Instructions for Forms

2011

Instructions for Forms

W-2AS, W-2GU, W-2VI, and

W-3SS

Department of the Treasury

Internal Revenue Service

Section references are to the Internal Revenue Code unless

otherwise noted.

Contents

Page

What’s New . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Reminders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Need Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

General Instructions for Form W-3SS . . . . . . . . . . . . . . . . . . 2

Who Must File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

When To File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Where To File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

General Instructions for Forms W-2AS, W-2CM,

W-2GU, and W-2VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Special Reporting Situations . . . . . . . . . . . . . . . . . . . . . . . . 3

Specific Instructions for Forms W-2AS, W-2GU, and

W-2VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Specific Instructions for Form W-3SS . . . . . . . . . . . . . . . . . . 8

Employment Tax Forms Referenced in These

Instructions

Form

Title

940

Employer’s Annual Federal Unemployment

(FUTA) Tax Return

941

Employer’s QUARTERLY Federal Tax Return

941-SS

Employer’s QUARTERLY Federal Tax Return

(American Samoa, Guam, the Commonwealth of

the Northern Mariana Islands, and the U.S. Virgin

Islands)

941-X

Adjusted Employer’s QUARTERLY Federal Tax

Return or Claim for Refund

943

Employer’s Annual Federal Tax Return for

Agricultural Employees

What’s New

943-X

Adjusted Employer’s Annual Federal Tax Return

for Agricultural Employees or Claim for Refund

Employee social security tax withholding. The Tax Relief,

Unemployment Insurance Reauthorization, and Job Creation

Act of 2010 has temporarily reduced the rate of social security

tax withholding (for employees only) from 6.2% to 4.2%, for

wage payments made in 2011. See Box 4 — Social security tax

withheld on page 6.

New electronic filing option. Employers in American

Samoa, Guam, and the U.S. Virgin Islands can now use the

SSA’s W-2 Online service to create, save, print, and submit up

to 20 Forms W-2AS, W-2GU, or W-2VI at a time over the

Internet. For more information, see E-filing on page 3.

Advance earned income (EIC) payments. Public Law

111-226 repealed the advance earned income credit payment

for tax years beginning after December 31, 2010. Box 9,

Advance EIC payments, has been eliminated from the 2011

Forms W-2GU and W-2VI.

Interim relief for Form W-2 reporting of the cost of

coverage of group health Insurance. Reporting the cost of

employer-sponsored health coverage will not be mandatory for

2011 Forms W-2. The Patient Protection and Affordable Care

Act added code DD to Box 12 of the 2011 Forms W-2AS,

W-2GU, and W-2VI to report this information. Additional

reporting guidance will be available on the Affordable Care Act

Tax Provisions page of IRS.gov. For details, see Notice

2010-69, 2010-44 I.R.B.576, available at www.irs.gov/irb/

2010-44_IRB/ar13.html.

Form W-3SS, Kind of Employer. To improve document

matching compliance, box b of Form W-3SS has been

expanded to include a new section, Kind of Employer, with five

new checkboxes. All filers are required to check the applicable

box. For more information, see Box b — Kind of Employer on

page 9.

Increase in information return penalties. The penalties for

failure to file correct information returns and failure to furnish

correct payee statements have increased. See Penalties in the

2011 Instructions for Forms W-2 and W-3.

Military Spouses Residency Relief Act (MSRRA). This Act

amends the 2003 Servicemembers Civil Relief Act. MSRRA

944

Employer’s ANNUAL Federal Tax Return

944-SS

Employer’s ANNUAL Federal Tax Return

(American Samoa, Guam, the Commonwealth of

the Northern Mariana Islands, and the U.S. Virgin

Islands)

944-X

Adjusted Employer’s ANNUAL Federal Tax

Return or Claim for Refund

applies to the 2009 tax year as well as subsequent tax years.

You may be required to report wages and taxes on a form

different from the form you generally use if an employee claims

residence or domicile under MSRRA in a different jurisdiction in

one of the 50 states, the District of Columbia, American Samoa,

the Commonwealth of the Northern Mariana Islands, Puerto

Rico, or the U.S. Virgin Islands.

Under MSRRA, the spouse of an active duty servicemember

(civilian spouse) may keep his or her prior residence or domicile

for tax purposes (tax residence) when accompanying the

servicemember spouse, who is relocating under military orders,

to a new military duty station in one of the 50 states, the District

of Columbia, or a U.S. possession. Before relocating, both

spouses must have had the same tax residence.

For example, if a civilian spouse is working in Guam but

properly claims tax residence in one of the 50 states under

MSRRA, his or her income from services would not be taxable

income for Guam tax purposes. Federal income taxes should

be withheld and remitted to the IRS. State and local income

taxes may need to be withheld and remitted to state and local

tax authorities. You should consult with state, local, or U.S.

possession tax authorities regarding your withholding

obligations under MSRRA.

Designated Roth contributions. The Small Business Jobs

Act of 2010 (Public Law 111-240) allows participants in

governmental section 457 plans to treat elective deferrals as

Roth contributions, beginning with taxable years after

December 31, 2010. Code EE, Designated Roth contributions

Cat. No. 48440A

Where To File

under a governmental section 457(b) plan, has been added to

the list of codes in Box 12 of Forms W-2AS, W-2GU, and

W-2VI. See Designated Roth contributions on page 4.

Copy A. Send the entire first page of Form W-3SS (Copy A)

with the entire Copy A page of Forms W-2AS, W-2CM, W-2GU,

or W-2VI to:

Reminders

Social Security Administration

Data Operations Center

Wilkes-Barre, PA 18769-0001

Note. If you use “Certified Mail” to file, change the ZIP code

to “18769-0002.” If you use an IRS-approved private delivery

service, add “ATTN: W-2 Process, 1150 E. Mountain Dr.” to the

address and change the ZIP code to “18702-7997.” See Pub.

15 (Circular E), Employer’s Tax Guide, for a list of

IRS-approved private delivery services.

Copy 1. File Copy 1 of Forms W-2AS and W-3SS with the

American Samoa Tax Office, Government of American Samoa,

Pago Pago, AS 96799.

File Copy 1 of Forms W-2GU and W-3SS with the

Department of Revenue and Taxation, Attn: Income Tax

Branch, P.O. Box 23607, GMF, GU 96921.

File Copy 1 of Forms W-2VI and W-3SS with the V.I. Bureau

of Internal Revenue, 9601 Estate Thomas, Charlotte Amalie, St.

Thomas, VI 00802.

Contact the Division of Revenue and Taxation,

Commonwealth of the Northern Mariana Islands at

670-664-1000 for the address to send Copy 1 of Forms W-2CM

and W-3SS.

Shipping and mailing. If you file forms for more than one

territory, use a separate Form W-3SS for each territory. For

example, send Forms W-2GU with one Form W-3SS and

Forms W-2AS with a second Form W-3SS. Forms W-2AS,

W-2CM, W-2GU, and W-2VI are printed two forms to a page.

Send the whole page of Copy A and Copy 1, even if one of the

forms on the page is blank or “Void.” See the specific

instructions for box b of Form W-3SS on page 8.

Prepare and file Forms W-2AS, W-2CM, W-2GU, or W-2VI

either alphabetically by employees’ last names or numerically

by employees’ social security numbers. Do not staple or tape

Form W-3SS to the related Forms W-2AS, W-2CM, W-2GU, or

W-2VI. Do not staple or tape any forms to each other. These

forms are machine read and staple holes or tears interfere with

machine reading. Also, do not fold or cut Forms W-2AS,

W-2CM, W-2GU, or W-2VI. Send the forms in a flat mailing.

