499R-2 2016

Form Fields:

Field Name	Size	Type	Description
See Form Filer Common Fields			Filer fields common to all form types.
See Recipient Common Fields			Recipient fields common to all form types.
Cease Ops Date	8	Date	Cease of operations date
Box 5 Amount	12	Amount	Cost of employer health coverage
Box 6 Amount	12	Amount	Charitable contributions
Box 7 Amount	12	Amount	Wages
Box 8 Amount	12	Amount	Commissions
Box 9 Amount	12	Amount	Allowances
Box 10 Amount	12	Amount	Tips
Box 11 Amount	12	Amount	Total = 7+8+9+10
Box 12 Amount	12	Amount	Reimb expenses and fringe benefits
Box 13 Amount	12	Amount	Tax withheld
Box 14 Amount	12	Amount	Governmental retirement fund
Box 15 Amount	12	Amount	Contributions to CODA plans
Box 16 Amount	12	Amount	Exempt salaries (see instructions)
Box 16a Amount	2	Text	Exempt salaries code
Box 16b Amount	12	Amount	Contributions to save and double prg
Box 17 Amount	12	Amount	Social security wages
Box 18 Amount	12	Amount	Social security tax withheld
Box 19 Amount	12	Amount	Medicare wages and tips
Box 20 Amount	12	Amount	Medicare tax withheld
Box 21 Amount	12	Amount	Social security tips
Box 22 Amount	12	Amount	Uncoll social security tax on tops
Box 23 Amount	12	Amount	Uncoll medicare tax on tips
See Form Common Fields			Form fields common to all form types.