Payroll Legal Alert March 2014 www.theHRSpecialist.com Sample Request Form for Corrected/Reissued 2013 W-2s To: Payroll Department Date: ______________________ Re: Request for Corrected/Reissued W-2 for 2013 Please reissue a W-2, Wage and Tax Statement, to me for wages I earned during the preceding year, 2013. PLEASE PRINT EMPLOYEE'S NAME: _______________________________________________________________________________ EMPLOYEE'S HOME ADDRESS: ____________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ EMPLOYEE'S ID NUMBER: _________________________________________________________________________ EMPLOYEE'S DEPARTMENT, ADDRESS, EMAIL ADDRESS, AND PHONE NUMBER: ________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ REASON FOR REQUEST: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please give the Payroll Department 10-14 days from the date you submitted your request to respond to you. If your original W-2 is wrong, list the box number of the form that contains the incorrect entry, the incorrect amount, and correct amount. Attach supporting documents. NOTE: Box 2 of your original W-2 form cannot be corrected unless the error is administrative (the numbers were transposed, for example). If you receive a Form W-2c in response to this request, and you have already filed your income tax return for the year, you may have to file an amended return. If you have not filed your return, attach Copy B of your original W-2 form and Copy B of a W-2c form to your return when you file it. I agree that $5 will be withheld from my next paycheck to cover the costs of processing a Reissued W-2. No charge will be made for providing you with a W-2c form. EMPLOYEE'S SIGNATURE: _______________________________________________________________________ May we email you a consent form to receive your future W-2 forms electronically? YES NO For Payroll Department use: Date received _______________________ Date corrected/reissued W-2 sent to employee ______________________ Processed by __________________________________________________ Payroll manager's signature __________________________________________________

8 Payroll Legal AlrtPayroll Legal Alrt Payroll Legal AlrtPayroll Legal Alrt March 2014 .hHRScal.co Sample Request Form for Corrected/Reissued 2013 W-2s To: Payroll Department Date:

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Page 1: 8 Payroll Legal AlrtPayroll Legal Alrt Payroll Legal AlrtPayroll Legal Alrt March 2014 .hHRScal.co Sample Request Form for Corrected/Reissued 2013 W-2s To: Payroll Department Date:

8 Payroll Legal AlertPayroll Legal Alert

March 2014 www.theHRSpecialist.com

Sample Request Form for Corrected/Reissued 2013 W-2s

To: Payroll Department

Date: ______________________

Re: Request for Corrected/Reissued W-2 for 2013

Please reissue a W-2, Wage and Tax Statement, to me for wages I earned during the preceding year, 2013.

PLEASE PRINT

EMPLOYEE'S NAME: _______________________________________________________________________________

EMPLOYEE'S HOME ADDRESS: ____________________________________________________________________

____________________________________________________________________________________________________________

EMPLOYEE'S ID NUMBER: _________________________________________________________________________

EMPLOYEE'S DEPARTMENT, ADDRESS, EMAIL ADDRESS, AND PHONE NUMBER: ________________

_____________________________________________________________________________________________________

____________________________________________________________________________________________________________

REASON FOR REQUEST:

____________________________________________________________________________________________________________

Please give the Payroll Department 10-14 days from the date you submitted your request to respond to you.

If your original W-2 is wrong, list the box number of the form that contains the incorrect entry, the incorrect amount, and correct amount. Attach supporting documents. NOTE: Box 2 of your original W-2 form cannot be corrected unless the error is administrative (the numbers were transposed, for example).

If you receive a Form W-2c in response to this request, and you have already filed your income tax return for the year, you may have to file an amended return. If you have not filed your return, attach Copy B of your original W-2 form and Copy B of a W-2c form to your return when you file it.

I agree that $5 will be withheld from my next paycheck to cover the costs of processing a Reissued W-2. No charge will be made for providing you with a W-2c form.

EMPLOYEE'S SIGNATURE: _______________________________________________________________________May we email you a consent form to receive your future W-2 forms electronically? YES NO

For Payroll Department use:

Date received _______________________Date corrected/reissued W-2 sent to employee ______________________Processed by __________________________________________________Payroll manager's signature __________________________________________________