Fillable Request for Form W-2 or Form 1095C Please (Central Carolina Technical College)

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Request for Form W-2 or Form 1095C Please (Central Carolina Technical College)

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Request for Form W-2 or Form 1095C
Please reissue a Form W-2 1095C for tax year for the employee
listed below:
EMPLOYEE NAME: ________________________________________
SSN (LAST 4 DIGITS): xxx-xx-
CURRENT MAILING ADDRESS:
PHONE NUMBER: ( )
REASON FOR REQUEST:
Never Received
Address Incorrect
Misplaced / Destroyed
SSN Incorrect
Name Incorrect
Other (Please explain)
**The reissued form W-2 or 1095C will be mailed to the address listed above unless
otherwise requested.
______________________________ ___________________
Employee Signature Date
Please bring / mail / email / fax this completed form to:
Central Carolina Technical College
Attn: Payroll
506 North Guignard Drive
Sumter, SC 29150
803-778-7878 (fax)
parkerhm@cctech.edu
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Request for Form W-2 or Form 1095C Please (Central Carolina Technical College)

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Completed 26 July 2020

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