Form 944-SS. If you file Form 944-SS, use the “944-SS”

checkbox in box b — Kind of Payer, on Form W-3SS.

Notice to employers in the Commonwealth of the Northern

Mariana Islands. If you are an employer in the

Commonwealth of the Northern Mariana Islands, contact the

Department of Revenue and Taxation, Capitol Hill, Saipan, MP

96959, to get Form W-2CM, Wage and Tax Statement, and the

instructions for completing and filing the form.

Need Help?

The IRS operates a centralized customer service site to answer

questions about reporting on information returns, including

Forms W-3SS, W-2AS, W-2CM, W-2GU, and W-2VI. If you

have questions about reporting on these forms, call

1-866-455-7438 (toll free except from American Samoa), or

1-304-263-8700 (not toll free). The hours of operation are

Monday through Friday from 8:30 a.m. to 4:30 p.m., Eastern

time.

Using TYY/TDD equipment. If you have questions about

reporting on any of the above forms, call 1-304-579-4827 (not

toll free). For any other information, call 1-800-829-4059 (toll

free except from American Samoa).

General Instructions for Form W-3SS

Use Copy A of Form W-3SS to transmit Copy A of Form

W-2AS, W-2CM, W-2GU, or W-2VI to the Social Security

Administration (SSA). File Copy 1 of Form W-3SS and Copy 1

of Form W-2AS, W-2CM, W-2GU, or W-2VI with your local tax

department.

Who Must File

Anyone required to file Forms W-2AS, W-2CM, W-2GU, or

W-2VI must file Form W-3SS to transmit Copy A of these forms

to the SSA. Make a copy of Form W-3SS; keep it and Copy D

(for employer) of Forms W-2AS, W-2CM, W-2GU, or W-2VI with

your records for 4 years. Be sure to use Form W-3SS for the

correct year. If you are filing these forms electronically, see

E-filing on page 3.

Household employers. Even employers with only one

household employee must file Form W-3SS with Form W-2AS,

W-2CM, W-2GU, or W-2VI. On Form W-3SS, check “Hshld.

emp.” in box b — Kind of Payer.

General Instructions for Forms W-2AS,

W-2CM, W-2GU, and W-2VI

Form W-2AS is used to report American Samoa wages, Form

W-2CM is used to report the Commonwealth of the Northern

Mariana Islands wages, Form W-2GU is used to report Guam

wages, and Form W-2VI is used to report U.S. Virgin Islands

wages. Do not use these forms to report wages subject to U.S.

income tax withholding. Instead, use Form W-2 to show U.S.

income tax withheld.

When To File

File Copy A of Form W-3SS with Copy A of Forms W-2AS,

W-2CM, W-2GU, or W-2VI by February 29, 2012.

However, if you file electronically, you may file by April 2,

2012. Visit SSA’s Business Services Online (BSO) website at

www.socialsecurity.gov/employer and click on “Business

Services Online” for electronic filing options.

Who Must File

Employers and other payers in American Samoa, the

Commonwealth of the Northern Mariana Islands (CNMI), Guam,

and the U.S. Virgin Islands (USVI) must report wages, withheld

income tax, U.S. social security, and U.S. Medicare taxes to

their local tax department and to the SSA.

Furnishing Copies B and C to employees. Furnish Copies B

and C of Forms W-2AS, W-2CM, W-2GU, or W-2VI to your

employees by January 31, 2012. You will meet the “furnish”

requirement if the form is properly addressed and mailed on or

before the due date.

Employment ends before December 31. You may furnish

copies to the employee any time after employment ends, but

not later than January 31, 2012. If an employee asks for the

form, furnish him or her the completed copies within 30 days of

the request or within 30 days of the final wage payment,

File Copy 1 of Form W-3SS with Copy 1 of Forms W-2AS,

W-2CM, W-2GU, or W-2VI by February 29, 2012.

Extension to file. You may request an automatic extension of

time to file Form W-2AS, W-2CM, W-2GU, or W-2VI by sending

Form 8809, Application for Extension of Time To File

Information Returns, to the address shown on that form. You

must request the extension by the due date of Form W-2AS,

W-2CM, W-2GU, or W-2VI. You will have an additional 30 days

to file. See Form 8809 for details.

Even if you receive an extension of time to file Forms

W-2AS, W-2CM, W-2GU, or W-2VI, you must still

CAUTION

furnish the forms to your employees by January 31,

2012. See Extension to furnish Forms W-2AS, W-2CM, W-2GU,

or W-2VI to employees, on page 3.

!

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Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

Waiver. You may request a waiver on Form 8508, Request

for Waiver From Filing Information Returns Electronically.

Submit Form 8508 to the IRS at least 45 days before the due

date of Form W-2AS, W-2CM, W-2GU, or W-2VI. See Form

8508 for filing information.

whichever is later. However, if you terminate your business, see

Terminating a business on page 5.

Extension to furnish Forms W-2AS, W-2CM, W-2GU, or

W-2VI to employees. You may request an extension of time

to furnish Form W-2AS, W-2CM, W-2GU, or W-2VI to

employees by sending a letter to:

!

IRS – Enterprise Computing Center – Martinsburg

Information Reporting Program

Attn: Extension of Time Coordinator

240 Murall Drive

Kearneysville, WV 25430

CAUTION

Taxpayer identification numbers (TINs). Employers use an

employer identification number (EIN) (00-0000000). Employees

use a social security number (SSN) (000-00-0000). When you

list a number, separate the nine digits properly to show the kind

of number. Do not accept an individual taxpayer identification

number (ITIN) for employment purposes. You can identify an

ITIN because it is a 9-digit number, beginning with the number

“9” with either a “7” or “8” as the fourth digit, and is formatted

like an SSN (for example, 9NN-7N-NNNN). For more

information about EINs and SSNs, see Pub. 80 (Circular SS),

Federal Tax Guide for Employers in the U.S. Virgin Islands,

Guam, American Samoa, and the Commonwealth of the

Northern Mariana Islands.

Social security numbers are used to record employee

earnings for future social security and Medicare benefits. When

you prepare Forms W-2AS, W-2CM, W-2GU, or W-2VI, be sure

to show the correct SSN for each employee. For information on

verification of SSNs, see section 3 of Pub. 80 (Circular SS) or

go to www.socialsecurity.gov/employer and select an option

under “Social Security Number Verification Service (SSNVS).”

Mail your letter on or before the due date for furnishing

Forms W-2AS, W-2CM, W-2GU, or W-2VI to employees. It

must include:

• Your name and address,

• Your employer identification number (EIN),

• A statement that you are requesting an extension to furnish

Forms W-2AS, W-2CM, W-2GU, or W-2VI to employees,

• Reason for delay, and

• Your signature or that of your authorized agent.

Requests for an extension of time to furnish recipient

statements for more than 10 payers must be submitted

CAUTION

electronically. See Publication 1220, Part D, Sec. 4.

!

Undeliverable forms. Keep for 4 years any employee

copies of Forms W-2AS, W-2CM, W-2GU, or W-2VI that you

tried to deliver but could not. However, if the undelivered forms

can be produced electronically through April 15th of the fourth

year after the year of issue, you do not need to keep

undeliverable employee copies. Do not send undeliverable

Forms W-2AS, W-2CM, W-2GU, or W-2VI to the SSA. For more

information on electronic recordkeeping, see Rev. Proc. 97-22,

which is on page 9 of Internal Revenue Bulletin 1997-13 at

www.irs.gov/pub/irs-irbs/irb97-13.pdf.

