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           MISSOURI DEPARTMENT OF REVENUE          FORM
           TAXATION DIVISION
           EMPLOYEE’S SUBSTITUTE WAGE              548
           AND TAX STATEMENT                   (REV.01-200 )8
NAME                                                         SOCIAL SECURITY NUMBER

ADDRESS                                        CITY                                                     STATEZIP CODE

I have been unable to obtain a Form W-2 from my employer, named below, and have so notified the Missouri Department
of Revenue, Taxation Division . The amounts shown below are my best estimates of the gross wages paid to me and the
Federal income tax withheld, Missouri state income tax withheld and F.I.C.A. employee tax withheld by this employer
during the tax year 20 ______ .
NAME OF BUSINESS                                             NAME OF OWNER

BUSINESS ADDRESS                               CITY                                                     STATEZIP CODE

GROSS WAGES            FED. INCOME TAX WITHHELDMO. STATE INCOME TAX WITHHELD       F.I.C.A. EMPLOYEE TAX WITHHELD

Please indicate the reason Form W-2 was not obtained from this employer. Provide an explanation of how you arrived at the
estimated figures and attach copies of check stubs or other documentation pertinent to this calculation.

SIGNATURE OF EMPLOYEE                                                       DATE

MO 860-1390 ( 1-200 )08