Request for Duplicate Copy of T4 / T4A Form
Western Human Resources
Instructions: You may print the form and complete it by hand (please print clearly), or you may
type in all fields (except the signature and date areas), then print and sign. Some versions of
Acrobat Reader will not allow you to save the form after you enter your information.
Please note:
Please be aware that this form requests personal information that allows us to confirm
your identity. Options for submitting this form are list at the bottom of the page.
Some T4A forms are also distributed by Western’s Office of the Registrar.
We can only provide copies of those T4/T4A forms produced by Human Resources.
Name: _________________________________________________________________
Western employee ID number: ________________________________________________
Personal Data Form and documentation)
Last four digits of Social Insurance Number: __________________________________________
(N.B. – If SIN has changed, you must also submit a
Please provide us with your current mailing address:
May we update Human Resources records with this new address if it doesn’t agree with our
records? Yes _____ No _______
T4/T4A tax year(s) requested: ________________________________________________
Do you wish to pick up the T4/T4A copy in the Human Resources Office Room 4159 Support
Services Building? Yes _____ No ______ . If you wish to pick up your new copy please
provide your phone number or email address so we may notify you when it is ready, otherwise
it will be mailed to the address above:
Signature __________________________________Date:____________________________
When completed, please do one of the following:
Deliver to Human Resources, Room 4159, Support Services Building
Fax form to 519-661-4104
Scan and email the form to
Mail to: Human Resources - T4s
Western University
Room 4159, Support Services Building
London, Ontario N6A 3K7
Questions? Visit our FAQ.
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