E-filing. If you are required to file 250 or more Forms W-2AS,

W-2CM, W-2GU, or W-2VI, you must file them electronically

unless the IRS granted you a waiver. The SSA encourages all

employers to e-file because it can save you effort and helps

ensure accuracy.

Special Reporting Situations

Corrections. Use the current version of Form W-2c, Corrected

Wage and Tax Statement, to correct errors (such as an

incorrect name, SSN, or amount) on a previously filed Form

W-2AS, W-2CM, W-2GU, or W-2VI. Always send Form W-3c,

Transmittal of Corrected Wage and Tax Statements, with Forms

W-2c to the SSA, even if you are filing a Form W-2c only to

correct an employee’s name or SSN. See the separate

Instructions for Forms W-2c and W-3c. Also, see below for

information on correcting an employee’s address.

If you are making a correction to a previously filed Form 941,

943, or 944, use Form 941-X, 943-X, or 944-X, for the return

period in which you found the error. See the Instructions for

Form 941-X for more details. Issue the employee a Form W-2c

if the error discovered was for the prior year. If you are

correcting social security or Medicare wages or tips, also file the

entire Copy A page of Form W-2c and Form W-3c with the SSA

to correct the social security records and any other items on the

original Form W-2AS, W-2CM, W-2GU, or W-2VI (or previously

filed Form W-2c) that were in error.

Incorrect employee address. If you filed a Form W-2AS,

W-2CM, W-2GU, or W-2VI with the SSA showing an incorrect

address for an employee but all other information on the form is

correct, do not file Form W-2c with the SSA merely to correct

the address.

However, if the address was incorrect on the Form W-2AS,

W-2CM, W-2GU, or W-2VI furnished to the employee, you must

do one of the following.

• Issue a new, corrected Form W-2AS, W-2CM, W-2GU, or

W-2VI to the employee, including the new address. Indicate

“REISSUED STATEMENT” on the new copies. Do not send

Copy A to the SSA.

• Issue a Form W-2c to the employee showing the correct

address in box i and all other correct information. Do not send

Copy A to the SSA.

• Mail the Form W-2AS, W-2CM, W-2GU, or W-2VI with the

incorrect address to the employee in an envelope showing the

correct address or otherwise deliver it to the employee.

Archer MSA. An employer’s contribution to an employee’s

Archer MSA is not subject to income tax withholding, social

security, or Medicare taxes if it is reasonable to believe at the

time of the payment that the contribution will be excludable from

the employee’s income. However, if it is not reasonable to

The SSA’s Business Services Online (BSO) website makes

e-filing easy by providing two ways to submit employee wage

data to SSA.

• Employers in American Samoa, Guam, and the USVI (but

currently not the CNMI) can create, save, and submit up to 20

Forms W-2AS, W-2GU, or W-2VI at a time using online fill-in

forms. You also can print copies of these forms to file with your

tax department, distribute to your employees, and keep for your

records. BSO generates Form W-3SS automatically based on

your Forms W-2AS, W-2GU, or W-2VI.

• Employers in American Samoa, the CNMI, Guam, and the

USVI can use BSO to upload files containing formatted wage

data to the SSA.

Employers also can use BSO’s W-2c Online service to

create, save, print, and submit Forms W-2c, Corrected Wage

and Tax Statement, to correct a previously submitted Form

W-2AS, W-2CM, W-2GU, W-2VI, or W-2c. To learn more about

using BSO, visit the SSA’s Employer W-2 Filing Instructions &

Information website at www.socialsecurity.gov/employer. Here

you also will find forms and publications needed for wage

reporting, information about verifying employee social security

numbers online, and more. Call the SSA at 1-888-772-2970 if

you experience problems using BSO services. To speak with

the SSA’s Employer Services Liaison Officer for your region,

call 1-212-264-1117 (not toll free) for the USVI or

1-510-970-8247 (not toll free) for Guam, American Samoa, and

the CNMI. SSA no longer accepts wage reports submitted on

any type of physical media (magnetic tape, cartridge, diskette,

etc.).

This website includes information on electronic filing, some

IRS and SSA publications, and general topics of interest about

annual wage reporting. You also can use BSO to ask questions

about wage reporting.

Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

If you file electronically, do not file the same returns on

paper.

-3-

believe at the time of payment that the contribution will be

excludable from the employee’s income, employer contributions

are subject to withholding of income, social security, and

Medicare taxes and must be reported in boxes 1, 3, and 5.

You must report all employer contributions to an Archer MSA

in box 12 with code R. Employer contributions to an Archer

MSA that are not excludable from the income of the employee

also must be reported in box 1.

An employee’s contributions to an Archer MSA are includible

in income as wages and are subject to income tax withholding

and social security and Medicare taxes. Employee contributions

may be deductible, within limits, on the employee’s tax return.

For more information, see Pub. 969, Health Savings

Accounts and Other Tax-Favored Health Plans, and Notice

96-53, 1996-2 C.B. 219, which is found on page 5 of Internal

Revenue Bulletin 1996-51 at www.irs.gov/pub/irs-irbs/irb96-51.

pdf.

Deceased employee’s wages. If an employee dies during the

year, you must report the accrued wages, vacation pay, and

other compensation paid after the date of death. Wages that

were constructively received by the employee while he or she

was alive are reported on Form W-2AS, W-2CM, W-2GU, or

W-2VI as any other regular wage payment, even if you may

have to reissue the payment in the name of the estate or

beneficiary.

If you made the payment after the employee’s death but in

the same year the employee died, you must withhold social

security and Medicare taxes on the payment and report the

payment on the employee’s Form W-2AS, W-2CM, W-2GU, or

W-2VI only as social security and Medicare wages to ensure

proper social security and Medicare credit is received.

On the employee’s Form W-2AS, W-2CM, W-2GU, or

W-2VI, show the payment as social security wages (box 3) and

Medicare wages and tips (box 5) and the social security and

Medicare taxes withheld in boxes 4 and 6. Do not show the

payment in box 1.

If you made the payment after the year of death, do not

report it on Form W-2AS, W-2CM, W-2GU, or W-2VI, and do

not withhold social security and Medicare taxes. Check with

your local taxing agency for any additional reporting

requirements.

Designated Roth contributions. Under section 402A, a

participant in a section 401(k) plan or under a 403(b) salary

reduction agreement that includes a qualified Roth contribution

program may elect to make designated Roth contributions to

the plan or program in lieu of elective deferrals. Designated

Roth contributions are subject to income tax withholding and

social security and Medicare taxes and must be reported in

boxes 1, 3, and 5.

Section 402A requires separate reporting of the yearly

designated Roth contributions. Designated Roth contributions to

401(k) plans will be reported using code AA in box 12;

designated Roth contributions under 403(b) salary reduction

agreements will be reported using code BB in box 12; and

designated Roth contributions under a governmental section

457(b) plan will be reported using code EE in box 12. For

reporting instructions, see Code AA, Code BB, and Code EE on

page 8.

Educational assistance programs. Employer-provided

educational assistance that qualifies as a working condition

benefit is excludable from an employee’s wages. For

educational assistance that does not qualify as a working

condition benefit, a $5,250 exclusion may apply if the

assistance is provided under an educational assistance

program under section 127. See Pub. 970, Tax Benefits for

Education, and section 2 of Pub. 15-B, Employer’s Tax Guide to

Fringe Benefits, for more information.

