W-2 Request Form

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W-2 Request Form
Name:__________________________________
SS#:_______________________
Form W-2 Tax Year ____________
Reason for request (
i.e., never received, misplaced or destroyed, SSN or name incorrect, other):
Hold for pickup ( )
Mail to address listed below: ( )
______________________
______________________
______________________
For Payroll Dept. Use Only
Date request received:______________________
Original W-2 delivered:_____________________
Duplicate W-2 reissued:_____________________
Processed by:______________________________
Date Processed:__________

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