Idaho Substitute W-2
FORM W-2 SUB                                  Wage and Tax Statement                                         20
1. Your name                                                                                    Social security number

     Address

     City                                     State                      Zip                    Phone number

2.   Employer (business name or owner's name)                                                   Employer's ID number, if known

     Address

     City                                     State                      Zip                    Phone number, if known

3. Wages, tips, other compensation  Federal income tax withheld   Idaho income tax withheld     Social security tax withheld
     $_____________________________ $____________________________ $ ___________________________ $ ______________________________
4.   How did you determine the amounts in 3?  You must attach copies of any documents or schedules used to determine this
     amount.

5.   Give reason, if known, why a W-2 form was not furnished by employer.

               Attach photocopy of payroll check stub(s)or other document(s)
                                    to verify the Idaho withholding amount(s) claimed.

I verify that I have made efforts to contact this employer and have given this employer sufficient time to mail or
otherwise provide this statement.
Your signature                                                                                  Date

                                                                                                                            EFO00169
                                                                                                                            01-27-2006