Please do not staple
1 Control number OMB No. 1545-0008
33333
2 941SS Military 943 3 4 5 Total
Kind number of
statements
of
Payer 942 Medicare govt. emp.
6 7 Advance EIC payments 8 Establishment number
9 Income tax withheld 10 Wages, tips, and other compensation 11 Social security tax withheld
12 Social security wages 13 Social security tips 14 Medicare tax withheld
15 Employer’s identification number 16 Medicare wages and tips
17 Employer’s name 18 Other EIN used this year
20 Adjusted total social security wages and tips
21 Adjusted total Medicare wages and tips
19 Employer’s address and ZIP code (If available, place label over Boxes 15, 17, and 19.)
Copy A—For Social Security Administration
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.
Signature Title Date
Department of the Treasury
Form W-3SS Transmittal of Wage and Tax Statements 1992 Internal Revenue Service
Notice to Employers in the Commonwealth of the Northern
Mariana Islands
If you are an employer in the Commonwealth of the Northern Mariana
Islands, you must contact the Division of Revenue and Taxation, Capital
Hill, Saipan, MP 96950, to get Form W-2CM and the instructions for
completing and filing that form.
Employers in Guam, the Commonwealth of the Northern
Mariana Islands, the Virgin Islands, and American Samoa
Please return this entire page along with Copy A of Forms W-2GU,
W-2CM, W-2VI, or W-2AS to the Social Security Administration, Data
Operations Center, Wilkes-Barre, PA 18769.
Note: Employers in Amer ican Samoa, send Copy 1 of For ms W-2AS to
the American Samoa Tax Office, Gover nment of Amer ican Samoa,
Pago Pago, AS 96799.
Paperwork Reduction Act Notice
We ask for the information on these forms to carry out the Internal
Revenue laws of the United States. You are required to give us the
information. We need it to ensure that taxpayers are complying with
these laws and to allow us to figure and collect the right amount of tax.
The time needed to complete and file these forms will vary depending on
individual circumstances. The estimated average times are:
Form W-2AS — 22 minutes Form W-2VI — 20 minutes
Form W-2GU — 22 minutes Form W-3SS — 22 minutes
If you have comments concerning the accuracy of these time estimates
or suggestions for making these forms more simple, we would be happy
to hear from you. You can write to both the Internal Revenue Service,
Washington, DC 20224, Attention: IRS Reports Clearance Officer, T:FP;
and the Office of Management and Budget, Paperwork Reduction
Project (1545-0008), Washington, DC 20503. Do NOT send the tax forms
to either of these offices. Instead, see the instructions for the forms for
information on where to file them.
Cat. No. 10117S
Please do not staple
1 Control number OMB No. 1545-0008
33333
2 941SS Military 943 3 4 5 Total
Kind number of
statements
of
Payer 942 Medicare govt. emp.
6 7 Advance EIC payments 8 Establishment number
9 Income tax withheld 10 Wages, tips, and other compensation 11 Social security tax withheld
12 Social security wages 13 Social security tips 14 Medicare tax withheld
15 Employer’s identification number 16 Medicare wages and tips
17 Employer’s name 18 Other EIN used this year
20 Adjusted total social security wages and tips
21 Adjusted total Medicare wages and tips
19 Employer’s address and ZIP code
Copy 1—For Local Tax Department
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief,
they are true, correct, and complete.
Signature Title Date
Department of the Treasury
Form W-3SS Transmittal of Wage and Tax Statements 1992 Internal Revenue Service
Special Instructions for (c) in Box 12, the words “Third- income in Box 6 on Form W-2AS,
party sick pay” in place of the W-2GU, or W-2VI, preceded by
Reporting Sick Pay employee’s name; code J.
