FORM W-2
(Wage & Tax Statement) Reissue Request
Please provide all requested information and
return the completed, signed form to your local
payroll ofce, or mail/fax to:
KCTCS System Ofce
ATTN: Payroll Department
300 North Main Street
Versailles, KY 40383
Fax: 859-256-3120
Part 1: Employee/Former Employee Information
Employee ID __________________________________ Last Four Digits of SSN _________________
Employee Name _______________________________________________________________________
College Work Location __________________________________________________________________
Current Mailing Address _________________________________________________________________
_____________________________________________________________________________________
City _____________________________________ State____________ Zip Code __________________
• Active employees, seeking to make a change to their current contact information, please use employee self-service:
https://employees.kctcs.edu/
• W-2 forms contain condential, personal information. Due to security reasons, reissued W-2’s cannot be transmitted
via fax or e-mail. All forms will be mailed to the address listed above.
Part 2: W-2 Information
Tax year to be reissued: _______________
Reason for Reissue (check one): ____ Lost ____ Destroyed ____ Never Received
____ Other (please specify) ______________________________________________________________
Part 3: Authorized Signature
Please reissue IRS Form W-2, Wage and Tax Statement for the single tax year requested. I certify I am the
individual listed above. I acknowledge KCTCS is not responsible for reprint requests that are lost, incom-
plete, misdirected, stolen, mutilated, illegible, postage due, or any combination thereof.
____________________________________________________ ___________________________
Signature Date
FOR PAYROLL DEPARTMENT USE ONLY:
Date Received __________ Processed By _______________________ Date Processed ____________
FORM PR101
01/25/2013
All W-2 Reissue requests will
be processed by system ofce
payroll staff. Please allow up
to three business days for form
processing. Requests for most
recent year tax forms will not be
processed prior to February 1.
