Charging Fees For Duplicate Copies Of Form W-2

Mail to: Charles County Public Schools P.O. Box 2770 Date of Request La Plata, Maryland 20646 Attn: Payroll Department Fax No: 301-934-7497

REQUEST FOR W-2 FORM PLEASE PRINT

Please reissue a WAGE AND TAX STATEMENT (Form W-2) to the following employee, for tax years:

EMPLOYEE NAME:

SOCIAL SECURITY NO.:

EMPLOYEE CURRENT MAILING ADDRESS:

Street Address

City State Zip Code

Work location:

The W-2 Form is requested for the following reason:

Never Received Misplaced or Destroyed Other (Explain):

Signature of Employee Date Please Select: Mail duplicate W-2 Pony to School Call for pick-up in Payroll Phone Number:

Employees Signature when picked up Date picked up

FOR PAYROLL DEPARTMENT USE ONLY: Date request rec'd: Processed by: Date Processed: