Fillable W-2 Replacement/correction Request Form printable pdf download

W-2 Replacement/correction Request Form

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W-2 REPLACEMENT / CORRECTION REQUEST FORM

This form must be filled out

by the Departmental Payroll Office and sent to PPSD

INSTRUCTIONS -

Please print or type:

Complete Section 1 and obtain the Payroll Officer’s signature at the bottom of Section 1.

Refer to either Replacement W-2, Section 2 or Corrected W-2, Section 3, and follow instructions

SECTION 1

MUST BE COMPLETED FOR ALL REQUESTS

Employee name

____________________________

Employee #

___________________

Social Security #

____________________________

Dept. Name and #

___________________

Address where the W-2 should be mailed:

___________________________________________________________________

Payroll Officer’s Signature

___________________________________________________________

Date

____/_____/_______

Phone #_________________________

Replacement W-2

To obtain a replacement W-2, complete Section 2 of this form and attach a $20 payment (check or money order) made

payable to City and County of San Francisco. Send payment to; PPSD, 875 Stevenson, Room 235, Attn: Tax Unit.

Please Note: Non-active employees must pay by money order.

SECTION 2

Complete only for a REPLACEMENT W-2

Replacement W-2 for tax year:

________________

Check #___________ attached

Money Order # _______________________________ attached

Corrected W-2

To obtain a corrected W-2, complete Section 3 of this form and send the form to; PPSD, 875 Stevenson, Room

235, Attention: Tax Unit.

SECTION 3

Complete only for a CORRECTED W-2

Corrected W-2 for tax year:

________________

Describe the problem (please explain fully) and attach copies of supporting documentation (such as pay

statements, Report 10, etc.):

_____________________________________________________________________________________________

__________________________________________________________________

F O R

P P S D

U S E

O N L Y

Replacement W-2:

Payment forwarded to City Hall on ____/____/201__ (date)

Replacement issued ____/____/201__ (date)

Corrected W-2:

Was a prior W-2 issued? NO / YES. If yes, date issued:

____/____/20__

Specify corrections that were made ______________________________________

___________________________________________________________________

Prepared by: _____________________________

Phone #: ______________

Date: ____/____/201__

W-2 Replacement/correction Request Form

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