(tips continued on the back) Updated 2/16/17 sh

NEW YORK STATE RESIDENT Tax Information (Forms IT-201 & IT-2): Due date: April 18, 2017

You may use the SPRINTAX software to complete your New York State forms for a fee of $26 or use our instructions here. You may also access ALL of this information on our web site at: http://isso.cornell.edu/financial/taxes/new-york-state-tax-information You are required to file a New York State tax return if you are a New York State RESIDENT for tax purposes (see the back of this page) AND: • New York State taxes were withheld from your pay in 2016 and you want a refund, or • You received more than $4000 in 2016 from a US source, AND some of that is from a New

York source.

If the above do NOT apply to you, you are NOT REQUIRED to file a New York State tax return! **In order to file your New York State Tax forms, you need to first complete a federal non-resident tax form using the SPRINTAX software: http://www.isso.cornell.edu/financial/taxes Tips for filing the IT-201: These are not the only lines you will need to fill in, but these tips cover the usual questions people have. Read these tips and ALSO read and follow the Instruction Booklet available here: http://www.tax.ny.gov/pdf/current_forms/it/it201i.pdf 1. If you file US federal NON-resident tax forms (1040NR or 1040NR-EZ), you may not file your

New York State forms electronically. 2. When filling out the state form, follow the amounts on your federal form as directed by our tips

below or the powerpoint on our website and USE whole dollar amounts ONLY. 3. If you do not have a social security number or an ITIN, but you have filed an ITIN (W-7)

application, then write “ITIN pending” at the upper right in the SSN box on the IT-201. 4. On the top, if you live in Ithaca, county of residence is Tompkins, School district name is Ithaca

and the code is 305. If you live elsewhere, look at the instruction booklet, page 43-46 (attached). 5. Fill in your mailing address in New York State--you do not have to fill in your home country

address (you can leave the permanent address section blank) 6. Line A: you may only choose Single or Married filing separately if you are still considered a

NON-resident for federal tax filing purposes; 7. Line B: Answer “yes” ONLY if the software allowed you to itemize deductions on your federal

return (line 11 on 1040NRez and line 35 on 1040NR) 8. Line C: If you are a NON-resident for U.S. federal tax purposes, answer “No” 9. Line D1: Internationals filing as non-residents for federal tax purposes should check “No” 10. Line D2: Most will answer “No.” If you lived in Yonkers at least part of the year, and you

received a check in the mail (last Fall) called “property tax freeze credit,” then answer “yes.” 11. Line E: Complete only if you lived in New York City part of the year. 12. Line F: Complete only if you lived in New York City part of the year. 13. Line G: leave blank (there is a code applying to internationals but only if don’t need to file) 14. Line H: Dependent exemption information. ONLY fill this in if the GTP software allowed you to

include dependents on your federal form—citizens of very few countries can do this.

Updated 2/16/17 sh

15. LINE 1: Report wages from the wage line on your 1040NR line 8, or 1040NR-EZ line 3 16. LINE 4: If you reported your last year state refund on the federal form, enter it on line 4

(1040NR line 11; 1040NR-EZ line 4) 17. Report fellowships and grants (on 1042-S or 1099) on Line 16 and identify (if you have a 1042-S

and the exemption code in box 6 is “00,” then this income is fellowship or grants. 18. You should leave off any treaty exempt income that is reported on a 1042-S (exemption code in

box 4a would be “04”)—you do NOT have to report it anywhere on the NY state form. 19. If you have treaty exempt income that was incorrectly included on your W-2 as taxable wage

income, but was correctly recorded as treaty exempt on your federal tax form, you should send a copy of your federal tax form to show that the income is treaty exempt.

20. Line 19 of IT-201 should equal the federal adjusted gross income on Form 1040NREZ or 1040NR.

21. Enter your standard deduction on Line 34 of the IT-201 -- $7950 for Married filing separately or Single.

22. Line 39: Figure the tax on your taxable income from the tax table (page 47-54 attached). 23. Line 40: Household credit—most people CAN take this (page 21-22 attached). 24. Line 59: Sales and use tax—don’t leave blank! (can be 0)! See instructions (page 26 attached). 25. Line 72: Report how much state tax was withheld from you from your W-2 and / or 1042-S 26. Lines 77-84: Figure how much you owe or are owed and how you will pay or receive that amount. 27. If you earned income in another state, you may be able to file an “IT-112-R” to claim tax credit for

taxes paid to that state. You can download that form from: http://www.tax.ny.gov 28. IT-2: Transfer all of the information from your W-2 forms to the IT-2 forms according to the

directions on the back of the IT-2 (every box from the W-2 has a corresponding box on the IT-2). 29. Putting it all together: Follow the instructions on pages 32-35 attached to this packet on how to

make payments if required and how to put together and mail your forms.

