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FORM W-2 (Wage & Tax Statement) Reissue Request

Please provide all requested information and return the completed, signed form to your local payroll office, or mail/fax to:

Kentucky State University ATTN: Payroll 400 East Main St. ASB 428 Frankfort, KY 40601 Fax: 502-597-6450

All W-2 Reissue requests will be processed by Kentucky State University Payroll Staff. Please allow up to three business days for form processing. Requests for most recent year tax forms will not be processed prior to February 8.

Part 1: Employee/Former Employee Information

Employee ID___ Last Four Digits of SSN ___

Employee Name ___

Current Mailing Address___

City___State___Zip Code___

Active employees, seeking to make a change to their current contact information, please use employee self-service: https://workforcenow.adp.com/workforcenow/login.html

W-2 forms contain confidential, personal information. Due to security reasons, reissued W-2's cannot be transmitted via fax or e-mail. All forms will be mailed to the address listed above.

Part 2: W-2 Information

Tax year to be reissued:_____

Reason for Reissue (check one): Lost __Destroyed

Other (please specify) _

——

___ Never Received

Part 3: Authorized Signature

Please reissue IRS Form W-2, Wage and Tax Statement for the single tax year requested. I certify I am the individual listed above. I acknowledge KYSU is not responsible for reprint requests that are lost, incomplete, misdirected, stolen, mutilated, illegible, postage due, or any combination thereof.

_____

___

Signature Date

OR PAYROLL DEPARTMENT USE ONLY:

Date Received Processed By Date Processed