Form W-2 SUB Substitute W-2 Wage and Tax Statement

1 Your name 2 Employer (business name or owner's name) 3 Wages tips other compensation $ Federal income tax withheld $ Idaho income tax withheld $ Social security tax withheld $ Address Attach photocopy of payroll check stub(s)or other document(s) to verify the Idaho withholding amount(s) claimed City State Zip City State Zip Phone number if known EFO00169 Employer's ID number if known Give reason if known why a W 2 form was not furnished by employer How did you determine the amounts in 3? You must attach copies of any documents or schedules used to determine this amount I verify that I have made efforts to contact this employer and have given this employer sufficient time to mail or otherwise provide this statement Idaho Substitute W 2 W 2 SUB Wage and Tax Statement 20 Phone number Social security number Your signature