201001160094

Department of Taxation and Finance

Resident Income Tax ReturnNew York State • New York City • Yonkers • MCTMT

IT-201

c Single

d� 0DUULHG�¿OLQJ�MRLQW�UHWXUQ (enter spouse’s social security number above)

e 0DUULHG�¿OLQJ�VHSDUDWH�UHWXUQ (enter spouse’s social security number above)

f +HDG�RI�KRXVHKROG�(with qualifying person)

g 4XDOLI\LQJ�ZLGRZ�HU��ZLWK�GHSHQGHQW�FKLOG

)or tKe IuOO year -anuary 1� 201�� tKrouJK 'ecemEer �1� 201�� or ¿scaO year EeJinninJ ... 1 6

and ending ...

A Filing status (mark an X in one box):

B Did you itemize�\RXU�GHGXFWLRQV�RQ� \RXU������IHGHUDO�LQFRPH�WD[�UHWXUQ"� ............�<HV� 1R

C Can you be claimed�DV�D�GHSHQGHQW� RQ�DQRWKHU�WD[SD\HU¶V�IHGHUDO�UHWXUQ"� ...........�<HV� 1R

Taxpayer’s permanent home address (see instructions, page 13) (number and street or rural route)� �$SDUWPHQW�QXPEHU

&LW\��YLOODJH��RU�SRVW�RI¿FH� 6WDWH� =,3�FRGH

NY7D[SD\HU¶V�GDWH�RI�GHDWK (mmddyyyy) 6SRXVH¶V�GDWH�RI�GHDWK (mmddyyyy)

Decedentinformation

For help completing your return, see the instructions, Form IT-201-I.Your ¿UVW�QDPH� 0,� <RXU�ODVW�QDPH�(for a joint return, enter spouse’s name on line below) <RXU�GDWH�RI�ELUWK�(mmddyyyy) <RXU�VRFLDO�VHFXULW\�QXPEHU

Spouse’s�¿UVW�QDPH� 0, 6SRXVH¶V�ODVW�QDPH 6SRXVH¶V�GDWH�RI�ELUWK�(mmddyyyy) 6SRXVH¶V�VRFLDO�VHFXULW\�QXPEHU

0DLOLQJ�DGGUHVV�(see instructions, page 13) (number and street or PO box)� $SDUWPHQW�QXPEHU� 1HZ�<RUN�6WDWH�FRXQW\�RI�UHVLGHQFH

&LW\��YLOODJH��RU�SRVW�RI¿FH� 6WDWH� =,3�FRGH� &RXQWU\�(if not United States) 6FKRRO�GLVWULFW�QDPH

6FKRRO�GLVWULFWFRGH�QXPEHU� ...............

)LUVW�QDPH 0, /DVW�QDPH 5HODWLRQVKLS 6RFLDO�VHFXULW\�QXPEHU 'DWH�RI�ELUWK�(mmddyyyy)

H Dependent exemption information (see page 15)

,I�PRUH�WKDQ���GHSHQGHQWV��PDUN�DQ�X�LQ�WKH�ER[�

)RU�RI¿FH�XVH�RQO\

D1� 'LG�\RX�KDYH�D�¿QDQFLDO�DFFRXQW� ORFDWHG�LQ�D�IRUHLJQ�FRXQWU\"�(see page 14) .......... �<HV� 1R

D2 Yonkers residents and Yonkers part-year residents only:� ���� 'LG�\RX�UHFHLYH�D�SURSHUW\�WD[�IUHH]H�RU� � � SURSHUW\�WD[�UHOLHI�FUHGLW" (see page 14) .................................................��<HV� 1R

� ���� ,I�Yes��HQWHU�WKH � � WRWDO�DPRXQW� ........... .��

E� ���� 'LG�\RX�RU�\RXU�VSRXVH�maintain living quarters in NYC�GXULQJ�����"�(see page 14) .. <HV� 1R

� ���� (QWHU�WKH�QXPEHU�RI�GD\V�VSHQW�LQ�1<&�LQ����� (any part of a day spent in NYC is considered a day) .........