Sick pay paid to an employee by a (d) in Box 13, the total of all sick pay You may include these amounts in
third party, such as an insurance subject to employee social security the Form W-2AS, W-2GU, or W-2VI
company or trust, requires special tax; you issue the employee showing
treatment at year-end because the IRS (e) in Box 15, the total of all sick pay wages, or you may give the employee
reconciles an entity’s Forms 941SS subject to employee Medicare tax; and a separate Form W-2AS, W-2GU, or
with the Forms W-2AS, W-2GU, W-2VI and state that the amounts are
W-2CM, or W-2VI and Form W-3SS (f) in Box 16, the total employee for third-party sick pay. In either case,
filed at the end of the year. See Pub. Medicare tax withheld and paid to the be sure to file Copy A of the forms
80 (Circular SS), Federal Tax Guide IRS on your Form 941SS. with the Social Security Administration.
for Employers in the Virgin Islands, On the separate Form W-3SS, B. If the third-party payer does not
Guam, American Samoa, and the complete only Boxes 2, 10, 11, 12, 14, notify the employer about sick pay,
Commonwealth of the Northern 15, 16, 17, and 19. then the following instructions apply:
Mariana Islands, for information on 2. Employers.—If you had employees
who should prepare the Forms W-2AS, who received sick pay in 1992 from an 1. Third-party payers.—Because you
W-2GU, W-2CM, or W-2VI and did not notify the employer about the
insurance company or other third-party sick pay payments, you are
W-3SS. Employers in the payer, you must report the following
Commonwealth of the Northern responsible for completing Form
on the employee’s Form W-2AS, W-3SS and Form W-2AS, W-2GU, or
Mariana Islands should contact the W-2GU, or W-2VI:
local tax division for instructions on W-2VI, including all the information
(a) in Box 10, the amount of sick pay described in item A-2 above as if you
reporting sick pay on Form W-2CM. the employee must include in income; were the employer.
A. If the third-party payer notifies (b) in Box 11, the employee social
the employer about the sick pay 2. Employers.—Since you were not
security tax withheld by the third-party notified timely about sick pay
payments, then the following
payer; payments made by a third-party, you
instructions apply:
(c) in Box 13, the amount of sick pay are not required to report these
1. Third-party payers.—Because you that is subject to employee social amounts on Form W-2AS, W-2GU, or
withheld social security and Medicare W-2VI.
security tax;
taxes from persons for whom you do
not file Forms W-2AS, W-2GU, or (d) in Box 15, the amount of sick Reporting on Magnetic Media
W-2VI, you must file a separate Form pay that is subject to employee
W-3SS with a single “dummy” Form Medicare tax; and We encourage employers and other
W-2AS, W-2GU, or W-2VI that shows (e) in Box 16, the employee payers with computer capabilities to
the following information: Medicare tax withheld by the use magnetic media for filing the
information on the Wage and Tax
(a) in Box 10, the total sick pay paid third-party payer. Statement. Many filers find that
by you during 1992; If any portion of the payment is not reporting on magnetic media saves
(b) in Box 11, the total employee includible in the employee’s income money and is efficient and flexible.
social security tax withheld and paid to because the employee paid part of the You can get specifications for
the IRS on Form 941SS; premiums, you must notify the furnishing this information on magnetic
employee of the excludable portion. media by writing the Social Security
Report the amount not includible in
Page 3
Administration, Office of Systems W-2GU, W-2CM, W-2VI, and W-3SS Box 1—Control number.—This is
Requirements, P.O. Box 2317, on a calendar year. for the employer to identify individual
Baltimore, MD 21235. E. Taxpayer Identifying Numbers.— forms. You do not have to use this
These numbers are used to post box.
Instructions for earnings to employees’ earnings Box 3—Employer’s identification
records for social security benefits. number.—Show the number assigned
Forms W-2AS, Please be sure to show the correct to you by the IRS. Do not use a prior
W-2GU, W-2CM, and social security number in Box 8 on the owner’s number.
Forms W-2AS, W-2GU, or W-2VI. Box 5—Statutory employee.—
W-2VI Persons in a trade or business use Check this box for statutory
General Instructions an EIN (00-0000000). Individuals use a employees whose earnings are subject
social security number (000-00-0000). to social security tax and Medicare tax
A. Who Must File.—Employers and When you list a number, please but not subject to income tax
other payers in American Samoa, separate the nine digits properly to withholding. (See Circular SS for more
Guam, the Commonwealth of the show the kind of number. information on statutory employees.)
