Local income tax

Local wages, tips, etc.

Locality name

State income tax

State wages, tips, etc.

Employer's state I.D. No.

Other:  Line 3

Other:  Line 2

Other:  Line 1

See Instrs. for Box 13:  Line 3

See Instrs. for Box 13:  Line 2

See Instrs. for Box 13:  Line 1

Benefits included in Box 1

Nonqualified plans

Dependent care benefits

Advance EIC payment

Allocated tips

Social security tips

Medicare tax withheld

Medicare wages and tips

Social security tax withheld

Social security wages

Federal income tax withheld

Wages, tips, other compensation