-3 to the SSA.
electronic Form W-3 will be created for you by the W-2 Online
However, if you file electronically, the due date is March 31,
service. For information, visit the SSA's Employer W-2 Filing
2016. See the separate instructions.
Instructions & Information website at www.socialsecurity.gov/
employer.
Future developments. Information about any future
developments affecting Form W-2 and its instructions (such as
legislation enacted after we release them) will be posted at
www.irs.gov/w2.