8922 Third-Party Sick Pay Recap

Version A, Cycle 9

CORRECTED
FILER'S name, street address, city or town, province or state, country, ZIP
or foreign postal code, and telephone no.

Filer is an (check one):

OMB No. 1545-XXXX

2014

Employer
Insurer/Agent

Third-Party
Sick Pay
Recap

Form 8922

FILER'S employer identification number

OTHER PARTY'S name (see instructions before entering)

OTHER PARTY'S employer identification number (see instructions before
entering)

1 Sick pay subject to federal
income tax

2 Federal income tax withheld
from sick pay

$

$

3 Sick pay subject to social
security tax

4 Social security tax withheld
from sick pay

$

$

5 Sick pay subject to
Medicare tax

6 Medicare tax withheld from
sick pay

$

$

2014 Instructions for Form 8922,
Third-Party Sick Pay Recap
Section references are to the Internal Revenue Code unless otherwise
noted.

Future Developments

Specific Instructions
Check box for employer or insurer/agent. Check the appropriate
box to state whether you are the employer or the insurer/agent filing
Form 8922.
Filer's name. If the Employer box is checked, the employer for whom
the sick pay was paid by the insurer or agent will complete the
information with the employer's name, address, and phone number.
If the Insurer/Agent box is checked, the insurer or agent who paid
the sick pay will complete the information with the insurer/agent's
name, address, and phone number.
Filer's EIN. If the employer box is checked, enter the EIN of the
employer.
If the Insurer/Agent box is checked, enter the EIN of the insurer or
agent.
Other party's name and employer identification number (EIN). If
the Employer box is checked, the employer must provide the name
and EIN of the insurer or agent. If the employer has contracts with
more than one insurer or agent, the employer must file a separate
Form 8922 for the wages and taxes related to each contract.
If the Insurer/Agent box is checked, the insurer or agent may, but is
not required to, provide the name and EIN of the employer. If it is
providing this information, and if it has contracts with more than one
employer, it must file a separate Form 8922 for the wages and taxes
related to each employer. Alternatively, it may file a separate Form
8922 for the wages and taxes related to each employer for which it is
supplying the name and EIN, and then file one Form 8922 for the
wages and taxes related to the employers for which it is not supplying
the name and EIN.
Box 1. Enter the total amount of sick pay subject to federal income
tax.
Box 2. Enter the total amount of federal income tax withheld from the
sick pay.
Box 3. Enter the total amount of sick pay subject to social security
tax.
Box 4. Enter the total amount of social security tax withheld from the
sick pay.
Box 5. Enter the total amount of sick pay subject to Medicare tax.
Box 6. Enter the total amount of the Medicare tax (including Additional
Medicare Tax) withheld from the sick pay.
Contact name and title. Enter the name and title of the individual
who completed the form.
Privacy Act and Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal Revenue laws of the
United States. We need it to figure and collect the right amount of tax.
Section 6051 and its regulations require you to furnish wage and tax
statements to employees, the Social Security Administration, and the
Internal Revenue Service. Section 6109 requires you to provide your
identification number. Failure to provide this information in a timely
manner or providing false or fraudulent information may subject you to
penalties.

INTERNAL USE ONLY

For the latest information about developments related to Form 8922
and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/form8922.

DRAFT AS OF
January 17, 2014

General Instructions

!
▲

Do not send this form to the Social Security
Administration. This form is processed solely by the IRS
for third-party sick pay reporting.

CAUTION

Purpose of Form

Form 8922 is filed to reconcile employment tax returns (for example,
Form 941) with Forms W-2 when third-party sick pay is paid. For more
information, see Sick Pay Reporting in Publication 15-A, Employer's
Supplemental Tax Guide.

Who Must File
The Form 8922 must be filed by:
• The employer, if sick pay is reported on Forms W-2 under the
name and EIN of the agent or insurer.
• The agent or insurer, if sick pay is reported on Forms W-2 under
the name and EIN of the employer.

When To File
File Form 8922 by March 2, 2015. If filing electronically, file by March
31, 2015.

Where To File
Mail Form 8922 to:
Department of the Treasury
Internal Revenue Service
[City], [ST], [ZIP]
Electronic filing. Publication 1220, Specifications for Filing
Electronically, provides the procedures for reporting electronically and
is updated annually. Pub. 1220 is available at IRS.gov.
You can file electronically through the Filing Information Returns
Electronically System (FIRE System); however, you must have
software that can produce a file in the proper format according to
Pub. 1220. The FIRE System does not provide a fill-in form option for
information return reporting. The FIRE System operates 24 hours a
day, 7 days a week. You may access the FIRE System via the Internet
at fire.irs.gov. See Pub. 1220 for more information.

Form

8922

Cat. No. 37734T

IRS.gov/form8922

Department of the Treasury - Internal Revenue Service

Version A, Cycle 9
Page 2

Form 8922 (2014)

INTERNAL USE ONLY

DRAFT AS OF
January 17, 2014

Generally, tax returns and return information are confidential, as
required by section 6103. However, section 6103 allows or requires
the Internal Revenue Service to disclose or give the information shown
on your return to others as described in the Code. For example, we
may disclose your tax information to the Department of Justice for
civil and/or criminal litigation, and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws. We may also disclose this information to
other countries under a tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to federal law enforcement
and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form
that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a
form or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law.

The time needed to complete and file this form will vary depending
on individual circumstances. The estimated average time is:
Recordkeeping
. . . . . . . . . . . x hr., x min.
Learning about the law or the form . . . . . x hr., x min.
Preparing, copying, assembling, and sending the
form to the IRS . . . . . . . . . . . . x hr., x min.
If you have comments concerning the accuracy of these time
estimates or suggestions for making Form 8922 simpler, we would be
happy to hear from you. You can send us comments from www.irs.
gov/formspubs. Click on More Information and then click on Comment
on Tax Forms and Publications. Or you can send your comments to
Internal Revenue Service, Tax Forms and Publications Division, 1111
Constitution Avenue, NW, IR-6526, Washington, DC 20224. Do not
send Form 8922 to this address. Instead, see Where To File, earlier.