Request For Duplicate W2 Form - Miami Dade County
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1For Finance Payroll Use Only:
_____________
Receipt #
Miami-Dade County
Paid
Finance Department – Payroll Unit
$ _________________
st
111 N.W. 1
Street, Suite 2630
Miami, FL 33128-1995
Phone: (305) 375-5165 x Fax: (305) 375-2570
REQUEST FOR DUPLICATE W-2 FORM
Employee's Name: ______________________________________
Phone Number:__________________
Employee’s Social Security Number or Employee ID: _______________________
Department: _________________________________________________________
Indicate your Request:
•
______ W-2 Form for 2008 – No Charge
•
______ W-2 Forms for 2000 through 2007 at $5.00 each copy.
Select applicable: _____ 2007, _____ 2006, _____ 2005, _____ 2004
_____ 2003, _____ 2002, _____ 2001, _____ 2000
• ______ W-2 Forms for 1999 and earlier at $ 10.00 each copy.
Indicate year(s) and quantity requested: ___________________________________________
Distribution of Form: (Circle One) Pick-up From Finance Payroll
Mail Form (*)
Forward Form to DPR
Reason for Request: (Circle One)
Never Received
Lost/Misplaced/Destroyed
______________________________
_____________________________
______/______/______
Employee/ DPR’s (Print Name)
Employee/ DPR’s Signature
Date
Method of Payment: Cash, Personal Check, or Money Order. If you are paying with a personal check or a
Money Order, please make it payable to Miami-Dade Board of County Commissioners.
(*) Form to be mailed: If requesting the form to be mailed, please provide a self-addressed stamped envelope.
Received:
_________________________ _____________________________
______/______/______
Print Name
Signature
Date
For Finance Payroll Use Only: Date form mailed to employee:
_______/_______/_______
Effective Date: 01/31/09
Revised:
01/26/09
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