EMPLOYEE’S REQUEST FOR DUPLICATE W-2

     

     
    Employee Name      
    Social Security Number
         
         
         
    Daytime Phone Number (
         
    )      


    Employee’s Current Mailing Address:

     
    Street Address      
    City       State       Zip      


     
    Employee’s Signature   
    Date of Request
         
    /
         
    /
         
    Year(s) Requesting      


     

    The FORM W-2 is requested for the following reason:

     
     Never Received
     Misplaced or Destroyed
     Social Security Number or Name Incorrect
     Other (Explain)   


    ----------------------------------------------------------------------------------------------------------

     


    For Business Office Use Only

     
    Date Request Received  /  /  Date Processed  /  /   
     
    Processed By  Mailed On  /  /   

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    Rev. 10/04  5.06a