Request for Duplicate Form W-2
There is a $5.oo fee charged for each request.
(Please print)
Please reissue a Wage and Tax Statement (Form W-2) for the following
Employee, for the tax year ending __________.
Employee Name:
_______________________________________________________________
Banner ID:
_________________________________________________________
Current Mailing Address of Employee
___________________________________________
___________________________________________
___________________________________________
The Form W-2 is requested for the following reason:
_____ Never Received
_____ Misplaced or Destroyed
_____ Social Security Number or Name Incorrect
_____ Other (explain) _____________________________________________________
Please distribute the duplicate as follows:
_____ Employee will pick up in Payroll Office
_____ Mail to the address above
__________________________________ __________
Signature of Employee (if possible) Date
For Department Use Only
Duplicate issued on : _____/_____/_____ Mailed on: _____/_____/_____
Processed by: _________________________________________
Receipt Number: ___________________
New Mexico Institute of Mining and Technology is an PT0001 Revised—12 Jul 2007
Equal Opportunity/Affirmative Action Institution.
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