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
