Cdc+ Corrected W-2/1099 Request Form - 2012 printable pdf download

Cdc+ Corrected W-2/1099 Request Form - 2012

2012 CDC+ Corrected W-2/1099 Request Form

Personal Information

1. Consumer Name:

2. Consumer #:

3. Provider Name:

4. Provider #:

5. Provider Contact Phone:

Provider is Requesting a Corrected W-2.

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

Provider is Requesting a Corrected 1099-MISC.

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

Reason for W-2(c)/corrected 1099-MiscRequest:

Incorrect Name

Correct name:

Verification of Name:

Check and Provide at least One Verification source:

□ Drivers License □ Social Security Card □ Court Documents □ Other:

Incorrect Wages/Pay Information

Correct wages/pay:

Copies of all timesheets/invoices for 2012 MUST be included.

Incorrect Social Security Number

Correct SS #

Check and Provide at least One Verification source:

□ Social Security Card or □ Other:

(To be completed by CDC+ Finance) Verification source (Correct in Provider paperwork and mis-keyed) Yes or No

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

Cdc+ Corrected W-2/1099 Request Form - 2012