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Request Form for Duplicate W-2 |
| Employee Name | Social Security Number |
| Department | Location |
Requesting duplicate W-2 form for year: ____________
Send completed form to Payroll Dept., Main Bldg, Rm 205.
The W-2 is requested for the following reason:
| Never received | |
| Misplaced or destroyed | |
| Incorrect Name or Social Security Number | |
| Other (explain) ________________________________________________________________ |
Check one:
| I will pick up my duplicate W-2 in person. | |
| Please mail my W-2 to the following address: | |
| Name | _______________________________________________________________ |
| Addr1 | _______________________________________________________________ |
| Addr2 | _______________________________________________________________ |
| City/St/Zip | _______________________________________________________________ |
| Employee Signature _______________________________________________________ | Date ________________ |
FOR PAYROLL DEPARTMENT USE ONLY
| Date Req Received: | Processed by: |