Cdc+ Duplicate W-2/1099 Request Form

2012 CDC+ Duplicate W-2/1099 Request Form

Date of Request:

Request For IRS Form W-2 or 1099

2012 Wage and Tax Statement (Form W-2) for the following employee

2012 Miscellaneous (Self-Employment) Income (Form 1099-MISC) for the following contractor

Personal Information

1. Consumer Name:

2. Consumer #:

3. Provider Name:

4. Provider #:

5. Provider Contact Phone:

Reason requested

The Form W-2/1099 is requested for the following reason:

Never Received

Misplaced or Destroyed

Incorrect Address (see below – If provider is a current provider, a new W-4 OR W-9 MUST be present.)

Address:

City & State:

Zip Code:

(To Be Completed by CDC+ Finance) Date New W4/I-9 Sent to CDC+ Finance

Certification Statement

Under penalty of perjury, I confirm that the above information is true and correct.

Signed:

Print Name:

Date:

Finance Authorization Name & Date

***Please FAX form back to (850) 413-9561***

Final 2/5/2013

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Parent category: Legal