Exhibit A — Internal Revenue Bulletin 2003-17

1.0"

7.5"

�	DO		NOT CUT, FOLD, OR STAPLE THIS FORM
Tax year/Form corrected a / W-2	44444	44444	OMB No. 1545-0008 For Official Use Only	OMB No. 1545-0008 For Official Use Only	OMB No. 1545-0008 For Official Use Only
Employee’s correct SSN b	Employee’s correct SSN b	Employee’s correct SSN b	Corrected name (if checked enter correct name inbox e andcomplete box i) c	Employer’s Federal EIN d	Employer’s Federal EIN d
Employee’s first name and initial e Last name Employee’s address and ZIP code f	Employee’s first name and initial e Last name Employee’s address and ZIP code f	Last name	Last name	Employer’s name, address, and ZIP code g 3.7"	Employer’s name, address, and ZIP code g 3.7"
Complete boxes h and/or i only if incorrect on last form filed.	Complete boxes h and/or i only if incorrect on last form filed.	Employee’sincorrectSSN h	Employee’sincorrectSSN h	Employee’s name (asincorrectlyshown on previous form) i	Employee’s name (asincorrectlyshown on previous form) i
Note:Only complete money fields that are being corrected (except MQGE).
Previously reported	Previously reported	Correct information	Correct information	Previously reported	Correct information
1 Wages, tips, other compensation	1 Wages, tips, other compensation	1 Wages, tips, other compensation	1 Wages, tips, other compensation	2 Federal income tax withheld	2 Federal income tax withheld
Social security wages 3	Social security wages 3	Social security wages 3	Social security wages 3	Social security tax withheld 4	Social security tax withheld 4
Medicare wages and tips 5	Medicare wages and tips 5	Medicare wages and tips 5	Medicare wages and tips 5	6 Medicare tax withheld	6 Medicare tax withheld
7 Social security tips	7 Social security tips	7 Social security tips	7 Social security tips	Allocated tips 8	Allocated tips 8
9 Advance EIC payment	9 Advance EIC payment	9 Advance EIC payment	9 Advance EIC payment	Dependent care benefits 10	Dependent care benefits 10
11 Nonqualified plans	11 Nonqualified plans	11 Nonqualified plans	11 Nonqualified plans	See instructions for box 12 12a C o d e	See instructions for box 12 12a C o d e
Retirement plan Third-party sick pay Statutory employee 13	Retirement plan Third-party sick pay Statutory employee 13	Retirement plan Third-party sick pay Statutory employee 13	Retirement plan Third-party sick pay Statutory employee 13	12b C o d e	12b C o d e
1.9" 14 Other (see instructions)	1.9" 14 Other (see instructions)	14 Other (see instructions) 1.9"	14 Other (see instructions) 1.9"	12c C o d e	12c C o d e
1.9" 14 Other (see instructions)	1.9" 14 Other (see instructions)	14 Other (see instructions) 1.9"	14 Other (see instructions) 1.9"	12d C o d e	12d C o d e

State Correction Information	State Correction Information	State Correction Information	State Correction Information	State Correction Information	State Correction Information
Previously reported	Previously reported	Correct information	Correct information	Previously reported	Correct information
15 State Employer’s state ID number	15 State Employer’s state ID number	15 State	15 State	15 State	15 State
15 State Employer’s state ID number	15 State Employer’s state ID number	Employer’s state ID number	Employer’s state ID number	Employer’s state ID number	Employer’s state ID number
16 State wages, tips, etc.	16 State wages, tips, etc.	16 State wages, tips, etc.	16 State wages, tips, etc.	State wages, tips, etc. 16	State wages, tips, etc. 16
17 State income tax	17 State income tax	17 State income tax	17 State income tax	State income tax 17	State income tax 17
Locality Correction Information	Locality Correction Information	Locality Correction Information	Locality Correction Information	Locality Correction Information	Locality Correction Information
18 Local wages, tips, etc.	18 Local wages, tips, etc.	18 Local wages, tips, etc.	18 Local wages, tips, etc.	Local wages, tips, etc. 18	Local wages, tips, etc. 18
19 Local income tax	19 Local income tax	19 Local income tax	19 Local income tax	Local income tax 19	Local income tax 19
20 Locality name	20 Locality name	20 Locality name	20 Locality name	Locality name 20	Locality name 20

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Copy A—For Social Security Administration

Department of the Treasury Form W-2c (Rev. 12-2002) Corrected Wage and Tax Statement Cat. No. 61437D Internal Revenue Service

W-2c (Rev. 12-2002) Corrected Wage and Tax Statement

(Rev. 12-2002)

April 28, 2003 844 2003–17 I.R.B.