Election workers. Report on Form W-2AS, W-2CM, W-2GU,

or W-2VI payments of $600 or more to election workers for

services performed in territorial, county, and municipal

elections. File Form W-2AS, W-2CM, W-2GU, or W-2VI for

payments of less than $600 paid to election workers if social

security and Medicare taxes were withheld under a section 218

(Social Security Act) agreement. Do not report election worker

payments on Form 1099-MISC.

Employee’s social security and Medicare taxes paid by

employer. If you paid your employee’s share of social security

and Medicare taxes rather than deducting them from the

employee’s wages, you must include these payments as wages

subject to income tax withholding and social security and

Medicare taxes. These payments are also subject to federal

unemployment (FUTA) taxes in the USVI. The amount to

include as wages is determined by using the formula contained

in the discussion of Employee’s Portion of Taxes Paid by

Employer in section 7 of Pub. 15-A, Employer’s Supplemental

Tax Guide.

This does not apply to household and agricultural

employers. If you pay a household or agricultural

CAUTION

employee’s social security and Medicare taxes, you

must include these payments in the employee’s wages for

income tax withholding purposes. However, the wage increase

due to the tax payments is not subject to social security,

Medicare, or FUTA (USVI only) taxes. For information on

completing Forms W-2AS, W-2CM, W-2GU, W-2VI, and W-3SS

in this situation, see the Instructions for Schedule H (Form

1040), Household Employment Taxes, and section 3 of Pub. 51

(Circular A), Agricultural Employer’s Tax Guide.

Group-term life insurance. You must include in your

employee’s wages (boxes 1, 3, and 5 of Form W-2AS, W-2CM,

W-2GU, or W-2VI) the cost of group-term life insurance beyond

$50,000 worth of coverage, reduced by the amount the

employee paid toward the insurance. The cost is determined by

the table in section 2 of Pub. 15-B. Also, show the amount in

box 12 with code C. For coverage provided to employees while

they were employed, you must withhold social security and

Medicare taxes, and you may, at your option, withhold federal

income tax. For coverage provided to employees after they

were employed, the employees must pay the employee part of

social security and Medicare taxes on the taxable cost of

group-term life insurance coverage over $50,000 on their tax

return. You are not required to collect those taxes. However,

you must report the uncollected social security tax with code M

and the uncollected Medicare tax with code N in box 12 of Form

W-2AS, W-2CM, W-2GU, or W-2VI.

Health savings account (HSA). An employer’s contribution

(including an employee’s contributions through a cafeteria plan)

to an employee’s HSA is not subject to income tax withholding,

social security, or Medicare taxes (or FUTA tax (USVI only)) if it

is reasonable to believe at the time of the payment that the

contribution will be excludable from the employee’s income.

However, if it is not reasonable to believe at the time of

payment that the contribution will be excludable from the

employee’s income, employer contributions are subject to

income tax withholding and social security and Medicare taxes

(and FUTA tax (USVI only)) and must be reported in boxes 1, 3,

and 5 (and on Form 940 (USVI only)).

You must report all employer contributions (including an

employee’s contribution through a cafeteria plan) to an HSA in

box 12 with code W. Employer contributions to an HSA that are

not excludable from the income of the employee also must be

reported in boxes 1, 3, and 5.

An employee’s contributions to an HSA (unless made

through a cafeteria plan) are includible in income as wages and

are subject to income tax withholding and social security and

Medicare taxes. Employee contributions may be deductible,

within limits, on the employee’s tax return. For more information

about HSAs, see Notice 2004-2, 2004-2 I.R.B. 269, available at

www.irs.gov/irb/2004-02_IRB/ar09.html. Also see Notice

2004-50, 2004-33 I.R.B. 196, available at www.irs.gov/irb/

2004-33_IRB/ar08.html, and Notice 2008-59, 2008-29 I.R.B.

123, available at www.irs.gov/irb/2008-29_IRB/ar11.html. You

also can find information in the Form 8889 instructions and Pub.

969, both dealing with health savings accounts.

Lost form — reissued statement. If an employee loses a

form, enter “REISSUED STATEMENT” on the new copy (unless

!

-4-

Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

Sick pay. If you had employees who received sick pay in 2011

from an insurance company or other third-party payer and the

third party notified you of the amount of sick pay involved, you

may be required to report the information on the employees’

Forms W-2AS, W-2CM, W-2GU, or W-2VI. If the insurance

company or other third-party payer did not notify you in a timely

manner about the sick pay payments, it must prepare Forms

W-2AS, W-2CM, W-2GU, or W-2VI, and W-3SS for your

employees showing the sick pay. For specific reporting

instructions, see section 6 of Pub. 15-A.

Terminating a business. If you terminate your business, you

must provide Forms W-2AS, W-2CM, W-2GU, or W-2VI to your

employees for the calendar year of termination by the due date

of your final Form 941-SS, 944-SS, or 943. If filing on paper,

make sure you obtain Forms W-2AS, W-2CM, W-2GU, or

W-2VI preprinted with the correct year. If filing electronically,

make sure your software has been updated for the current tax

year. You also must file Forms W-2AS, W-2CM, W-2GU, or

W-2VI with the SSA by the last day of the month that follows the

due date of your final Form 941-SS, 944-SS, or 943.

If any of your employees are immediately employed by a

successor employer, see Rev. Proc. 2004-53 for information on

who must file Forms W-2AS, W-2CM, W-2GU, or W-2VI, and

employment tax returns. You can find Rev. Proc. 2004-53,

2004-34 I.R.B. 320, at www.irs.gov/irb/2004-34_IRB/ar13.html.

For information on automatic extensions for furnishing Forms

W-2AS, W-2CM, W-2GU, or W-2VI to employees and filing

them with the SSA, see Rev. Proc. 96-57, which is on page 14

of Internal Revenue Bulletin 1996-53 at www.irs.gov/pub/

irs-irbs/irb96-53.pdf.

it was furnished electronically), and furnish it to the employee.

Do not send Copy A of the reissued statement to the SSA.

Employers are not prohibited (by the Internal Revenue Code)

from charging a fee for issuing a duplicate Form W-2AS,

W-2CM, W-2GU, or W-2VI.

Moving expenses. Report moving expenses as follows.

• Qualified moving expenses that an employer paid to a third

party on behalf of the employee (for example, to a moving

company) and services that an employer furnished in kind to an

employee are not reported on Form W-2AS, W-2CM, W-2GU,

or W-2VI.

• Qualified moving expense reimbursements paid directly to an

employee by an employer are reported only in box 12 of Form

W-2AS, W-2CM, W-2GU, or W-2VI with code P.

• Nonqualified moving expense reimbursements are reported

in boxes 1, 3, and 5 of Form W-2AS, W-2GU, or W-2VI. These

amounts are subject to income tax withholding and social

security and Medicare taxes.

Qualified and nonqualified moving expenses are defined in

Pub. 521, Moving Expenses. See the information under

Deductible Moving Expenses and Nondeductible Expenses.

Nonqualified deferred compensation plans. Section 409A

provides that all amounts deferred under a nonqualified

deferred compensation (NQDC) plan for all tax years are

currently includible in gross income unless certain requirements

are met. Section 409A, generally, is effective with respect to

amounts deferred in tax years beginning after December 31,

2004, but deferrals made prior to that year may be subject to

section 409A under some circumstances.