F NYC residents and NYC part-year residents only (see page 14):� ���� 1XPEHU�RI�PRQWKV�you�OLYHG�LQ�1<&�LQ������ ................

� ���� 1XPEHU�RI�PRQWKV�your spouse OLYHG�LQ�1<&�LQ������........................................................

G� (QWHU�\RXU�2-character special condition code(s) if applicable (see page 14) ......................

201002160094

20 ,QWHUHVW�LQFRPH�RQ�VWDWH�DQG�ORFDO�ERQGV�DQG�REOLJDWLRQV��EXW�QRW�WKRVH�RI�1<6�RU�LWV�ORFDO�JRYHUQPHQWV� 20 .�� 21 3XEOLF�HPSOR\HH�����K��UHWLUHPHQW�FRQWULEXWLRQV�IURP�\RXU�ZDJH�DQG�WD[�VWDWHPHQWV�(see page 16) 21 .�� 22 New York’s ����FROOHJH�VDYLQJV�SURJUDP�GLVWULEXWLRQV�(see page 16) .......................................... 22 .�� 23 Other (Form IT-225, line 9) ............................................................................................................. 23 .�� 24� $GG�OLQHV�19�WKURXJK�23 .............................................................................................................. 24 .��

New York additions (see page 16)

Page 2�RI��� IT-201�������

1� :DJHV��VDODULHV��WLSV��HWF�� ........................................................................................................... 1 .��

2� 7D[DEOH�LQWHUHVW�LQFRPH�............................................................................................................... 2 .�� 3� 2UGLQDU\�GLYLGHQGV� ...................................................................................................................... 3 .�� 4� 7D[DEOH�UHIXQGV��FUHGLWV��RU�RIIVHWV�RI�VWDWH�DQG�ORFDO�LQFRPH�WD[HV�(also enter on line 25) ........... 4 .�� 5� $OLPRQ\�UHFHLYHG� ......................................................................................................................... 5 .�� 6� %XVLQHVV�LQFRPH�RU�ORVV�(submit a copy of federal Schedule C or C-EZ, Form 1040) .......................... 6 .�� 7� &DSLWDO�JDLQ�RU�ORVV�(if required, submit a copy of federal Schedule D, Form 1040) .............................. 7 .�� 8� 2WKHU�JDLQV�RU�ORVVHV�(submit a copy of federal Form 4797) ............................................................. 8 .�� 9� 7D[DEOH�DPRXQW�RI�,5$�GLVWULEXWLRQV��,I�UHFHLYHG�DV�D�EHQH¿FLDU\��PDUN�DQ�X�LQ�WKH�ER[� ... 9 .�� 10 7D[DEOH�DPRXQW�RI�SHQVLRQV�DQG�DQQXLWLHV��,I�UHFHLYHG�DV�D�EHQH¿FLDU\��PDUN�DQ�X�LQ�WKH�ER[ 10 .�� 11 5HQWDO�UHDO�HVWDWH��UR\DOWLHV��SDUWQHUVKLSV��6�FRUSRUDWLRQV��WUXVWV��HWF��(submit copy of federal Schedule E, Form 1040) 11 .��

Federal income and adjustments (see page 15)Whole dollars only

<RXU�VRFLDO�VHFXULW\�QXPEHU

New York subtractions (see page 17)

Standard deduction or itemized deduction (see page 20)

34 (QWHU�\RXU�standard deduction (table on page 20) or�\RXU�itemized deduction (from Form IT-201-D) 0DUN�DQ�X LQ�WKH�DSSURSULDWH�ER[� Standard - or - Itemized 34 .��

35� 6XEWUDFW�OLQH����IURP�OLQH����(if line 34 is more than line 33, leave blank) .......................................... 35 .�� 36� 'HSHQGHQW�H[HPSWLRQV�(enter the number of dependents listed in item H; see page 20) ..................... 36 000.00

37 Taxable income (subtract line 36 from line 35) ............................................................................... 37 .��

12� 5HQWDO�UHDO�HVWDWH�LQFOXGHG�LQ�OLQH���� ................................. 12 .�� 13� )DUP�LQFRPH�RU�ORVV�(submit a copy of federal Schedule F, Form 1040) ............................................. 13 .�� 14� 8QHPSOR\PHQW�FRPSHQVDWLRQ� ..................................................................................................... 14 .�� 15 7D[DEOH�DPRXQW�RI�VRFLDO�VHFXULW\�EHQH¿WV�(also enter on line 27) .................................................. 15 .�� 16 Other income (see page 15) Identify: 16 .��

