*Form Type:

• W-2 Form (Clergy)
• W-2 From (Non-clergy)
• 1099 Form (Contractor)
• W-2c Form (Correction)

*Tax Year:

-- Please Select --2019 2018 2017

*Church / Employer Federal Employer Identification Number (FEIN):

*Church / Employer Name and Mailing Address:

*Employee - Social Security Number (SSN):

*Employee's Name and Mailing Address

Contractor Payments (1099 Form):

Base Salary (W-2 Form):

Social Security Allowance / FICA Off-Set (W-2 Form):

Auto Allowance (W-2 Form):

Professional Allowance (W-2 Form):

Gifts from Church (W-2 Form):

Bonus (W-2 Form):

Other Line Items of Compensation (W-2 Form):

*Housing (W-2 Form):

• N/A
• Own
• Rent
• Church Owned Parsonage

Housing/Parsonage Allowance:

Fair Rental Value (Parsonage Only):

Utilities Paid by the Church (Parsonage Only):

*Select the following benefits that were paid:

• None
• Forgiveness of debt
• Dependent Care Benefits - Salary Reduction Election
• Group-term Life (over $50,000)
• Health Saving Account (HSA) - Paid by the Church
• Honoraria paid by church
• Moving Expenses Paid by the Church
• Personal Use of Church Vehicle
• QSEHRA Contributions
• Sabbatical compensation
• Spouse travel without legitimate ministry purpose
• Severance
• Student Loan Payments
• Taxable Fringe Benefits
• Other payment of personal expenses

List the line item and amount(s) that were paid from the list above:

403(b) Contributions - Salary Reduction Election (W-2 Form):

Retirement Plan provided by the church (W-2 Form):

• Check if "Yes"

Other Benefits Paid:

*Taxes Withheld (W-2 Form):

• Yes
• No

Federal Income Tax Withheld:

Social Security Tax Withheld:

Medicare Tax Withheld (non-clergy only):

State ID Number:

State Tax Withheld:

Local Tax Withheld (If applicable):

Localty Name (If applicable):

Have you filed the Employer's Quarterly Federal Tax Returns (941 form)?

• None
• Yes
• No

Comment/Notes:

Upload Payroll Summary or Compensation Package (Required for W-2 Forms):

Allowed file extensions to upload: PDF

*Confirmation:

• I hereby certify that the above information is true and correct to the best of my knowledge:

*Submitted by / Phone Number:

* Required Fields