It is not necessary to show amounts deferred during the year

under an NQDC plan subject to section 409A. However, if you

report section 409A deferrals, show the amount in box 12 using

code Y. For more information, see Notice 2008-115, 2008-52

I.R.B. 1367, available at www.irs.gov/irb/2008-52_IRB/ar10.

html.

Income included under section 409A from an NQDC plan will

be reported in box 1, and in box 12 using code Z. This income

is also subject to an additional tax that is calculated on the

employee’s tax return. For more information, see section 5 of

Pub. 15-A. For more information on amounts includible in gross

income, see Notice 2008-113, 2008-51 I.R.B. 1305, available at

www.irs.gov/irb/2008-51_IRB/ar12.html, and Notice 2008-115.

Repayments. If an employee repays you for wages received

in error, do not offset the repayments against current year’s

wages unless the repayments are for amounts received in error

in the current year. Repayments made in the current year, but

related to a prior year or years, must be repaid in gross, not net,

and require special tax treatment by employees in some cases.

You may advise the employee of the total repayments made

during the current year and the amount (if any) related to prior

years. This information will help the employee account for such

repayments on his or her federal and/or local income tax return.

If the repayment was for a prior year, you must file Form

W-2c with the SSA to correct only social security and Medicare

wages and taxes. Do not correct ‘‘Wages, tips, other

compensation’’ in box 1, or ‘‘Federal income tax withheld’’ in

box 2, on Form W-2c. File the amended return as appropriate

for the return on which the wages were originally reported

(Form 941-X, 943-X, or 944-X). Amend the social security and

Medicare wages and taxes for the period during which the

wages were originally paid. For information on reporting

adjustments to Form 941-SS, Form 943, or Form 944-SS, see

Pub. 80 (Circular SS).

Specific Instructions for Forms W-2AS,

W-2GU, and W-2VI

Form W-2CM. For specific instructions for the 2011 Form

W-2CM, see the 2011 Supplemental Instructions for Forms

W-2CM and OS-3710, published by the Division of Revenue

and Taxation, Commonwealth of the Northern Mariana Islands.

How to complete Forms W-2AS, W-2GU, or W-2VI. These

are 5-part forms. Ensure that all copies are legible. Send Copy

A to the SSA, Copy 1 to your tax department, and Copies B and

C to your employee. Keep Copy D, and a copy of Form W-3SS,

with your records for 4 years.

Type entries on these forms using black ink and 12-point

Courier font. Copy A is read by machine and must be typed

clearly with no corrections made to the entries and no entries

exceeding the size of the boxes. Entries completed by hand, in

script or italics fonts, or in colors other than black cannot be

read by the machines. Make all dollar entries without the dollar

sign and comma, but with the decimal point (00000.00). Show

the cents portion of the money amounts. If a box does not

apply, leave it blank.

Calendar year basis. Base all entries on Forms W-2AS,

W-2GU, W-2VI, or W-3SS on a calendar year. Use the current

year form.

Void. Check this box when an error is made on Forms W-2AS,

W-2GU, or W-2VI and you are voiding it because you will

complete a new form. Do not include any amounts shown on

“Void” forms in the totals you enter on Form W-3SS. See

Corrections on page 3.

Box a — Employee’s social security number. Enter the

number shown on the employee’s social security card. If the

employee does not have a card, he or she should apply for one

by completing Form SS-5, Application for a Social Security

Card. If the employee has applied for a social security number,

enter “Applied For” in box a on paper Forms W-2AS, W-2GU, or

W-2VI filed with the SSA. Enter zeros (000000000) if the form is

filed electronically.

Ask the employee to inform you of the number and name as

they are shown on the social security card when it is received.

Then correct your previous report by filing Form W-2c showing

the employee’s SSN. If the employee needs to change his or

Tell your employee that the wages paid in error in a prior

TIP year remain taxable to him or her for that year. This is

because the employee received and had use of those

funds during that year. The employee is not entitled to file an

amended return (Form 1040X) to recover the income tax on

these wages. Instead, the employee is entitled to a deduction

(or a credit, in some cases) for the repaid wages on his or her

Form 1040 for the year of repayment. Refer your employee to

Repayments in Pub. 525, Taxable and Nontaxable Income.

Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

-5-

Box 4 — Social security tax withheld. Show the total

employee social security tax (not your share) withheld or paid

by you for the employee, including social security tax on tips.

For 2011, the amount shown should not exceed $4,485.60

($106,800 x 4.2%). Include only tax withheld (or paid by you for

the employee) for 2011 wages and tips. If you paid your

employee’s share, see Employee’s social security and

Medicare taxes paid by employer on page 4.

Box 5 — Medicare wages and tips. Show the total wages

paid and tips reported subject to employee Medicare tax. There

is no wage base limit for Medicare tax. Be sure to enter tips the

employee reported even if you did not have enough employee

funds to collect the Medicare tax for those tips. If you paid your

employee’s share of taxes, see Employee’s social security and

Medicare taxes paid by employer on page 4.

Box 6 — Medicare tax withheld. Enter the total employee

Medicare tax (not the employer’s share) withheld or paid by you

for the employee. Include only tax withheld for 2011 wages and

tips. The rate is 1.45% of all wages and tips. If you paid your

employee’s share of taxes, see Employee’s social security and

Medicare taxes paid by employer on page 4.

Box 7 — Social security tips. Show the tips that the employee

reported to you even if you did not have enough employee

funds to collect the social security tax for the tips. The total of

boxes 3 and 7 should not be more than $106,800 for 2011.

Report all tips in box 1, along with wages and other

compensation. Include in box 5 any tips reported in box 7.

Box 11 — Nonqualified plans. The purpose of box 11 is for

the SSA to determine if any part of the amount reported in box

1 or box(es) 3 and/or 5 was earned in a prior year. The SSA

uses this information to verify that they have properly applied

the social security earnings test and paid the correct amount of

benefits.

Show distributions to an employee from a nonqualified

deferred compensation plan or nongovernmental section 457(b)

plan. Also report these distributions in box 1. Make only one

entry in this box. Distributions from governmental section 457(b)

plans must be reported on Form 1099-R, not in box 1 of Form

W-2AS, W-2GU, or W-2VI.

If you did not make distributions this year, show deferrals

(plus earnings) under a nonqualified deferred compensation

plan or any section 457(b) plan that became taxable for social

security and Medicare taxes during the year (but were for prior

year services) because the deferred amounts were no longer

subject to a substantial risk of forfeiture. Also report these

amounts in boxes 3 (up to the social security wage base) and 5.

Do not report in box 11 deferrals included in box(es) 3 and/or 5

and deferrals for current year services (such as those with no

risk of forfeiture).

her name from that shown on the card, the employee should

call the SSA at 1-800-772-1213 (toll free except in American

Samoa).

If you do not provide the correct employee name and TIN on

Form W-2AS, W-2GU, or W-2VI, you may owe a penalty unless

you have reasonable cause. For more information, see

Publication 1586, Reasonable Cause Regulations and

Requirements for Missing and Incorrect Name/TINs.

Box b — Employer identification number (EIN). Show the

employer identification number (EIN) assigned to you by the

IRS (00-0000000). This should be the same number that you

used on your Form 941-SS, 944-SS, or 943. Do not use a prior

owner’s EIN. If you do not have an EIN, enter “Applied For” in

box b; do not use your SSN. You can get an EIN by applying

online at IRS.gov, by calling the toll-free (except in American

Samoa) number 1-800-829-4933, or by filing Form SS-4,

Application for Employer Identification Number.