17� $GG�OLQHV�1 through 11 and 13 through 16 ................................................................................ 17 .�� 18 7RWDO�IHGHUDO�DGMXVWPHQWV�WR�LQFRPH (see page 15) Identify: 18 .��

19 Federal adjusted gross income (subtract line 18 from line 17) ..................................................... 19 .��

25 7D[DEOH�UHIXQGV��FUHGLWV��RU�RIIVHWV�RI�VWDWH�DQG�ORFDO�LQFRPH�WD[HV�(from line 4) 25 .�� 26 3HQVLRQV�RI�1<6�DQG�ORFDO�JRYHUQPHQWV�DQG�WKH�IHGHUDO�JRYHUQPHQW�(see page 17) 26 .�� 27 7D[DEOH�DPRXQW�RI�VRFLDO�VHFXULW\�EHQH¿WV (from line 15) ........ 27 .�� 28� ,QWHUHVW�LQFRPH�RQ�8�6��JRYHUQPHQW�ERQGV� ...................... 28 .�� 29� 3HQVLRQ�DQG�DQQXLW\�LQFRPH�H[FOXVLRQ�(see page 18) ........ 29 .�� 30 New York’s�����FROOHJH�VDYLQJV�SURJUDP�GHGXFWLRQ�HDUQLQJV 30 .�� 31 Other (Form IT-225, line 18) ................................................... 31 .�� 32� $GG�OLQHV����WKURXJK���� .............................................................................................................. 32 .��

33 New York adjusted gross income (subtract line 32 from line 24) .................................................. 33 .��

201003160094

Tax computation, credits, and other taxes

38 Taxable income (from line 37 on page 2) ....................................................................................... 38 .��

39� 1<6�WD[�RQ�OLQH����DPRXQW�(see page 21) ..................................................................................... 39 .�� 40� 1<6�KRXVHKROG�FUHGLW�(page 21, table 1, 2, or 3) ................... 40 .�� 41� 5HVLGHQW�FUHGLW�(see page 22) ............................................... 41 .�� 42 2WKHU�1<6�QRQUHIXQGDEOH�FUHGLWV�(Form IT-201-ATT, line 7) 42 .�� 43� $GG�OLQHV���������DQG����.............................................................................................................. 43 .��

44� 6XEWUDFW�OLQH����IURP�OLQH����(if line 43 is more than line 39, leave blank) .......................................... 44 .�� 45� 1HW�RWKHU�1<6�WD[HV�(Form IT-201-ATT, line 30) ............................................................................. 45 .��

46 Total New York State taxes (add lines 44 and 45) ........................................................................ 46 .��

See instructions on pages 22 through 25 to compute New York City and Yonkers taxes, credits, and surcharges, and MCTMT.

47� 1<&�UHVLGHQW�WD[�RQ�OLQH����DPRXQW�(see page 22) ............. 47 .�� 48� 1<&�KRXVHKROG�FUHGLW�(page 22, table 4, 5, or 6) .................. 48 .�� 49� 6XEWUDFW�OLQH����IURP�OLQH����(if line 48 is more than line 47, leave blank) .......................................................... 49 .�� 50� 3DUW�\HDU�1<&�UHVLGHQW�WD[�(Form IT-360.1) ....................... 50 .�� 51� 2WKHU�1<&�WD[HV�(Form IT-201-ATT, line 34) ........................ 51 .�� 52� $GG�OLQHV���������DQG���� .................................................. 52 .�� 53� 1<&�QRQUHIXQGDEOH�FUHGLWV�(Form IT-201-ATT, line 10) ........ 53 .��

IT-201�������� Page 3�RI��

54� 6XEWUDFW�OLQH����IURP�OLQH��� (if line 53 is more than line 52, leave blank) ......................................................... 54 .�� 54a MCTMT net � � � HDUQLQJV�EDVH .... 54a .�� 54b MCTMT ............................................................................ 54b .�� 55 <RQNHUV�UHVLGHQW�LQFRPH�WD[�VXUFKDUJH�(see page 25) ..... 55 .�� 56� <RQNHUV�QRQUHVLGHQW�HDUQLQJV�WD[�(Form Y-203) ............... 56 .�� 57 3DUW�\HDU�<RQNHUV�UHVLGHQW�LQFRPH�WD[�VXUFKDUJH�(Form IT-360.1) 57 .�� 58 Total New York City and Yonkers taxes / surcharges and MCTMT (add lines 54 and 54b through 57) .. 58 .��

