Wage Statement Form
A wage statement form is a statement that must be prepared by employers each year for employees, showing the employee’s total gross earnings, Social Security and Medicare earnings, taxes withheld for the employee. These forms also provide information about deductions for employee benefit plans and other deductions that must be reported on the employee’s income tax return.
Sample Wage Statement Form
Name of employer: ______________________
Address of employer: ______________________
Employer’s customary work week: ______________________
Employee Name: ______________________ Social Security Number: _______________
Telephone: ______________________
Week From: ______________________ Week To: ______________________
Gross Wages: ______________________ Net Wages: ______________________
Days worked:
Days worked per week: Rate: _____________________
Hours worked per week: Rate: ______________________
Gratuities as reported to the employer in writing as taxable income:
______________________
Fringe benefits (received by employee at employer cost only)
Rent/Housing/Lodging Allowance: ______________________
Meal Allowance: ______________________
Payments in Kind:
______________________
______________________
______________________
Total:
Total Gross Pay/Fringes and Gratuities: ______________________
Total Fringe Benefits: ______________________
Preparer’s Name: Telephone Date
_________________ ____________________ ____________________
Category: Statement Forms