Northern Mariana Islands, and the U.S. Sole proprietors who are payers
Virgin Islands must report wages, Pension plan.—Check this box if
should show their EIN on the the employee was an “active
income tax withheld, U.S. social statements they prepare.
security taxes, and U.S. Medicare participant” (for any part of the year) in
Please show the full name, address, a retirement plan (including a simplified
taxes to their local tax department and
and identifying number of the payer employee pension (SEP)) maintained
to the U.S. Social Security
and recipient on the form. by you. See IRS Notice 87-16, 1987–1
Administration (SSA). Form W-2AS is
used to report American Samoa F. Statements To Employees.— C.B. 446, reprinted as Pub. 1602, for
wages; Form W-2GU is used to report Generally, you should give statements the definition of an active participant.
Guam wages; Form W-2CM is used to to employees by January 31, 1993. If 942 employee.—For household
report the Commonwealth of the employment ends before December employers only. Check this box if you
Northern Mariana Islands wages; and 31, 1992, you may give the statement had only one household employee
Form W-2VI is used to report Virgin any time after employment ends. If the during 1992.
Islands wages. Do not use these employee asks for the form, give him
or her the completed copies within 30 Subtotal.—Employers submitting 41
forms to report wages subject to U.S. or fewer individual Forms W-2 need
Federal income tax withholding. days of the request or the last wage
payment, whichever is later. not give subtotals. Other employers
Rather, use Form W-2 to show U.S. should give subtotals. (See instruction
income tax withheld. Keep for 4 years any employee H above.)
Form W-3SS is used as a transmittal copies of Forms W-2AS, W-2GU,
W-2CM, or W-2VI that you tried to Put an X in the square on the Form
document to send the Forms W-2AS, W-2AS, W-2GU, or W-2VI that shows
W-2GU, W-2CM, or W-2VI to the deliver but could not.
the subtotal dollar amounts for the
proper authority. G. Corrections.—Use Form W-2c,
preceding 41 forms. The subtotal
Statement of Corrected Income and amounts are to be shown in Boxes 7,
B. Where and When To File.—File Tax Amounts, to correct errors in
Copy A of Forms W-2AS, W-2GU, 9, 10, 11, 13, 14, 15, and 16.
previously filed Forms W-2AS, W-2GU,
W-2CM, or W-2VI, and Copy A of W-2CM, and W-2VI. Use Form W-3c, Example: An employer with forms for
Form W-3SS, with the Social Security 86 employees should show a subtotal
Transmittal of Corrected Income and
Administration, Data Operations on the 42nd statement, the 84th
Tax Statements, to transmit the W-2c
Center, Wilkes-Barre, PA 18769, by forms to the SSA. Instructions are on statement (showing the subtotal for
March 1, 1993. statements 43 through 83), and the
the forms. If an employee loses a
File Copy 1 of Forms W-2GU or statement, write “REISSUED 89th statement (showing the subtotal
W-2VI with Copy 1 of Form W-3SS STATEMENT” on the new copy, but for statements 85 through 88). The last
with the local tax department. (For do not send Copy A of the reissued subtotal should be the last completed
more information concerning Copy 1, statement to SSA. form on the page. Void statements are
contact your local tax department.) H. Forms W-2AS, W-2GU, and W-2VI counted in order with good
File Copy 1 of Forms W-2AS and Formats.—Copy A of Forms W-2AS, statements, but do not include the
W-3SS with the American Samoa Tax W-2GU, and W-2VI are printed with money amounts from the void
Office, Government of American three forms to an unperforated page. statements in the subtotal figures.
Samoa, Pago Pago, AS 96799. Send the whole page even if one or Deferred compensation.— Check
C. Shipping and Mailing.—If you send two of the forms are blank or void. If this box if you made contributions on
more than one kind of form, please you are sending 42 or more forms, behalf of the employee to a section
group forms of the same kind, and please show subtotals on every 42nd 401(k), 403(b), 408(k)(6), 457, or
send them in separate groups. For form for the preceding 41 forms to 501(c)(18)(D) retirement plan. See also
example, send Forms W-2GU with one permit checking the transmittal totals. instruction (e) under Box 6.