Box c — Employer’s name, address, and ZIP code. This

entry should be the same as shown on your Form 941-SS,

944-SS, or 943.

Box d — Control number. You may use this box to identify

individual forms. You do not have to use this box.

Boxes e and f — Employee’s name and address. Enter the

name as shown on the employee’s social security card (first,

middle initial, last). Do not enter “Jr.,” “Sr.,” etc. on Copy A

unless the suffix appears on the card. You may enter an

employee’s name suffix in the designated area of box e, but

SSA prefers that you do not enter the suffix on Copy A. If the

name does not fit, you may show first name initial, middle initial,

and last name (and ignore the vertical lines). If the name has

changed, the employee must get a corrected card from any

SSA office. Use the name on the original card until you see the

corrected card. Do not show titles or academic degrees, such

as “Dr.,” “RN,” or “Esq.,” at the beginning or end of the

employee’s name.

Include in the address the number, street, apartment or suite

number (or P.O. box number if mail is not delivered to a street

address).

Third-party payers of sick pay filing a third-party sick pay

recap Form W-2AS, W-2GU, or W-2VI must enter “Third-Party

Sick Pay Recap” in place of the employee’s name in box e. Do

not enter the employee’s SSN in box a. See section 6 of Pub.

15-A.

Box 1 — Wages, tips, other compensation. Show the total

taxable wages, tips, and other compensation (before any

payroll deductions) you paid to your employee during the year,

such as: (a) wages, bonuses, prizes, and awards; (b) noncash

payments, including certain fringe benefits; (c) tips reported; (d)

taxable cost of group-term life insurance over $50,000; (e)

distributions from a nonqualified or nongovernmental section

457(b) plan; and (f) cost of current insurance protection under a

compensatory split-dollar life insurance arrangement. Other

compensation includes amounts you pay the employee from

which income tax is not withheld. You may show other

compensation on a separate Form W-2AS, W-2GU, or W-2VI.

Note. Show payments to statutory employees whose earnings

are subject to social security and Medicare taxes but not

subject to income tax withholding in box 1 as other

compensation. See Pub. 80 (Circular SS) for the definition of a

statutory employee.

If you made distributions and are also reporting any

deferrals in box(es) 3 and/or 5, do not complete box 11.

CAUTION

See Pub. 957, Reporting Back Pay and Special Wage

Payments to the Social Security Administration, and Form

SSA-131, Employer Report of Special Wage Payments, for

special reporting instructions for these and other kinds of

compensation earned in prior years. However, do not file Form

SSA-131 in this situation if the employee will not be age 62 or

older by the end of that year.

Note. Do not report special wage payments, such as

accumulated sick or vacation pay, in box 11. For more

information on reporting special wage payments, see Pub. 957.

Box 12 — Codes. Complete and code this box for all items

described on pages 7 and 8. On Copy A, do not enter more

than four items in box 12. If more than four items need to be

reported in box 12, use a separate Form W-2AS, W-2GU, or

W-2VI for additional items. You may enter more than four items

on all other copies when using an approved substitute form.

Show the IRS code (using a capital letter or letters) to the left

of the vertical line in boxes 12a – 12d and the dollar amount to

the right of the vertical line. Use decimal points but no dollar

signs or commas (for example, D 5300.00).

!

Box 2 — Income tax withheld. Show the total American

Samoa, Guam, or USVI income tax withheld.

Box 3 — Social security wages. Show the total wages paid

(before payroll deductions) subject to employee social security

tax. Do not include tips. Generally, noncash payments are

considered wages. If you paid the employee’s share of social

security and Medicare taxes rather than deducting them from

wages, see Employee’s social security and Medicare taxes paid

by employer on page 4. The total of boxes 3 and 7 cannot be

more than $106,800 (2011 maximum social security wage

base). See Pub. 80 (Circular SS) for more information.

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Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

Code A — Uncollected social security tax on tips. Show

the employee social security tax on tips that you could not

collect because the employee did not have enough funds from

which to deduct it. Do not include this amount in box 4.

Code B — Uncollected Medicare tax on tips. Show the

employee Medicare tax on tips that you could not collect

because the employee did not have enough funds from which

to deduct it. Do not include this amount in box 6.

Code C — Taxable cost of group-term life insurance over

$50,000. Show the taxable cost of group-term life insurance

coverage over $50,000 provided to your employee (including a

former employee). See Group-term life insurance on page 4.

Also include this amount in boxes 1, 3 (up to the social security

wage base), and 5.

Codes D through H, S, Y, AA, BB, and EE. Use these

codes to show pre-tax elective deferrals and designated Roth

contributions made to the plans listed. Do not report amounts

for other types of plans. The example under Code D (see

below) shows how to report elective deferrals under a section

401(k) plan.

Report as elective deferrals and designated Roth

contributions only the part of the employee’s salary (or other

compensation) that he or she did not receive because of the

deferrals or designated Roth contributions. Only elective

deferrals and designated Roth contributions should be reported

in box 12 for all coded plans; except when using code G for

section 457(b) plans, include both elective and nonelective

deferrals.

For employees who were 50 years of age or older at any

time during the year and made elective deferral and/or

designated Roth “catch-up” contributions, report the elective

deferrals and the elective deferral “catch-up” contributions as a

single sum in box 12 using the appropriate code, and the

designated Roth contributions and the designated Roth

“catch-up” contributions as a single sum in box 12 using the

appropriate code.

The following are not elective deferrals and may be reported

in box 14, but not in box 12: (a) nonelective employer

contributions on behalf of an employee; (b) after-tax

contributions that are not designated Roth contributions, such

as voluntary contributions to a pension plan that are deducted

from an employee’s pay; and (c) required employee and

employer matching contributions. See the code AA, BB, and EE

instructions on page 8 for reporting designated Roth

contributions.

Code D — Elective deferrals to a section 401(k) cash or

deferred arrangement (plan). Also show deferrals under a

SIMPLE retirement account that is part of a section 401(k)

arrangement.

nonelective contribution and the $3,000 nonelective

profit-sharing employer contribution are not required to be

reported on Form W-2AS, W-2GU, or W-2VI, but may be

reported in box 14.

Check the “Retirement plan” box in box 13.

Code E — Elective deferrals under a section 403(b)

salary reduction agreement.

Code F — Elective deferrals under a section 408(k)(6)

salary reduction SEP.

Code G — Elective deferrals and employer contributions

(including nonelective deferrals) to any governmental or

nongovernmental section 457(b) deferred compensation

plan. Do not report either section 457(b) or section 457(f)

amounts that are subject to a substantial risk of forfeiture.

Code H — Elective deferrals under a section

501(c)(18)(D) tax-exempt organization plan. Be sure to

include this amount in box 1 as wages. The employee will

deduct the amount on his or her income tax return.

Code J — Nontaxable sick pay. Show any sick pay that

was paid by a third party and was not includible in income (and

not shown in boxes 1, 3, and 5) because the employee

contributed to the sick pay plan.

Code M — Uncollected social security tax on taxable

cost of group-term life insurance over $50,000 (for former

employees). If you provided your former employees (including

retirees) more than $50,000 of group-term life insurance

coverage for periods during which an employment relationship

no longer existed, enter the amount of uncollected social

security tax on the coverage in box 12. See Group-term life

insurance on page 4.

Code N — Uncollected Medicare tax on taxable cost of

group-term life insurance over $50,000 (for former

employees). Enter any uncollected Medicare tax on the cost

of group-term life insurance coverage over $50,000 for your

former employees. See Code M above.

