Print Form REISSUED IRS FORM W REQUEST Use this by Yearoveryear

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                            REISSUED IRS FORM W-2 REQUEST
                            Use this form to request a reprinted IRS Form W-2, Wage and Tax Statement for tax years
                            2004 through 2008. OSPS will not provide this confidential information to anyone other than
                            the employee or agency payroll representative for any reason.
                            See the back of this form for reprint schedule times and instructions for completing this form.

                            Personal Information – Required
OREGON STATEWIDE
                            Social Security Number              NOTE: Do not use an EIN (OR#).
PAYROLL SERVICES
     (OSPS)
                            Name (Last, First, Initial)
All OSPS Forms are
available on the OSPS
Web site.                   NOTE: If the address below differs from what was on the original file, it will not match the reprinted W-2. This
                            address may be used to mail the reprint to you.

Forms on the OSPS           Current Street Address
Web site can be
completed online and        City                                                             State          ZIP+4
printed.


Web site address:           Employment Information – Required
http://tinyurl.com/3b4lsg
                            Agency Name or Number
OSPS Form:
OSPS.99.04
                            Reprint this Tax Year: (Request ONLY ONE TAX YEAR per form)
                            (We will process only one tax year per form. We will choose the most-recent year.)
Revised:                        2008                      2007                     2006                     2005                      2004
January 15, 2009
                            Reason for Request – Required
                            EMPLOYEE:                                                       AGENCY:
                                   Never Received (verify address above)                            Dept. of Revenue Request
                                   Misplaced or Destroyed                                           Corrected W-2 Information
                                   Incorrect Name or SSN                                            Other: _________________
                                   Other: _________________________                                 _______________________
                            Please reissue IRS Form W-2, Wage and Tax Statement, for the tax year requested. I certify: I am the employee
                            listed above or the duly authorized representative thereof OR an agency payroll representative and certify that this
                            request is being made to serve a legitimate business obligation.
     RECEIVED
     Date Stamp
         for
                            ________________________________                                _______________________________
   OSPS Use ONLY            EMPLOYEE SIGNATURE                                              AGENCY SIGNATURE

                              FOR AGENCY PAYROLL USE ONLY:                                 AGENCY NUMBER _____________
                                        All required fields completed?
                                        Employed during tax year?                          INITIAL/DATE:       _________________
                                        Faxed to OSPS?
                                        Given/mailed to Employee?

  For OSPS Use Only: RETURNED UNPROCESSED
        Information Missing or Illegible                                       Prior to 2004
        No Wages for Year                                                      Not a State Employee
                    Instructions to Complete the Reissued IRS Form W-2 Request
                                           Please read this information carefully

To request a Reissued Form W-2, Wage and Tax Statement, complete this form as follows:

Personal Information – Required
Social Security Number: Tax records are stored electronically by Social Security number (SSN). OSPS uses this number to retrieve
your record and produce a Reissued Form W-2. OSPS will not use your SSN for any other purpose.

Address: Provide this information if you believe your address of record to be incorrect. Your address of record is what is printed on
your pay check or pay stub. PLEASE NOTE: If information provided here differs from what was on file at the time of original
printing, changed information will not be printed on your Reissued Form W-2.

Employment Information – Required
Reprint this Tax Year: Choose ONLY ONE of the tax years given. If you want more than one tax year, submit additional forms.
Audit requirements mandate we have a request for each Form W-2 reissued. If you need tax information for years prior to 2004, you
will need to obtain this from another source, such as the Internal Revenue Service (IRS). OSPS complies with Secretary of State,
Audits Division retention schedule of five (5) years for Form W-2 records.

Agency Name or Number: Supply the agency name or five (5) digit agency number where you’d like this Reissued Form W-2 to be
delivered. Contact your current or former payroll office if you need help with this information.

Reason for Request – Required
Employee: Select a reason for this request. If you choose “Incorrect Name or SSN”, you may
receive a Corrected Form W-2 instead of a Reissued Form W-2. In this instance, allow up to       Before submitting this
two (2) weeks for processing.                                                                    form to your payroll
                                                                                                 office, have you:
Agency: Select a reason for this request. If requesting back-up for a Corrected Form W-2,
please be sure to work with the OSPS Accountant to ensure timely delivery of the Corrected       •    Provided all required
Form W-2.                                                                                             information?
Authorization Signature: For requests by an employee or representative, (i.e., holder of         •    Written legibly?
power of attorney) the employee or representative must sign this form. For requests by the       •    Signed the form?
agency, the agency representative submitting the form must sign. We will not process a
request without an authorization signature.




                                            REPRINT SCHEDULE
 We issue reprinted statements according to this schedule. We stop accepting requests at 3:00 PM on the order day (right column).
 We deliver reprinted statements to agency lockboxes or to the shuttle pickup area by 3:00 PM on the next business day.

     Requests received between these dates:                                   Will be ordered on these days:
     February and March                                                                       Weekly on Thursdays
     April 1 to 15                                                                                           Daily
     April 16 to January 31                                                        Day before payday twice a month

								
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