State of New Jersey
Department of The Treasury
Division of Taxation
Employee’s Substitute Wage and Tax Statement
Name Social Security Number
Address (Number, Street, City, State, ZIP Code)
I have been unable to obtain a Form W-2, Wage and Tax Statement, from my employer, named below, and have so notied the
Internal Revenue Service. The amounts shown below are my best estimates of the gross wages paid to me and the New Jersey
Gross Income Tax withheld by this employer during
.
Name and Address of Employer Gross Wages, Tips, and
Other Compensation
New Jersey Gross Income
Tax Withheld
How did you estimate the above gross wages and New Jersey Gross Income Tax?
Give reason Form W-2 was not furnished by employer, if known, and explain your efforts to obtain it.
Under penalties of perjury, I declare that I have made reasonable attempts to obtain the Wage and Tax Statement or copy there-
of and that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.
Your Signature Date
The Division of Taxation will contact your employer for verication of the information reported on this form and to determine the
reason no Wage and Tax Statement was issued.
THIS FORM IS TO BE USED ONLY IF A WAGE AND TAX STATEMENT
CANNOT BE SECURED FROM YOUR EMPLOYER
C-4267 (10-99)