Code P — Excludable moving expense reimbursements

paid directly to employee. Show the total moving expense

reimbursements that you paid directly to your employee for

qualified (deductible) moving expenses. See Moving expenses

on page 5.

Code Q — Nontaxable combat pay. If you are a military

employer, report any nontaxable combat pay in box 12.

Code R — Employer contributions to an Archer MSA.

Show any employer contributions to an Archer MSA. See

Archer MSA on page 3.

Code S — Employee salary reduction contributions

under a section 408(p) SIMPLE. Show deferrals under a

section 408(p) salary reduction SIMPLE retirement account.

However, if the SIMPLE is part of a section 401(k)

arrangement, use code D.

Code T — Adoption benefits. Show the total that you paid

or reimbursed for qualified adoption expenses furnished to your

employee under an adoption assistance program. Also include

adoption benefits paid or reimbursed from the pre-tax

contributions made by the employee to a section 125 (cafeteria)

plan. However, do not include adoption benefits forfeited from a

section 125 (cafeteria) plan. Report all amounts including those

in excess of the $13,360 exclusion.

Code V — Income from the exercise of nonstatutory

stock option(s). Show the spread (that is, fair market value of

stock over the exercise price of option(s) granted to your

employee with respect to that stock) from your employee’s (or

former employee’s) exercise of nonstatutory stock option(s).

Include this amount in boxes 1, 3 (up to the social security

wage base), and 5.

This reporting requirement does not apply to the exercise of

a statutory stock option, or the sale or disposition of stock

acquired pursuant to the exercise of a statutory stock option.

For more information about the taxability of employee stock

options, see Pub. 15-B.

Example of reporting excess elective deferrals and

designated Roth contributions under a section 401(k) plan.

For 2011, Employee A (age 45) elected to defer $18,300 under

a section 401(k) plan. The employee also made a designated

Roth contribution to the plan of $1,000, and made a voluntary

(non-Roth) after-tax contribution of $600. In addition, the

employer, on A’s behalf, made a qualified nonelective

contribution of $2,000 to the plan and a nonelective

profit-sharing employer contribution of $3,000.

Even though the 2011 limit for elective deferrals and

designated Roth contributions is $16,500, the employee’s total

elective deferral amount of $18,300 is reported in box 12 with

code D (D 18300.00). The designated Roth contribution is

reported in box 12 with code AA (AA 1000.00). The employer

must separately report the actual amounts of $18,300 and

$1,000 in box 12 with the appropriate codes. The amount

deferred in excess of the limit is not reported in box 1. The

return of excess salary deferrals and excess designated

contributions, including earnings on both, is reported on Form

1099-R.

The $600 voluntary after-tax contribution may be reported in

box 14 (this is optional) but not in box 12. The $2,000

Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

-7-

Code W — Employer contributions to an employee’s

health savings account (HSA). Show any employer

contributions (including amounts the employee elected to pay

using a section 125 (cafeteria) plan) to your employee’s HSA.

See Health savings account (HSA) on page 4.

Code Y — Deferrals under a section 409A nonqualified

deferred compensation plan. It is not necessary to show

deferrals under this type of plan. For more information see

Notice 2008-115, 2008-52 I.R.B. 1367, available at www.irs.

gov/irb/2008-52_IRB/ar10.html. However, if you do report these

deferrals, show current year deferrals, including earnings during

the year on current year and prior year deferrals, in box 12 with

code Y. See Nonqualified deferred compensation plans on

page 5.

Code Z — Income under section 409A on a nonqualified

deferred compensation plan. Enter all amounts deferred

(including earnings on amounts deferred) that are includible in

income under section 409A because the nonqualified deferred

compensation (NQDC) plan fails to satisfy the requirements of

section 409A. Do not include amounts properly reported on a

Form 1099-MISC, or a corrected Form 1099-MISC, W-2AS,

W-2GU, W-2VI, or W-2c for a prior year. Also, do not include

amounts that are considered to be subject to a substantial risk

of forfeiture for purposes of section 409A. For more information,

see Regulations sections 1.409A-1 through 1.409A-6, Notice

2008-113, and Notice 2008-115.

The amount reported in box 12 using code Z is also reported

in box 1, and is subject to an additional tax reported on the

employee’s tax return.

Code AA — Designated Roth contributions under a

section 401(k) plan. Use this code to report designated Roth

contributions under a section 401(k) plan. Do not use this code

to report elective deferrals under code D. See Designated Roth

contributions on page 4.

Code BB — Designated Roth contributions under a

section 403(b) plan. Use this code to report designated Roth

contributions under a section 403(b) plan. Do not use this code

to report elective deferrals under code E. See Designated Roth

contributions on page 4.

Code DD — Cost of employer-sponsored health

coverage. The amount reported with code DD is not taxable.

See Interim relief for Form W-2 reporting of the cost of

coverage of group health insurance on page 1.

Code EE — Designated Roth contributions under a

governmental section 457(b) plan. Use this code to report

designated Roth contributions under a governmental section

457(b) plan. Do not use this code to report elective deferrals

under code G. See Designated Roth contributions on page 4.

Box 13 — Checkboxes. Check all boxes that apply.

• Statutory employee. Check this box for statutory employees

whose earnings are subject to social security and Medicare

taxes but not subject to income tax withholding. Do not check

this box for common law employees. See section 1 of Pub.

15-A for the definition of statutory employees.

• Retirement plan. Check this box if the employee was an

“active participant” (for any part of the year) in any of the

following plans.

1. A qualified pension, profit-sharing, or stock bonus plan

described in section 401(a) (including a 401(k) plan).

2. An annuity plan described in section 403(a).

3. An annuity contract or custodial account described in

section 403(b).

4. A simplified employee pension (SEP) plan described in

section 408(k).

5. A SIMPLE retirement account described in section

408(p).

6. A trust described in section 501(c)(18).

7. A plan for federal, state, or local government employees,

or an agency or instrumentality thereof (other than a section

457(b) plan).

Generally, an employee is an active participant if covered by

(a) a defined benefit plan for any tax year that he or she is

eligible to participate, or (b) a defined contribution plan (for

example, a section 401(k) plan) for any tax year that employer

or employee contributions (or forfeitures) are added to his or

her account. For additional information on employees who are

eligible to participate in a plan, contact your plan administrator.

For details on the active participant rules, see section

219(g)(5); Notice 87-16, 1987-1 C.B. 446; and Pub. 590,

Individual Retirement Arrangements (IRAs). Also see Notice

98-49, which is on page 5 of Internal Revenue Bulletin 1998-38

at www.irs.gov/pub/irs-irbs/irb98-38.pdf.

!

Do not check this box for contributions made to a

nonqualified plan or section 457(b) plan.

CAUTION

• Third-party sick pay. Check this box only if you are a

third-party sick pay payer filing a Form W-2AS, W-2GU, or

W-2VI for an insured’s employee or are an employer reporting

sick pay payments made by a third party. See section 6 of Pub.

15-A.

Box 14 — Other. The lease value of a vehicle provided to your

employee and reported in box 1 must be reported here or on a

separate statement to your employee. You also may use this

box for any other information that you want to give to your

employee, such as health insurance premiums deducted, union

dues, voluntary after-tax contributions (but not designated Roth

contributions) to a pension plan, or nontaxable income. Label

each entry.

Specific Instructions for Form W-3SS

How to complete Form W-3SS. Type entries using black ink

and 12-point Courier font. Make all entries without the dollar

sign and comma but with the decimal point (00000.00). If a box

does not apply, leave it blank.

