Exhibit B — Internal Revenue Bulletin 2003-17

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			DO NOT CUT, FOLD OR STAPLE
Tax year/Form corrected a / W-	55555	55555	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008	For Official Use Only OMB No. 1545-0008
b Employer’s name, address, and ZIP code 3.8"	b Employer’s name, address, and ZIP code 3.8"	b Employer’s name, address, and ZIP code 3.8"	b Employer’s name, address, and ZIP code 3.8"	b Employer’s name, address, and ZIP code 3.8"	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218	943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay Sec. 218
Number of Forms W-2c d	Number of Forms W-2c d	e Employer’s Federal EIN	e Employer’s Federal EIN	e Employer’s Federal EIN	f Establishment number	g Employer’s state ID number	g Employer’s state ID number	g Employer’s state ID number	g Employer’s state ID number	g Employer’s state ID number
Complete boxes h, i, or jonlyif incorrect on last form filed.	Complete boxes h, i, or jonlyif incorrect on last form filed.	h Employer’sincorrectFederal EIN	h Employer’sincorrectFederal EIN	h Employer’sincorrectFederal EIN	i Incorrectestablishment number	j Employer’sincorrectstate ID number	j Employer’sincorrectstate ID number	j Employer’sincorrectstate ID number	j Employer’sincorrectstate ID number	j Employer’sincorrectstate ID number
Total of amounts previously reported as shown on enclosed Forms W-2c.	Total of amounts previously reported as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of amounts previously reported as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.	Total of corrected amounts as shown on enclosed Forms W-2c.
1 Wages, tips, other compensation	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	2 Federal income tax withheld	2 Federal income tax withheld	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 wages 3	Social security tax withheld 4	Social security tax withheld 4	Social security tax withheld 4	Social security tax withheld 4	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	Medicare wages and tips 5	6 Medicare tax withheld	6 Medicare tax withheld	6 Medicare tax withheld	6 Medicare tax withheld	6 Medicare tax withheld	6 Medicare tax withheld
7 Social security tips	7 Social security tips	7 Social security tips	7 Social security tips	7 Social security tips	Allocated tips 8	Allocated tips 8	Allocated tips 8	Allocated tips 8	Allocated tips 8	Allocated tips 8
Advance EIC payments 9	Advance EIC payments 9	Advance EIC payments 9	Advance EIC payments 9	Advance EIC payments 9	10 Dependent care benefits	10 Dependent care benefits	10 Dependent care benefits	10 Dependent care benefits	10 Dependent care benefits	10 Dependent care benefits

			DO NOT CUT, FOLD OR STAPLE
11 Nonqualified plans	11 Nonqualified plans	11 Nonqualified plans	11 Nonqualified plans	11 Nonqualified plans	12a-d (Coded items) 1.9"	12a-d (Coded items) 1.8"	12a-d (Coded items) 1.8"	12a-d (Coded items) 1.8"	12a-d (Coded items) 1.8"	12a-d (Coded items) 1.8"
14 Inc. tax W/H by 3rd party sick pay payer
16 State wages, tips, etc.	16 State wages, tips, etc.	16 State wages, tips, etc.	16 State wages, tips, etc.	16 State wages, tips, etc.	17 State income tax	17 State income tax	17 State income tax	17 State income tax	17 State income tax	17 State income tax
18 Local wages, tips, etc.	18 Local wages, tips, etc.	18 Local wages, tips, etc.	18 Local wages, tips, etc.	18 Local wages, tips, etc.	19 Local income tax	19 Local income tax	19 Local income tax	19 Local income tax	19 Local income tax	19 Local income tax
Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:	Explain decreases here:
Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?	Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?		Yes		No
If “Yes,” give date the return was filed
Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true, correct, and complete. Date Title Signature
Contact person	Contact person	Contact person	Contact person	Telephone number ( )	Telephone number ( )	Telephone number ( )	For Official Use Only	For Official Use Only	For Official Use Only	For Official Use Only

			DO NOT CUT, FOLD OR STAPLE
E-mail address	E-mail address	E-mail address	E-mail address	Fax number ( )	Fax number ( )	Fax number ( )	Fax number ( )	Fax number ( )	Fax number ( )	Fax number ( )

Purpose of Form

Use this form to transmit Copy A of Form(s) W-2c, Corrected Wage and Tax Statement (Rev. 12-2002). Make a copy of Form W-3c and keep it with Copy D (For Employer) of Forms W-2c for your records. File Form W-3c even if only one Form W-2c is being filed or if those Forms W-2c are being filed only to correct an employee’s name or social security number (SSN). See the separate Instructions for Forms W-2c and W-3c (Rev. December 2002) for information on completing this form.

When To File

File this form and Copy A of Form(s) W-2c with the Social Security Administration as soon as possible after you discover an error on Forms W-2, W-2AS, W-2GU, W-2CM, or W-2VI. Also provide Copies B, C, and 2 of Form W-2c to your employees as soon as possible.

Where To File

If you use the U.S. Postal Service, send Forms W-2c and W-3c to the following address:

Social Security Administration Data Operations Center P.O. Box 3333 Wilkes-Barre, PA 18767-3333

If you use a carrier other than the U.S. Postal Service, send Forms W-2c and W-3c to the following address:

Social Security Administration Data Operations Center Attn: W-2c Process 1150 E. Mountain Drive Wilkes-Barre, PA 18702-7997