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
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of it, printed from this website, is not. A penalty of $50 per information return may be
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You may file Forms W-2 and W-3 electronically on the SSA’s website at
Employer Reporting Instructions & 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

14 Other

Retirement
plan

12a See the separate instructions
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

2010

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.
Cat. No. 10140H

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

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

2010

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

2010

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

Notice to Employee
Refund. Even if you do not have to file a tax return, you
should file to get a refund if box 2 shows Samoa income tax
withheld.
Copies B and C; corrections. File Copy B of this form with
your 2010 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.
Estimated tax. If you expect to owe $1,000 or more in tax
for 2011 (including self-employment tax), you may have to
make estimated tax payments to the U.S. Internal Revenue
Service. Use Form 1040-ES, Estimated Tax for Individuals.
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.

Credit for excess social security tax. If you had more than
one employer in 2010 and more than $6,621.60 in social
security tax was withheld, you may 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. If you
are required to file Form 1040 with the United States, you
must claim the excess tax as a credit on Form 1040.
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. Review the information shown on your
annual (for workers over 25) Social Security Statement.
(Also see the Instructions for Employee on the 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.)

2010

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

Instructions for Employee
(Also see Notice to Employee on the back of Copy B.)
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
any 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.
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 and BB) under all plans are generally
limited to a total of $16,500 ($11,500 if you have only SIMPLE plans; $19,500 for
section 403(b) plans if you qualify for the 15-year rule explained in Pub. 571).
Deferrals under code G are limited to $16,500. Deferrals under code H are limited
to $7,000.
However, if you were at least age 50 in 2010, your employer may have allowed
an additional deferral of up to $5,500 ($2,500 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.
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.
B—Uncollected Medicare tax on tips. Report on U.S. Form 1040 or on Form
1040-SS if not required to file Form 1040.
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).
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).
T—Adoption benefits (not included in box 1). Complete Form 8839, Qualified
Adoption Expenses, to figure taxable and nontaxable amounts.
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 and instructions for
Schedule D (Form 1040) 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, Health Savings Accounts (HSAs).
Y—Deferrals under a section 409A nonqualified deferred compensation plan.
Z—Income under section 409A on a nonqualified deferred compensation plan.
This amount is also included in box 1. It is subject to an additional 20% tax plus
interest. See “Total Tax” 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.
CC (For employer use only)—HIRE exempt wages and tips.
Box 13. If the “Retirement plan” box is checked, special limits may apply to the
amount of traditional IRA contributions that you may deduct.

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 the separate instructions
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

2010

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

Employers, Please Note—
Note. A minimum income tax of 4% must be withheld on
wages and other compensation.
Who must file. File Form W-2AS for each employee from
whom American Samoa income tax or U.S. social security
and Medicare taxes were withheld or required to be withheld
during 2010.
Distribution of copies. By January 31, 2011, furnish Copies
B and C to each person who was your employee during
2010. For anyone who stopped working for you before the
end of 2010, you may furnish Copies B and C to them any
time after employment ends but no later than January 31,
2011. If the employee asks for Form W-2AS, furnish the
completed copies within 30 days of the request or within 30
days of the final wage payment, whichever is later. You may
also file Copy A and Form W-3SS, Transmittal of Wage and
Tax Statements, with the Social Security Administration
(SSA) at the same time.

Note. If you terminate your business, see the rules on
furnishing and filing Forms W-2AS and W-3SS under
Terminating a business in the separate instructions.
When to file. By February 28, 2011, send Copy A of Forms
W-2AS and W-3SS to the SSA. However, if you file
electronically, the due date is March 31, 2011. See the
separate instructions.
Reporting electronically. If you file 250 or more Forms
W-2AS, you must file electronically. For information, visit
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.
See the Instructions for Forms W-2AS, W-2GU, W-2VI,
and Form W-3SS for more information on how to complete
Form W-2AS.