Form Osps.99.04 - W-2 Reprint / Reissued Statement Request
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W-2 REPRINT / REISSUED STATEMENT REQUEST
This form is only for State Government Employees. In-Home Caregivers do not qualify.
Section A: About the Request
1
Employee Social Security Number
(Do not use your Employee ID [OR#])
Tax Year:
_________
OREGON STATEWIDE
Last Name
First Name, Middle Initial
Only the last 5
PAYROLL SERVICES
years are
(OSPS)
Daytime Telephone No.
Delivery Options
(503) 378-3518 fax
available to
Pick up at payroll office
E-mail:
request.
Mail to home (complete address below)
OSPS.Help@oregon.gov
1-Internal Revenue Code section 6109(3) establishes the social security number as the
Need more than
identifying number for tax records. We will use this number solely to verify and retrieve your
one year? Use
Online Resource Center:
record for purposes of this request. This disclosure is mandatory. Failure to provide this
additional forms.
information means we cannot give you a Reissued W-2 Statement.
Section B: Address Information
If you checked “Mail to Home” above, complete this information. The Reissued W-2 prints
INSTRUCTIONS TO
with the original address on file.
EMPLOYEES:
2
Street Address
1. Complete this form
City
State
ZIP/Postal Code
online at
2
-This address is
New – change my personnel record or
N/A
2. Print and give to your
agency payroll office.
Section C: Reason for Request
Forms submitted directly
Misplaced or Destroyed
Dept. of Revenue Request
to OSPS without an
Original Not Received
Corrected W-2 Information
(Complete Address Information, above)
agency signature are
Other (specify):
not honored.
Section D: Employee Authorization
Please reissue IRS Form W-2, Wage and Tax Statement, for the single tax year requested.
I certify: I am the employee listed above or the duly authorized representative thereof.
INSTRUCTIONS TO
PAYROLL OFFICES:
Signature:
Date:
Section E: Agency Request Authorization / Certification
1. Refer to Section E.
Pre-request agency checklist:
P090 / PPDB checked for valid wages during year
Verify form is complete.
Print locally using online reports
Agency Number
Telephone No.
Contact Name (Please PRINT or TYPE)
Agency Use Only
Received Date Stamp
Please reissue IRS Form W-2, Wage and Tax Statement, for the single tax year requested.
I certify: that this request is being made to serve a legitimate business obligation.
Signature:
Date:
For Agency Use Only
Return to Agency – UNPROCESSED:
No Wages for Tax Year
Not a State Government Employee
No Agency Signature
Info Missing or Illegible (specify):
Revised 5/2017
Request Year Not Available
Form No. OSPS.99.04
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