STATE OF CALIFORNIA STATE CONTROLLER'S OFFICE
DUPLICATE WAGE AND TAX STATEMENT REQUEST
STD. 436 (REV. 9/2006c)
SCO USE ONLY
DATE RECEIVED
DATE MAILED
MAIL TO: STATE CONTROLLER’S OFFICE
PERSONNEL/PAYROLL SERVICES DIVISION
ATTN: W2 UNIT
P.O. BOX 942850
SACRAMENTO, CA 94250-5878
INITIALS
SECTION A — PLEASE TYPE OR PRINT
SOCIAL SECURITY NUMBER
LAST NAME
FIRST INITIAL
MIDDLE INITIAL
TAX YEAR(S) REQUESTED
SECTION B — COMPLETE ONLY IF YOU WOULD LIKE YOUR W2 TO BE MAILED
EMPLOYEE NAME OR AGENCY/CAMPUS NAME SEND TO HUMAN RESOURCES ATTENTION
NUMBER AND STREET DAYTIME TELEPHONE NUMBER
CITY STATE ZIPCODE
SECTION C — COMPLETE ONLY IF YOU WOULD LIKE TO PICK UP YOUR W2
NOTE: SCO WILL CONTACT YOU WHEN W2 IS READY FOR PICKUP. A PICTURE ID IS REQUIRED TO RELEASE W2.
CONTACT DAYTIME TELEPHONE NUMBER
SECTION D — METHOD OF PAYMENT (must be completed)
(Check one below) Include $8.50 processing fee for each tax year requested. NO PERSONAL CHECKS ACCEPTED.
Payroll Deduction $ . I authorize this deduction to be taken from my next pay warrant (must be currently
employed by the State).
Payment Enclosed $ . Cashier check/money order number (must be
Retired Annuitants, student assistants, separated).
SECTION E — EMPLOYEE AUTHORIZING SIGNATURE (must be completed)
SIGNATURE DATE SIGNED
SECTION F — AGENCY/CAMPUS USE ONLY
AGENCY CODE AGENCY/CAMPUS NAME
Departmental Billing $ . Authorized signature is required for Agency/Campus billing.
Fee waiver: W2 was not received by employee. Agency has verified address to be correct from W2 mailing list.
Fee Waiver only available February 1
st
through March 1
st
.
AGENCY/CAMPUS AUTHORIZING SIGNATURE
PRINT NAME TELEPHONE NUMBER
SIGNATURE DATE SIGNED
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