W-2 REPRINT REQUEST FORM
Use this form to correct an employee’s Social Security Number, misspelled name, or to replace a W-2 that was lost.
DO NOT USE THIS FORM AFTER FEBRUARY 28 FOR A NAME OR SSN CHANGE. Form W-2C is required after that date.
Company Name: ______ Company #: ______________________
Contact Name:____________________________________________________________________
Employee's Correct Name: ________ ____________________________________________________
Employee's Name on W-2______________________________________________________________
Correct SSN:____________--______-- ___________ |
Tax Year Needed: _______________ |
SSN on W2:____________--______-- ____________ |
Employee #:_____________________ |
Information to correct on the W2:
____________________________________________________________________________________
____________________________________________________________________________________
W-2 reprints will be sent to the employer for distribution to the employee. Please check one of the following delivery methods:
____ U. S. Mail |
____ FedEx 2-day |
_____FedEx Overnight |
____ Local Courier |
____ Email PDF |
Email Address:______ _______________________________________________ |
I understand the fee for a W-2 reprint is $25.00 , plus delivery charges, and will be debited from our company account on file. The IRS does not require a reprinted W-2 to be on an official W-2 form. A reprinted W-2 will be stamped with the words “REISSUED STATEMENT”.
Authorized Signature: ________ __________________ Date: _______________
PLEASE FAX THIS COMPLETED AND SIGNED FORM TO 770-395-6617.
Proliant Use Only: |
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Reprint Date: _______________________ |
Delivery Date:________________________ |
Billing Date: _______________________ |
Billing Amount: ______________________ |
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