Form W-3SS and Forms W-2AS with a Make all dollar entries without the Void.—Put an X in this square when
second Form W-3SS. Send the whole dollar sign and comma but with the an error has been made. If possible,
first page with Copy A of Forms decimal point (0000.00). the forms should have no erasures,
W-2AS, W-2GU, W-2CM, or W-2VI. whiteouts, or strikeovers on Copy A.
If you have a large number of forms Specific Instructions Be sure the amounts shown on void
forms are NOT included in your
with one Form W-3SS, you may send for Completing Forms subtotals.
them in separate packages. Show your
name and employer identification W-2AS, W-2GU, and Box 6.—Complete and label this box
number (EIN) on each package. for all items described in (a) through (e)
Number them in order (1 of 4, 2 of 4,
W-2VI below that apply.
etc.), and place Form W-3SS in The instructions below are for boxes (a) You did not collect employee
package 1. Show the number of on the forms. If an entry does not social security tax on all of the
packages at the bottom of Form apply to you, leave it blank. Employers employee’s tips. Show the amount of
W-3SS. If you mail them, you must in the Commonwealth of the Northern the tax that you could not collect
send them first class. Mariana Islands should contact the because the employee did not have
D. Calendar Year Basis.—You must local tax division for instructions on
base all entries on Forms W-2AS, completing Forms W-2CM.
Page 4
1 Control number OMB No. 1545-0008
2 941SS Military 943 3 4 5 Total
Kind number of
statements
of
Payer 942 Medicare govt. emp.
6 7 Advance EIC payments 8 Establishment number
9 Income tax withheld 10 Wages, tips, and other compensation 11 Social security tax withheld
12 Social security wages 13 Social security tips 14 Medicare tax withheld
15 Employer’s identification number 16 Medicare wages and tips
17 Employer’s name 18 Other EIN used this year
20 Adjusted total social security wages and tips
21 Adjusted total Medicare wages and tips
19 Employer’s address and ZIP code
Department of the Treasury
Form W-3SS Transmittal of Wage and Tax Statements 1992 Internal Revenue Service
enough funds from which to deduct it. (such as voluntary contributions to a (g) You provided your former
This amount is not included in Box 11. pension plan that are deducted from employees (including retirees) more
Use code A to label the amount of an employee’s pay after all other than $50,000 of group-term life
uncollected social security tax on tips. deductions have been computed). insurance coverage. Enter the amount
(b) You did not collect employee Neither of these two items, therefore, of uncollected Medicare tax on the
Medicare tax on all of the employee’s should be reported in Box 6. coverage in Box 6. Use code N for
tips because the employee did not The following examples illustrate the uncollected Medicare tax.
have enough funds from which to reporting of elective deferrals in Box 6 Check the “Deferred compensation”
deduct it. Enter the uncollected of Form W-2AS, W-2GU, or W-2VI. checkbox in Box 5, enter the elective
Medicare tax on tips and label code B. Example 1: deferral in Box 6, and label it “401(k),”
This amount is not included in Box 16. “403(b),” etc.
For calendar year 1992, Employee A
(c) Filers of Forms W-2GU and electively deferred $4,000 and made a Box 7—Advance EIC payment.—
W-2VI only. If you provided your voluntary after-tax contribution of Forms W-2GU and W-2VI only. Show
employee more than $50,000 of $500. In addition, the employer, on the amount of the advance earned
group-term life insurance, show the Employee A’s behalf, made a qualified income credit paid to the employee.
cost of the coverage over $50,000. nonelective contribution of $1,000 to Box 8—Employee’s social security
Label the amount with code C. Include the plan and a nonelective number.—Give the number shown on
it in Boxes 10, 13, and 15. profit-sharing employer contribution of the employee’s social security card. An
(d) You are reporting sick pay. Show $2,000. employee without a number should
the amount of any sick pay NOT The total elective deferral of $4,000 apply for one at any SSA office.
includible in income because the is reported in Box 6 preceded with the Box 9—Income tax withheld.—
employee contributed to the sick pay label 401(k). Enter the total amount of income tax
plan. Label it as code J. If you issue a withheld.
