Duplicate_W2_Request_Form by keralaguest

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									                                      REQUEST FOR DUPLICATE W-2



Date                               Department Employed

Employee Name

Current Address

City / State / Zip Code

Payroll Number                                       Social Security No.

Tax Year(s) Requested



    The undersigned requests a duplicate W-2 Wage and Tax Statement be issued by
    the Iowa Department of Administrative Services at a fee of $5.00 for each tax year
    requested.


                                                  Employee Signature


              Cash             Check Make checks payable to: Treasurer, State of Iowa


       Mail this request to:    Iowa Department of Administrative Services
                                State Accounting Enterprise, Centralized Payroll
                                1305 East Walnut, Hoover Building, 3rd Floor
                                Des Moines, IA 50319


       Duplicate W-2 Request forms received by email will not be accepted.
       Reissuance of a Duplicate W-2 may require up to 30 days.


       TO BE COMPLETED BY CENTRALIZED PAYROLL STAFF:
        1. Federal Wages                              9. Advance EIC Pymt

        2. Fed Tax Withheld                         10. Dep. Care Benefits

        3. Social Sec Wages                         12. Annuities / Code / Amount

        4. SS Tax Withheld                          14. Retirement Type / Amount

        5. Medicare Wages                           16. State Wages

        6. Medicare Tax WH                          17. State Withholding

								
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