FORM W-2
(Wage & Tax Statement) Reissue Request
Please provide all requested information and
return the completed, signed form to your local
payroll ofce, or mail/fax to:
KCTCS System Ofce
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 condential, 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 ofce
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.