W-2AS American Samoa Wage and Tax Statement

Attention:
You may file Forms W-2 and W-3 electronically on the SSA’s Employer
W-2 Filing Instructions and Information web page, which is also accessible
at www.socialsecurity.gov/employer. 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.
Note: Copy A of this form is provided for informational purposes only. Copy A appears in
red, similar to the official IRS form. The official printed version of this IRS form is scannable,
but the online version of it, printed from this website, is not. Do not print and file Copy A
downloaded from this website with the SSA; 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, available at www.irs.gov/w2, for more information.
Please note that Copy B and other copies of this form, which appear in black, may be
downloaded, filled in, and printed and used to satisfy the requirement to provide the
information to the recipient.
To order official IRS information returns such as Forms W-2 and W-3, which include a
scannable Copy A for filing, go to IRS’ Online Ordering for Information Returns and
Employer Returns page, or visit www.irs.gov/orderforms and click on Employer and
Information returns. We’ll mail you the scannable forms and any other products you order.
See IRS Publications 1141, 1167, and 1179 for more 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

Suff.

10

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

2023

Department of the Treasury—Internal Revenue Service

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.

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

For Privacy Act and Paperwork Reduction Act
Notice, see the separate instructions.
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

9

e Employee’s first name and initial

Last name

Suff.

10

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

2023

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

2023

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

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 don’t 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 2023 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.
Estimated tax. If you expect to owe $1,000 or more in tax for 2024, you may have
to make estimated tax payments to your local territory tax department. You may
also have to make estimated tax payments to the U.S. Internal Revenue Service if
you are subject to self-employment taxes. See Pub. 570 for additional information.
Employee’s social security number (SSN). For your protection, this form may
show only the last four digits of your SSN. However, your employer has reported
your complete SSN to the American Samoa Tax Office and the SSA.
Clergy and religious workers. If you aren’t subject to social security and
Medicare taxes, see Pub. 517.
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 2023
and more than $9,932.40 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 or 1040-SR with
the United States, you must claim the excess tax as a credit on Form 1040 or
1040-SR.
Unreported tip income. You must file Form 4137 with your income tax return to
figure the social security and Medicare tax owed on tips you didn’t report to 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 6.) By filing this form, your

social security tips will be credited to your social security record (used to figure
your benefits).
(See also the Instructions for Employee on this page and the back of Copy C.)

Instructions for Employee
(See also Notice to Employee on this page.)
Box 5. You may be required to report this amount on Form 8959. See the Form
1040 instructions to determine if you are required to complete Form 8959.
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.
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 box 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 shouldn’t 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.
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 $22,500 ($15,500 if you have only SIMPLE plans;
$25,500 for section 403(b) plans if you qualify for the 15-year rule explained in
Pub. 571). Deferrals under code G are limited to $22,500. Deferrals under code H
are limited to $7,000.
However, if you were at least age 50 in 2023, your employer may have allowed an
additional deferral of up to $7,500 ($3,500 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

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

2023

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.
A—Uncollected social security tax on tips. Report on U.S. Form 1040 or 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
B—Uncollected Medicare tax on tips. Report on U.S. Form 1040 or 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
C—Taxable cost of group-term life insurance over $50,000 included in boxes 1, 3
(up to the 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.

R—Employer contributions to your Archer MSA. Report on Form 8853.
S—Employee salary reduction contributions under a section 408(p) SIMPLE plan
(not included in box 1)
T—Adoption benefits (not included in box 1). Complete Form 8839 to figure
taxable and nontaxable amounts.
V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3
(up to the social security wage base), and 5). See Pub. 525 for reporting
requirements.
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.
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

E—Elective deferrals under a section 403(b) salary reduction agreement

BB—Designated Roth contributions under a section 403(b) plan

F—Elective deferrals under a section 408(k)(6) salary reduction SEP

DD—Cost of employer-sponsored health coverage. The amount reported with
code DD is not taxable.

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 box 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 1040-SR.
Report on Form 1040-SS if not required to file Form 1040 or 1040-SR.
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 1040-SR. Report
on Form 1040-SS if not required to file Form 1040 or 1040-SR.
P—Excludable moving expense reimbursements paid directly to a member of the
U.S. Armed Forces (not included in box 1, 3, or 5)
Q—Nontaxable combat pay. See your tax return instructions for details on
reporting this amount.

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.
FF—Permitted benefits under a qualified small employer health reimbursement
arrangement
GG—Income from qualified equity grants under section 83(i)
HH—Aggregate deferrals under section 83(i) elections as of the close of the
calendar year
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.
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.