Name:
EMail Address:
		payer 1	payer 2	payer 3	payer 4	payer 5
	Description
	Check if spouse's W2
	Employer's ID Number
	Employer Name
1	Wages, Tips, Etc.
2	Federal Tax Withheld
3	Social Security Wages
4	Social Security Tax W/H
5	Medicare Wages
6	Medicare Tax W/H
7	Social Security Tips
8	Allocated Tips
9	Advance EIC Payments
10	Dependent Care Benefits
11	Distribution from Non-Qualified
12	A1 Code (one letter)
	A2 Amount
	B1 Code (one letter)
	B2 Amount
	C1 Code (one letter)
	C2 Amount
	D1 Code (one letter)
	D2 Amount
13	Check if statutory employee
	Check if retirement plan
	Check if 3rd party sick pay
14	Other Items
	Description 1
	Amount 1
	Description 2
	Amount 2
	Description 3
	Amount 3
15	State Name
	Employer State ID
16A	State Wages
17A	State Income Tax
18A	Local Wages
19A	Local Income Tax
20A	Locality Name
	Associated State