59 Sales or use tax (see page 26; do not leave line 59 blank) .......................................................... 59 .��

New York City and Yonkers taxes, credits, and surcharges, and MCTMT

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Voluntary contributions �ࣰVHH�SDJH����

60a� 5HWXUQ�D�*LIW�WR�:LOGOLIH�................................................................ 60a .�� 60b� 0LVVLQJ�([SORLWHG�&KLOGUHQ�)XQG� ................................................. 60b .�� 60c� %UHDVW�&DQFHU�5HVHDUFK�)XQG� .................................................... 60c .�� 60d� $O]KHLPHU¶V�)XQG� ......................................................................... 60d .�� 60e� 2O\PSLF�)XQG�($2 or $4; see page 27) ............................................ 60e .�� 60f� 3URVWDWH�DQG�7HVWLFXODU�&DQFHU�5HVHDUFK�DQG�(GXFDWLRQ�)XQG� .. 60f .�� 60g� �����0HPRULDO� .............................................................................. 60g .�� 60h 9ROXQWHHU�)LUH¿JKWLQJ��(06�5HFUXLWPHQW�)XQG ......................... 60h .�� 60i 7HHQ�+HDOWK�(GXFDWLRQ ................................................................. 60i .�� 60j 9HWHUDQV�5HPHPEUDQFH ............................................................... 60j .�� 60k +RPHOHVV�9HWHUDQV ...................................................................... 60k .�� 60l 0HQWDO�,OOQHVV�$QWL�6WLJPD�)XQG� .................................................. 60l .�� 60m :RPHQ¶V�&DQFHUV�(GXFDWLRQ�DQG�3UHYHQWLRQ�)XQG� .................... 60m .�� 60n $XWLVP�)XQG� ................................................................................ 60n .�� 60 Total voluntary contributions (add lines 60a through 60n) ........................................................... 60 .��

61 Total New York State, New York City, Yonkers, and sales or use taxes, MCTMT, and voluntary contributions (add lines 46, 58, 59, and 60) .............................................................. 61 .��

<RXU�VRFLDO�VHFXULW\�QXPEHU

201004160094

<RXU�VLJQDWXUH

<RXU�RFFXSDWLRQ

6SRXVH¶V�VLJQDWXUH�DQG�RFFXSDWLRQ�(if joint return)

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Page 4�RI��� IT-201�������

Payments and refundable credits (see page 28)

Your refund, amount you owe, and account information (see pages 31 through 33)

79� $PRXQW�RI�OLQH����WKDW�\RX�ZDQW�DSSOLHG�WR�\RXU� 2017�HVWLPDWHG�WD[ (see instructions) ............................... 79 .��

80� $PRXQW�\RX�owe (if line 76 is less than line 62, subtract line 76 from line 62). 7R�SD\�E\�HOHFWURQLF � � � IXQGV�ZLWKGUDZDO��PDUN�DQ�X�LQ�WKH�ER[� DQG ¿OO�LQ�OLQHV����DQG�����,I�\RX�SD\�E\�FKHFN � � � RU�PRQH\�RUGHU�\RX�must�FRPSOHWH�)RUP�,7�����9�DQG�PDLO�LW�ZLWK�\RXU�UHWXUQ� .................... 80 .�� 81� (VWLPDWHG�WD[�SHQDOW\�(include this amount in line 80 or reduce the overpayment on line 77; see page 31) ................. 81 .�� 82� 2WKHU�SHQDOWLHV�DQG�LQWHUHVW�(see page 32) ......................... 82 .�� 83� $FFRXQW�LQIRUPDWLRQ�IRU�GLUHFW�GHSRVLW�RU�HOHFWURQLF�IXQGV�ZLWKGUDZDO�(see page 32). ,I�WKH�IXQGV�IRU�\RXU�SD\PHQW��RU�UHIXQG��ZRXOG�FRPH�IURP��RU�JR�WR��DQ�DFFRXQW�RXWVLGH�WKH�8�6���PDUN�DQ�X�LQ�WKLV�ER[�(see pg. 32)

See page 35 for the proper assembly of your return.