separate Form W-2 for sick pay, use Example 2:
Box 6 to label the Form W-2 as “Sick For calendar year 1992, Employee B Box 10—Wages, tips, and other
pay.” electively deferred $9,000 and made a compensation.—Show, before any
voluntary after-tax contribution of payroll deductions, the total of (1)
(e) Elective deferrals were made to a wages paid, (2) noncash payments,
section 401(k) cash or deferred $500. In addition, the employer, on
Employee B’s behalf, made a qualified including fringe benefits, (3) tips
arrangement, to a section 403(b) salary reported, and (4) all other
reduction agreement to purchase an nonelective contribution of $1,000 to
the plan and nonelective profit-sharing compensation. Other compensation is
annuity contract, amounts deferred amounts that you pay the employee
under a section 408(k)(6) salary employer contribution of $2,000.
from which income tax is not withheld.
reduction SEP, to a section 457 The total elective deferral of $9,000 If you prefer not to include it in the
deferred compensation plan for state is reported in Box 6 preceded with the total, you may show it on a separate
or local government employees, or to a label 401(k). Even though the 1992 Form W-2AS, W-2GU, or W-2VI.
section 501(c)(18)(D) tax-exempt limit for elective deferrals is $8,728 the
organization plan. employer would report the total Note: Payments to statutory
amount of $9,000 as the elective employees that are subject to social
The amount to be reported as an security and Medicare taxes but not
elective deferral in Box 6 of Form deferral.
subject to income tax withholding,
W-2AS, W-2GU, or W-2VI is only that (f) You provided your former must be shown in Box 10 as other
portion of the employee’s salary (or employees (including retirees) more compensation. (See Circular SS for the
other compensation) that he or she did than $50,000 of group-term life definition of a statutory employee.)
not receive because of the deferral. insurance coverage. Enter the amount
of uncollected social security tax on Box 11—Social security tax
Nonelective contributions made by withheld.—Show the total employee
an employer on behalf of employees the coverage in Box 6. Use code M
for uncollected social security tax. social security tax (not your share)
are not “elective deferrals.” Nor are
voluntary “after-tax contributions” Page 5
withheld or paid by you for the employee in Box 18 or on a separate Box 9—Income tax withheld.—
employee. Include only taxes withheld statement so that the employee can Show the total withheld income tax
for 1992 wages. If you are making an compute the value of any business use reported.
adjustment in 1992 to correct social of the vehicle. Box 10—Wages, tips, and other
security tax for a prior year, you must compensation.—Show the total
file Form 941c, Statement To Correct Instructions for Form wages, tips, and other compensation
Information Previously Reported on the reported.
Employer’s Federal Tax Return, with W-3SS
your Form 941SS, Employer’s Box 11—Social security tax
A. Who Must File, When to File, and
Quarterly Federal Tax Return, in the withheld.—Show the total withheld
Where to File.—See page 4 under
quarter you find the error, file Copy A social security tax reported.
General Instructions for this
of Form W-2c and give the employee a information. Box 12—Social security wages.—
copy of Form W-2c for the prior year. Show the total social security wages
B. How To Complete Form W-3SS.—
Box 12a—Employee’s name.— reported.
Please type or print entries. Make all
Enter the name as shown on the entries without the dollar sign and Box 13—Social security tips.—
employee’s social security card. comma but with the decimal point Show the total social security tips
If an employee’s social security card (0000.00). reported.
shows a name different from the one The instructions below are for the Box 14—Medicare tax withheld.—
you will use, have the employee get a boxes on Form W-3SS. If an entry Show the total withheld Medicare tax
corrected card from any SSA office. does not apply, leave it blank. reported.
Use the name on the original card until Box 1—Control number.—This box Box 15—Employer identification
you see the corrected one. is for numbering the whole transmittal. number.—Show the number assigned
Box 12b—Employee’s address and You do not have to use this box. to you by the IRS. Do not use a prior
ZIP code.— Enter the employee’s owner’s number. If available, use the
Box 2—Kind of Payer.—Check only
address and ZIP code. label sent to you with Circular SS that
one box.
Box 13—Social security wages.— shows your name, address, and EIN.
