W-2 REQUEST FORM
Employee Name (First, Middle, Last)
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone Number
*
Email
*
example@example.com
Last four of S.S. #
*
Employee Signature
*
Date
*
/
Month
/
Day
Year
Date
Requested W-2 Tax Year
*
This form was requested for the following reasons
*
Never Received
Misplaced or Destroyed
Other
If other, please explain
How would you like your W-2 sent to you?
*
Email
Fax
Mail
Fax Number:
Preview PDF
Submit
Should be Empty: