W-2AS American Samoa Wage and Tax Statement

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to the
official IRS form. Do not file Copy A downloaded from this website with the SSA. The
official printed version of this IRS form is scannable, but the online version of it, printed from
this website, is not. A penalty may be imposed for filing forms that can’t be scanned. See
the penalties section in the current General Instructions for Forms W-2 and W-3 for more
information.
To order official IRS forms, go to Online Ordering for Information Returns and Employer
Returns, and we’ll mail you the scannable forms and other products.
You may file Forms W-2 and W-3 electronically on the SSA’s website at Employer W-2
Filing Instructions and Information. You can create fill-in versions of Forms W-2 and W-3
for filing with SSA. You may also print out copies for filing with state or local governments,
distribution to your employees, and for your records.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information about
printing these tax forms.

22222

a Employee’s social security number

Void

For Official Use Only ▶
OMB No. 1545-0008

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8

d Control number

9

e Employee’s first name and initial

Last name

10

Suff. 11 Nonqualified plans
13

Statutory
employee

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

14 Other

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa
Wage and Tax Statement

2016

Copy A For Social Security Administration—Send this entire page with Copy A of
Form W-3SS to the Social Security Administration; photocopies are not acceptable.

Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction Act
Notice, see the separate instructions.

Do Not Cut, Fold, or Staple Forms on This Page

Cat. No. 10140H

22222

a Employee’s social security number

Void

OMB No. 1545-0008

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8

d Control number

10

9

e Employee’s first name and initial

Last name

Suff.

11 Nonqualified plans
13

Statutory
employee

14 Other

Retirement
plan

12a
C
o
d
e

Third-party
sick pay

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa
Wage and Tax Statement

Copy 1—For American Samoa Treasurer

2016

Department of the Treasury—Internal Revenue Service

a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8

d Control number

9

e Employee’s first name and initial

Last name

Suff.

10

11 Nonqualified plans
13

Statutory
employee

14 Other

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa
Wage and Tax Statement

Copy B—To Be Filed With Employee’s American Samoa Tax Return

2016

Department of the Treasury—Internal Revenue Service
This information is being furnished to
the American Samoa Tax Office,
Government of American Samoa.

Notice to Employee
Do you have to file? Refer to the Form 1040 instructions to determine if you are
required to file a tax return. Even if you do not have to file a tax return, you may be
eligible for a refund if box 2 shows an amount or if you are eligible for any credit.
Copies B and C; corrections. File Copy B of this form with your 2016 American
Samoa income tax return. Keep Copy C for your records. If your name, social
security number (SSN), or address is incorrect, correct Copies B and C and ask
your employer to correct your employment record. Be sure to ask your employer
to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security
Administration (SSA) to correct any name, amount, or SSN error reported to the
SSA. Be sure to get your copies of Form W-2c from your employer for all
corrections made so you may file them with your tax return.

your employer. Enter this amount on the wages line of your tax return. (Form
1040-SS filers, see the instructions for Form 1040-SS, Part I, line 5.) By filing this
form, your social security tips will be credited to your social security record (used
to figure your benefits).
(Also see the Instructions for Employee on this page and the back of Copy C.)

Instructions for Employee
(Also see Notice to Employee on this page.)
Box 5. You may be required to report this amount on Form 8959, Additional
Medicare Tax. See the Form 1040 instructions to determine if you are required to
complete Form 8959.

Estimated tax. If you expect to owe $1,000 or more in tax (including selfemployment tax) for 2017, you may have to make estimated tax payments to the
U.S. Internal Revenue Service. Use Form 1040-ES, Estimated Tax for Individuals.

Box 6. This amount includes the 1.45% Medicare Tax withheld on all Medicare
wages and tips shown in box 5, as well as the 0.9% Additional Medicare Tax on
any of those Medicare wages and tips above $200,000.

Clergy and religious workers. If you are not subject to social security and
Medicare taxes, see Pub. 517, Social Security and Other Information for Members
of the Clergy and Religious Workers.

Box 11. This amount is (a) reported in box 1 if it is a distribution made to you from
a nonqualified deferred compensation or nongovernmental section 457(b) plan or
(b) included in box 3 and/or 5 if it is a prior year deferral under a nonqualified or
section 457(b) plan that became taxable for social security and Medicare taxes this
year because there is no longer a substantial risk of forfeiture of your right to the
deferred amount. This box should not be used if you had a deferral and a
distribution in the same calendar year. If you made a deferral and received a
distribution in the same calendar year, and you are or will be age 62 by the end of
the calendar year, your employer should file Form SSA-131, Employer Report of
Special Wage Payments, with the Social Security Administration and give you a
copy.

Cost of employer-sponsored health coverage (if such cost is provided by the
employer). The reporting in box 12, using code DD, of the cost of employersponsored health coverage is for your information only. The amount reported
with code DD is not taxable.
Credit for excess social security tax. If you had more than one employer in 2016
and more than $7,347 in social security tax was withheld, you can have the excess
refunded by filing Form 843, Claim for Refund and Request for Abatement, with
the Department of the Treasury, Internal Revenue Service Center, Austin, TX
73301-0215, USA. However, if you are required to file Form 1040 with the United
States, you must claim the excess tax as a credit on Form 1040.
Unreported tip income. You must file Form 4137, Social Security and Medicare
Tax on Unreported Tip Income, with your income tax return to report at least the
allocated tip amount unless you can prove a smaller amount with adequate
records. If you have records that show the actual amount of tips you received,
report that amount even if it is more or less than the allocated tips. Use Form 4137
to figure the social security and Medicare tax owed on tips you did not report to

Box 12. The following list explains the codes shown in box 12. You may need this
information to complete your tax return. Elective deferrals (codes D, E, F, and S)
and designated Roth contributions (codes AA, BB, and EE) under all plans are
generally limited to a total of $18,000 ($12,500 if you have only SIMPLE plans;
$21,000 for section 403(b) plans if you qualify for the 15-year rule explained in
Pub. 571). Deferrals under code G are limited to $18,000. Deferrals under code H
are limited to $7,000.
However, if you were at least age 50 in 2016, your employer may have allowed
an additional deferral of up to $6,000 ($3,000 for section 401(k)(11) and 408(p)
SIMPLE plans). This additional deferral amount is not subject to the overall limit on
elective deferrals. For code G, the limit on elective deferrals may be higher for the
last 3 years before you reach retirement age. Contact your plan administrator for
more information. Amounts in excess of the overall elective deferral limit must be
included in income. See the “Wages, Salaries, Tips, etc.” line instructions for your
tax return.

(continued on back of Copy C)

a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8

d Control number

10

9

e Employee’s first name and initial

Last name

Suff.

11 Nonqualified plans
13

Statutory
employee

14 Other

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa
Wage and Tax Statement

Copy C—For EMPLOYEE'S RECORDS (See Notice to Employee
on the back of Copy B.)

2016

Department of the Treasury—Internal Revenue Service
This information is being furnished to
the American Samoa Tax Office,
Government of American Samoa.

Instructions for Employee (continued from
back of Copy B)
Box 12 (continued)
Note: If a year follows code D through H, S, Y, AA, BB, or EE, you made a makeup pension contribution for a prior year(s) when you were in military service. To
figure whether you made excess deferrals, consider these amounts for the year
shown, not the current year. If no year is shown, the contributions are for the
current year.

Q—Nontaxable combat pay. See your tax return instructions for details on
reporting this amount.
R—Employer contributions to your Archer MSA. Report on Form 8853, Archer
MSAs and Long-Term Care Insurance Contracts.
S—Employee salary reduction contributions under a section 408(p) SIMPLE plan
(not included in box 1)

A—Uncollected social security tax on tips. Report on U.S. Form 1040, or on Form
1040-SS if not required to file Form 1040.

T—Adoption benefits (not included in box 1). Complete Form 8839, Qualified
Adoption Expenses, to figure taxable and nontaxable amounts.

B—Uncollected Medicare tax on tips. Report on U.S. Form 1040, or on Form
1040-SS if not required to file Form 1040.

V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3
(up to social security wage base), and 5). See Pub. 525, Taxable and Nontaxable
Income, for reporting requirements.

C—Taxable cost of group-term life insurance over $50,000 included in boxes 1, 3
(up to social security wage base), and 5
D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also
includes deferrals under a SIMPLE retirement account that is part of a section
401(k) arrangement.
E—Elective deferrals under a section 403(b) salary reduction agreement
F—Elective deferrals under a section 408(k)(6) salary reduction SEP
G—Elective deferrals and employer contributions (including nonelective deferrals)
to a section 457(b) deferred compensation plan
H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan. (You
may be able to deduct.)
J—Nontaxable sick pay (information only, not included in boxes 1, 3, or 5)
M—Uncollected social security tax on taxable cost of group-term life insurance
over $50,000 (former employees only). Report on U.S. Form 1040, or on Form
1040-SS if not required to file Form 1040.
N—Uncollected Medicare tax on taxable cost of group-term life insurance over
$50,000 (former employees only). Report on U.S. Form 1040, or on Form 1040-SS
if not required to file Form 1040.
P—Excludable moving expense reimbursements paid directly to employee (not
included in boxes 1, 3, or 5)

W—Employer contributions (including amounts the employee elected to contribute
using a section 125 (cafeteria) plan) to your health savings account (HSA). Report
on Form 8889, Health Savings Accounts (HSAs).
Y—Deferrals under a section 409A nonqualified deferred compensation plan
Z—Income under a nonqualified deferred compensation plan that fails to satisfy
section 409A. This amount is also included in box 1. It is subject to an additional
20% tax plus interest. See “Other Taxes” in the instructions for your tax return.
AA—Designated Roth contributions under a section 401(k) plan
BB—Designated Roth contributions under a section 403(b) plan
DD—Cost of employer-sponsored health coverage. The amount reported with
code DD is not taxable.
EE—Designated Roth contributions under a governmental section 457(b) plan.
This amount does not apply to contributions under a tax-exempt organization
section 457(b) plan.
Box 13. If the “Retirement plan” box is checked, special limits may apply to the
amount of traditional IRA contributions that you may deduct. See Pub. 590-A,
Contributions to Individual Retirement Arrangements (IRAs).
Note: Keep Copy C of Form W-2AS for at least 3 years after the due date for filing
your income tax return. However, to help protect your social security benefits,
keep Copy C until you begin receiving social security benefits just in case there is
a question about your work record and/or earnings in a particular year.

a Employee’s social security number

Void

OMB No. 1545-0008

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8

d Control number

10

9

e Employee’s first name and initial

Last name

Suff.

11 Nonqualified plans
13

Statutory
employee

14 Other

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

Form

W-2AS

Copy D—For Employer

American Samoa
Wage and Tax Statement

2016

Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction Act
Notice, see the separate instructions.

Employers, Please Note—
Specific information needed to complete Form W-2AS is
available in a separate booklet titled the 2016 General
Instructions for Forms W-2 and W-3. You can order these
instructions and additional forms at www.irs.gov/orderforms.

304-263-8700 (not toll free). For TTY/TDD equipment for
persons who are deaf, hard of hearing, or have a speech
disability, call 304-579-4827 (not toll free). The hours of
operation are 8:30 a.m. to 4:30 p.m. Eastern time.

Caution: Do not send the SSA Forms W-2AS and W-3SS that
you have printed from IRS.gov. The SSA is unable to process
these forms. Instead, you can create and submit them online.
See E-filing, later.

E-filing. If you file 250 or more Form(s) W-2AS, you must file
electronically. Even if you are not required to file electronically,
doing so can save you time and effort. Employers may now use
the SSA's W-2 Online service to create, save, print, and submit
up to 50 Form(s) W-2AS at a time over the Internet. When you
e-file with the SSA, no separate Form W-3SS filing is required.
An electronic Form W-3SS will be created for you by the W-2
Online service. For information, visit the SSA’s Employer W-2
Filing Instructions & Information website at
www.socialsecurity.gov/employer or contact your Employer
Services Liaison Officer (ESLO) at 1-510-970-8247 (not toll free).

Due dates. By January 31, 2017, furnish Copies B and C to
each person who was your employee during 2016. By
January 31, 2017, send Copy A of Forms W-2AS and W-3SS
to the SSA. If you file electronically, the due date is also
January 31, 2017. See the separate instructions.
Need help? If you have questions about reporting on Form
W-2AS, call the information reporting customer service site at
1-866-455-7438 (not toll free from American Samoa) or

Future developments. Information about any future
developments affecting Form W-2AS and its instructions (such
as legislation enacted after we release them) will be posted at
www.irs.gov/w2.