Box a — Control number. This is an optional box that you

may use for numbering the whole transmittal.

Box b — Kind of Payer. Check only one box unless the

second checked box is “Third-party sick pay.” If you have

Forms W-2AS, W-2CM, W-2GU, or W-2VI with more than one

kind of payer, send each type with a separate Form W-3SS.

However, “third-party sick pay” does not designate a separate

kind of payer. When this box is checked, it will always be in

addition to the box that designates the kind of payer.

941-SS. Check this box if you file Form 941-SS and no

other category (except “Third-party sick pay”) applies. A church

or church organization should check this box even if it is not

required to file Form 941-SS or 944-SS.

Military. Check this box if you are a military employer

sending Forms W-2AS, W-2CM, W-2GU, or W-2VI for members

of the uniformed services.

943. Check this box if you file Form 943 and are sending

forms for agricultural employees. For nonagricultural

employees, send their Forms W-2AS, W-2CM, W-2GU, or

W-2VI with a separate Form W-3SS.

944-SS. Check this box if you file Form 944-SS and no

other category (except “Third-party sick pay”) applies.

Hshld. emp. Check this box if you are a household

employer sending Forms W-2AS, W-2CM, W-2GU, or W-2VI for

household employees, and you did not include a household

employee’s taxes on Form 941-SS, 944-SS, or 943.

Medicare govt. emp. Check this box if you are a U.S. or a

U.S. Virgin Islands government employer with employees

subject only to the 1.45% Medicare tax.

Third-party sick pay. Check this box (at far right of form)

and one other box if you are a payer of third-party sick pay (or

are reporting sick pay payments made by a third party) filing

Forms W-2AS, W-2CM, W-2GU, or W-2VI with “Third-party sick

pay” checked in box 13.

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Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

Box b — Kind of Employer. Check the box that applies to

you. Check only one box unless the second box checked is

‘‘Third-party sick pay’’.

None apply. Check this box if none of the checkboxes

below apply to you.

501c non-govt. Check this box if you are a

non-governmental tax-exempt section 501(c) organization.

State/local non-501c. Check this box if you are a state or

local government or instrumentality that is not a tax-exempt

section 501(c) organization.

State/local 501c. Check this box if you are a dual status

state or local government or instrumentality that is also a

tax-exempt section 501(c) organization.

Federal govt. Check this box if you are a Federal

government entity or instrumentality.

Box c — Total number of Forms W-2. Show the number of

completed individual Forms W-2AS, W-2CM, W-2GU, or W-2VI

filed with this Form W-3SS. Do not count “Void” forms.

Box d — Establishment number. You may use this box to

identify separate establishments in your business. You may file

a separate Form W-3SS, with Forms W-2AS, W-2CM, W-2GU,

or W-2VI, for each establishment even if they all have the same

EIN; or you may use a single Form W-3SS for all Forms

W-2AS, W-2CM, W-2GU, or W-2VI of the same type.

Box e — Employer identification number (EIN). If you

received a preprinted Form W-3SS from the IRS with Pub. 80

(Circular SS), verify that your EIN is correct. Make any

necessary corrections on the form. If you are not using a

preprinted IRS Form W-3SS, enter the nine-digit EIN assigned

to you by the IRS. The EIN should be the same as that shown

on your Form 941-SS, 944-SS, or 943 and in the following

format: 00-0000000. Do not use a prior owner’s EIN. If you do

not have an EIN, see Box b — Employer identification number

(EIN) on page 6. See also Box h below.

Boxes f and g — Employer’s name and address. If you are

not using a preprinted Form W-3SS, enter your name and

address as shown on your Form 941-SS, 944-SS, or 943. Make

any necessary corrections on your preprinted Form W-3SS.

Box h — Other EIN used this year. If you have used an EIN

(including a prior owner’s EIN) on Form 941-SS, 944-SS, or 943

submitted for 2011 that is different from the EIN reported in

box e on this form, enter the other EIN used.

Contact person, telephone number, fax number, and email

address. Include this information for use by the SSA if

questions arise during processing.

Boxes 1 through 7. Enter the totals reported in boxes 1

through 7 of Forms W-2AS, W-2CM, W-2GU, or W-2VI being

filed with this Form W-3SS.

Box 11 — Nonqualified plans. Enter the total reported in box

11 on Forms W-2AS, W-2CM, W-2GU, or W-2VI being filed with

this Form W-3SS.

Box 12a — Deferred compensation. Enter the total of all

amounts reported with codes D through H, S, Y, AA, BB, and

EE in box 12 on Forms W-2AS, W-2GU, W-2CM, or W-2VI. Do

not enter a code.

Box 13 — For third-party sick pay use only. Third-party

payers of sick pay (or employers using the optional rule for

Form W-2AS, W-2CM, W-2GU, or W-2VI described in section 6

Inst. for Form W-2AS, W-2GU, W-2VI, and W-3SS (2011)

of Pub. 15-A) filing third-party sick pay recap Forms W-2AS,

W-2CM, W-2GU, or W-2VI, and W-3SS must enter “Third-Party

Sick Pay Recap” in this box. See section 6 of Pub. 15-A for

details.

Box 14 — Income tax withheld by payer of third-party sick

pay. Complete this box only if you are the employer and have

employees who had income tax withheld on third-party

payments of sick pay. Show the total income tax withheld by

third-party payers on payments to all of your employees.

Although this tax is included in the box 2 total, it must be shown

separately here.

Box 15 — Type of form. Check this box for the type of forms

you are submitting with this Form W-3SS.

Signature. The signature on Copies A and 1 of Form W-3SS

must be an original (not a copy).

Privacy Act and Paperwork Reduction Act Notice We ask

for the information on Forms W-2AS, W-2CM, W-2GU, W-2VI,

and W-3SS to carry out the Internal Revenue laws of the United

States. We need it to figure and collect the right amount of tax.

Section 6051 and its regulations require you to furnish wage

and tax statements to employees, the Social Security

Administration, and the Internal Revenue Service. Section 6109

requires you to provide your employer identification number

(EIN). Failure to provide this information, or providing false or

fraudulent information, may subject you to penalties.

You are not required to provide the information requested on

a form that is subject to the Paperwork Reduction Act unless

the form displays a valid OMB control number. Books or

records relating to a form or its instructions must be retained as

long as their contents may become material in the

administration of any Internal Revenue law.

Generally, tax returns and return information are confidential,

as required by section 6103. However, section 6103 allows or

requires the Internal Revenue Service to disclose or give the

information shown on your return to others as described in the

Code. For example, we may disclose your tax information to the

Department of Justice for civil and/or criminal litigation, and to

cities, states, the District of Columbia, and U.S.

commonwealths and possessions for use in administering their

tax laws. We also may disclose this information to other

countries under a tax treaty, to federal and state agencies to

enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism.

The time needed to complete and file these forms will vary

depending on individual circumstances. The estimated average

times are: Form W-2AS — 23 minutes; Form W-2GU — 24

minutes; Form W-2VI — 24 minutes; Form W-3SS — 24

minutes.

If you have comments concerning the accuracy of these

time estimates or suggestions for making these forms simpler,

we would be happy to hear from you. You can write to the

Internal Revenue Service, Tax Products Coordinating

Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.

NW, IR-6526, Washington, DC 20224. Do not send Form

W-2AS, W-2CM, W-2GU, W-2VI, or W-3SS to this address.

Instead, see Where To File on page 2.

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