W-2 Duplicate Request
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1Reset Form
Mail:
W-2 Adjustment Unit
5 Manhattan West, 4
Floor
th
W-2 Duplicate Request
New York, NY 10001
If paying by Credit Card or Payroll Deductions:
Fax:
(212) 857-7259
AGENCY NAME
PAYROLL #
AGENCY
IDENTIFICATION
W-2 COORDINATOR NAME
AGENCY PHONE
(if known)
EMPLOYEE SECTION
FIRST
M.I.
LAST
EMPLOYEE
SOCIAL SECURITY NUMBER
(Mandatory for DoE employees)
DAYTIME TELEPHONE
IDENTIFICATION
__ CHECK HERE IF THIS IS AN AGENCY ADDRESS
STREET ADDRESS
MAILING
ADDRESS
STREET ADDRESS CONTINUATION
(Address to which
copies of documents
will be mailed)
BOROUGH / CITY / TOWN
STATE
ZIP CODE + 4
_
Enter the year(s) of your request (YYYY).
YEAR
YEAR
YEAR
YEAR
YEAR
YEAR
TAX YEAR(S)
REQUESTED
rd
W-2
1127 STATEMENT
3
PARTY DISABILITY
Employee Signature
__ Other Authorized Person
___________________________________________
REQUESTED
Relationship
BY
Signature
___________________________________________________
PAYMENT METHOD – Select method of payment (cash not accepted)
FEE CALCULATION – Enter quantity and total
NUMBER
FEE PER
Certified Check
TOTAL
OF ITEMS
ITEM
Please make certified check or money order payable to:
City of NY Office of Payroll Administration
Duplicate W-2
Money Order
X
$5.00
Request Forms
A fee of $5 is charged for each copy of a W-2 or 1127 more than
Payroll Deduction
(Active employees only)
three years old. Fees do not apply to copies of documents of active
Employee Authorization for Payroll Deduction
employees of NYCHA, NYCERS, TRS, Police Pension Fund, or the
(Complete section below)
Water Authority
.
Credit Card
CREDIT CARD ACCOUNT NUMBER
CVV
EXPIRATION DATE (MM/YY)
Credit Card Type
VISA
MasterCard
American Expres
Discover
s
Cardholder Signature
Cardholder Name
(Print name as it appears on card)
FOR OPA USE ONLY
Payroll Deduction entered by:
Request for copies received by:
Certified Check, Money Order, or Credit Card processed by:
Name
Name
Name
(Please Print)
(Please Print)
(Please Print)
Signature
Signature
Signature
(MM/DD/YY)
(MM/DD/YY)
(MM/DD/YY)
Date
Date
Date
(MM/DD/YY)
Items Mailed:
Date
Initials
Deduction Code
____________
________________
_______
7 0 5 9
____________
F430-006 - W-2 Duplicate Request____Rev.05/2017
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Parent category: Financial