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years 2019 and forward must be retrieved from (Hawaii DOE)

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DOE OFS 100-003
Last revised: 12/06/2018
Former DOE Form(s): Duplicate Statement Request Form
DUPLICATE STATEMENT REQUEST FORM
DEPARTMENT OF EDUCATION
Office of Fiscal Services
Operations Section
P.O. Box 2360 Honolulu, HI 96804
This form will be used to request duplicate statements for years 2018 and prior. Any duplicate statements for
years 2019 and forward must be retrieved from the Hawaii Information Portal (HIP) website at hip.hawaii.gov.
Processing time is 7 to 10 business days. The processing time will begin once the completed request form and
payment is received by the Payroll Unit. Walk-in requests will not be accepted.
I. EMPLOYEE INFORMATION
a. Name: ____________________________________________ SSN#: _____________________
b. Address: ________________________________________________________________________
________________________________________________________________________________
c. Telephone: _________________________ Payroll #/Warrant Distribution Code: ____________
(if available – e.g. “E10-230”)
II. STATEMENT DATE(S)
Pay Date
# of Copies
Cost
Total
x
=
x
=
x
=
x
=
x
=
x
=
x
=
x
=
x
=
x
=
Total Cost =
III. PAYMENT OPTIONS
☐ Cash (Note: Exact amount; no change will be given)
☐ Cashier’s Check (Note: Make Cashier’s Check payable to “Dept. of Education”)
☐ Money Order (Note: Make Money Order payable to “Dept. of Education”)
☐ Personal Check (Note: Make Personal Check payable to “Dept. of Education”)
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 1.00
$ 0.00
$ 0.00
DOE OFS 100-003
Last revised: 12/06/2018
Former DOE Form(s): Duplicate Statement Request Form
IV. REASON FOR REQUEST
__________________________________________________________________________________
__________________________________________________________________________________
V. DELIVERY OPTIONS
☐ I will pick up my duplicate statement(s). Please contact me at the phone number listed above.
☐ Please mail my duplicate statement(s). I will provide a self-addressed stamped envelope.
VI. EMPLOYEE AUTHORIZATION
Please verify all fields are completed and form is signed before submittal. Please mail this Duplicate
Statement Request Form and payment to:
DOE Operations Section – Payroll Unit, P.O. Box 2360, Honolulu, HI 96804
Signature: ________________________________________________ Date: ___________________
VII. FOR PAYROLL UNIT USE ONLY
☐ Cash Total Amount Paid: _________
☐ Cashier’s Check #: _____________________ Initials: _________
☐ Money Order #: _______________________ Date Received: ____________
☐ Personal Check #: _____________________
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years 2019 and forward must be retrieved from (Hawaii DOE)

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Completed 8 September 2021

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