Sample Request Form For Corrected/reissued 2015 W-2s printable pdf download

Payroll Legal Alert

Sample Request Form for Corrected/Reissued 2015 W-2s

To: Payroll Department

Date: ______________________

Re: Request for Corrected/Reissued W-2 for 2015

Please reissue a W-2, Wage and Tax Statement, to me for wages I earned during the preceding year, 2015.

PLEASE PRINT

EMPLOYEE’S NAME: _______________________________________________________________________________

EMPLOYEE’S HOME ADDRESS: ____________________________________________________________________

____________________________________________________________________________________________________________

EMPLOYEE’S ID NUMBER: _________________________________________________________________________

EMPLOYEE’S DEPARTMENT, ADDRESS, EMAIL ADDRESS, AND PHONE NUMBER: ________________

_____________________________________________________________________________________________________

____________________________________________________________________________________________________________

REASON FOR REQUEST:

____________________________________________________________________________________________________________

Please give the Payroll Department 10-14 days from the date you submitted your request to respond to you.

If your original W-2 is wrong, list the box number of the form that contains the incorrect entry, the incorrect

amount, and correct amount. Attach supporting documents. NOTE: Box 2 of your original W-2 form cannot

be corrected unless the error is administrative (the numbers were transposed, for example).

If you receive a Form W-2c in response to this request, and you have already filed your income tax return

for the year, you may have to file an amended return. If you have not filed your return, attach Copy B of your

original W-2 form and Copy B of a W-2c form to your return when you file it.

I agree that $5 will be withheld from my next paycheck to cover the costs of processing a Reissued W-2.

No charge will be made for providing you with a W-2c form.

EMPLOYEE’S SIGNATURE: _______________________________________________________________________

May we email you a consent form to receive your future W-2 forms electronically?

YES

For Payroll Department use:

Date received _______________________

Date corrected/reissued W-2 sent to employee ______________________

Processed by __________________________________________________

Payroll manager’s signature __________________________________________________

March 2016

Sample Request Form For Corrected/reissued 2015 W-2s