941SS.—Check this box if you file
Show the total wages paid (before Box 16—Medicare wages and
Form 941SS and none of the other
payroll deductions) subject to tips.—Show the total Medicare wages
categories apply.
employee social security tax. The total and tips reported.
of Boxes 13 and 14 should not be Military.—Check this box if you are
Box 17—Employer’s name.—If
more than $55,500 (the maximum a military employer sending Forms
available, use the label sent to you
social security wage base for 1992). W-2AS, W-2GU, W-2CM, or W-2VI for
with Circular SS.
Generally, noncash payments are members of the uniformed services.
Box 18—Other EIN used this
considered wages. (See Circular SS for 943.—Check this box if you file
year.—If you have used an EIN
more information.) Form 943 and are sending forms for
(including a prior owner’s number) on
Box 14—Social security tips.— agricultural employees. If you also
Forms 941SS (or 941c), 942, or 943
Show the amount the employee have employees who are not
submitted for 1992 that is different
reported even if you did not have agricultural employees, send each
from the EIN reported in Box 15 on
enough employee funds to collect the group’s Forms W-2AS, W-2GU,
this form, enter the other EIN used.
social security tax for the tips. When W-2CM, or W-2VI with a separate
Form W-3SS. Send the nonagricultural Box 19—Employer’s address and
tips and wages subject to social
security taxes amount to $55,500 (for employees’ forms with a Form W-3SS ZIP code.—If available, use the label
that generally has a checkmark in the sent to you with Circular SS. Make any
1992), do not show any additional tips
941SS box. necessary corrections on the label.
in this box. Show all tips reported in
Box 10 along with wages and other Box 20—Adjusted total social
942.—Check this box if you are a
compensation. security wages and tips.—The
household employer sending Forms
amount reported in this box in most
Box 15—Medicare wages and W-2AS, W-2GU, W-2CM, or W-2VI for
tips.—Show the total wages paid and household employees. If you also have cases should agree with the total
social security wages and tips reported
tips reported subject to employee employees who are not household
to the IRS on your quarterly Forms
Medicare tax. The amount entered in employees, send each group’s forms
941SS (or 941c), 942, and annual
this box should not exceed $130,200 with a separate Form W-3SS.
Form 943 for 1992. However, if you
(the maximum Medicare wage base for Medicare government employee.— filed corrections during the year for the
1992). Check this box if you are a U.S., Virgin previously reported amounts, the total
Box 16—Medicare tax withheld.— Islands, or local agency with reported in this box should reflect
Enter the total employee Medicare tax employees subject only to the 1.45% those changes. To get the adjusted
(not your share) withheld or paid by Medicare tax. total of social security wages and tips,
you for the employee. Include only Box 5—Number of statements you must take into account any
taxes withheld for 1992 wages and attached.—Show the number of current or prior year adjustments in
tips. individual Forms W-2AS, W-2GU, social security wages and tips shown
Box 17—Employer’s use.—You W-2CM, or W-2VI filed with this Form on Forms 941SS (or 941c), 942, or 943
may show any information you want to W-3SS. (such as corrections to prior year
give your employee here such as Box 7—Advance EIC payments.— returns or to errors made when
medical insurance premiums deducted, To be shown only for Forms W-2GU reporting for the current year). If these
union dues deducted, or certain and W-2VI. Enter the total amount of totals do not match, the IRS or the
employee business expense payments shown. SSA may require you to explain any
reimbursements. You should clearly difference and make any corrections.
label the entries. Box 8—Establishment number.—
You may use this block to identify Box 21—Adjusted total Medicare
Box 18—Benefits included in Box separate establishments in your wages and tips.—Generally, the
10.—Show the total value of the business. Use any four-digit number amounts reported in this box should
taxable noncash fringe benefits you choose if you wish to identify agree with the total Medicare wages
included in Box 10 as other them. You may file a separate Form and tips reported to the IRS on Forms
compensation. If you provided a W-3SS, with Forms W-2AS, W-2GU, 941SS (or 941c), 942, and 943 for
vehicle and you included 100% of the W-2CM, or W-2VI, for each 1992. See Box 20 above for more
value in the employee’s income, you establishment even if they all have the information.
must separately report this value to the same EIN.
Page 6