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Sections marked with * are required. The official IRS form fills in live on the right.

1 Employer Information

Tax Year *

Employer Identification Number (EIN) *

Format: XX-XXXXXXX

Business Name *

Company Street Address *

City *

State *

ZIP *

Control Number (Box d)

Employer State ID Number (Box 15)

2 Employee Information

First Name & Middle Initial *

Last Name *

Social Security Number (SSN)

Format: XXX-XX-XXXX

Employee Street Address *

City *

State *

ZIP *

Annual Salary (Box 1 wages) *

Boxes 1–6 and 16–17 are calculated automatically from this — you can override any box below.

3 Box Overrides & Extras (optional) click to expand ▾

Box 1 — Wages, tips, other comp.

Box 2 — Federal income tax withheld

Box 3 — Social security wages

Box 4 — Social security tax withheld

Box 5 — Medicare wages and tips

Box 6 — Medicare tax withheld

Box 7 — Social security tips

Box 8 — Allocated tips

Box 10 — Dependent care benefits

Box 11 — Nonqualified plans

Box 16 — State wages

Box 17 — State income tax

Box 18 — Local wages

Box 19 — Local income tax

Box 20 — Locality name

Box 12a Code

Box 12a Amount

Box 12b Code

Box 12b Amount

Box 13 — Statutory employee

Box 13 — Retirement plan

Box 13 — Third-party sick pay

Box 14 — Other

4 Your Email & Checkout

Your email address *

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