See instructions for where to mail your return.

Refund?�'LUHFW�GHSRVLW�LV�WKH�HDVLHVW��IDVWHVW�ZD\�WR�JHW�\RXU�UHIXQG�See page 32 for payment options.

,I�DSSOLFDEOH��FRPSOHWH Form(s) IT-2 and/or IT-1099-R�DQG�VXEPLW�WKHP�ZLWK�\RXU�UHWXUQ�(see page 12).Do not send federal Form W-2 with your return.

77 Amount overpaid (if line 76 is more than line 62, subtract line 62 from line 76) ................................. 77 .��

78 $PRXQW�RI�OLQH����WR�EH�refunded direct paper Mark one refund choice: deposit �¿OO�LQ�OLQH����� - or - check ............................. 78 .��

62� (QWHU�DPRXQW�IURP�OLQH��� ........................................................................................................... 62 .��

83a� $FFRXQW�W\SH�� 3HUVRQDO�FKHFNLQJ� - or -� 3HUVRQDO�VDYLQJV� - or -� %XVLQHVV�FKHFNLQJ� - or -� %XVLQHVV�VDYLQJV

83b� 5RXWLQJ�QXPEHU� 83c $FFRXQW�QXPEHU

84� (OHFWURQLF�IXQGV�ZLWKGUDZDO�(see page 33) ................... 'DWH� $PRXQW� .��

63� (PSLUH�6WDWH�FKLOG�FUHGLW� ................................................... 63 .�� 63a�)DPLO\�WD[�UHOLHI�FUHGLW� ....................................................... 63a .�� 64� 1<6�1<&�FKLOG�DQG�GHSHQGHQW�FDUH�FUHGLW� ....................... 64 .�� 65� 1<6�HDUQHG�LQFRPH�FUHGLW��(,&�� ................................ 65 .�� 66� 1<6�QRQFXVWRGLDO�SDUHQW�(,& ............................................ 66 .�� 67� 5HDO�SURSHUW\�WD[�FUHGLW� ..................................................... 67 .�� 68� &ROOHJH�WXLWLRQ�FUHGLW� .......................................................... 68 .�� 69� 1<&�VFKRRO�WD[�FUHGLW�(also complete F on page 1; see page 29) 69 .�� 70� 1<&�HDUQHG�LQFRPH�FUHGLW ........................................... 70 .�� 70a�1<&�HQKDQFHG�UHDO�SURSHUW\�WD[�FUHGLW� .............................. 70a .�� 71� 2WKHU�UHIXQGDEOH�FUHGLWV (Form IT-201-ATT, line 18) .............. 71 .��

72 Total New York State�WD[�ZLWKKHOG� .................................... 72 .�� 73 Total New York City�WD[�ZLWKKHOG� ...................................... 73 .�� 74 Total Yonkers�WD[�ZLWKKHOG� ................................................ 74 .�� 75� 7RWDO�HVWLPDWHG�WD[�SD\PHQWV and�DPRXQW�SDLG�ZLWK�)RUP�,7���� 75 .��

76 Total payments (add lines 63 through 75) ...................................................................................... 76 .��

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Third-partydesignee? (see instr.)

Yes No

ź Taxpayer(s) must sign here ź

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ź Paid preparer must complete ź (see instructions)

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3UHSDUHU¶V�VLJQDWXUH� 3UHSDUHU¶V�SULQWHG�QDPH

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Date

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102001160094

N Y

N Y

IT-2Department of Taxation and Finance

Summary of W-2 StatementsNew York State • New York City • Yonkers

Box b (PSOR\HU�LGHQWL¿FDWLRQ�QXPEHU��(,1�

Box b (PSOR\HU�LGHQWL¿FDWLRQ�QXPEHU��(,1�

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Box 1 Wages, tips, other compensation

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Box 1 Wages, tips, other compensation

.00Box 8 Allocated tips

.00Box 10� 'HSHQGHQW�FDUH�EHQH¿WV

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W-2 Record 1

W-2 Record 2

Employer’s name

Employer’s name

Box c Employer’s information

Box c Employer’s information

Employer’s address (number and street)

Employer’s address (number and street)

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&LW\� 6WDWH� =,3�FRGH� &RXQWU\�(if not United States)

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Box a Employee’s VRFLDO�VHFXULW\�QXPEHU�for this W-2 Record

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