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Get NY W-2 Duplicate/ Correction Request Form 2003

SUBMIT COMPLETED FORM TO THE CITY OF NEW YORK PAYROLL MANAGEMENT SYSTEM W - 2 Duplicate Request AGENCY IDENTIFICATION If paying by Credit Card or Payroll Deduction you may fax to 212 669-4928 www. NYC. gov/payroll Office of Payroll Administration W-2 Adjustment Unit One Centre Street Room 200N New York NY 10007 Payroll Number Agency Name Agency Telephone W-2 Coordinator Name If known EMPLOYEE SECTION M. NYC. gov/payroll Office of Payroll Administration W-2 Adjustment Unit One Centre Street Room 200N New York NY 10007 Payroll Number Agency Name Agency Telephone W-2 Coordinator Name If known EMPLOYEE SECTION M. I. FIRST EMPLOYEE LAST SOCIAL SECURITY NUMBER DAYTIME TELEPHONE Mandatory for DoEd employees CHECK HERE IF THIS AN AGENCY ADDRESS STREET ADDRESS MAILING ADDRESS Address to which copies of documents STATE BOROUGH / CITY / TOWN will be mailed ZIP CODE 4 Enter the year s of your request. YEAR TAX YEAR S REQUESTED Requested by W -2 Employee Signature 3RD PARTY DISABILITY Other Authorized Person 1127 STATEMENT Relationship Signature FEE CALCULATION - Enter quantity and total NUMBER OF ITEMS FEE PER Duplicate W-2 Request Forms X PAYMENT METHOD - Select method of payment Cash Not Accepted TOTAL Payroll Deduction A fee of 5 is charged for each copy of a W-2 or 1127 more than three years old. SUBMIT COMPLETED FORM TO THE CITY OF NEW YORK PAYROLL MANAGEMENT SYSTEM W - 2 Duplicate Request AGENCY IDENTIFICATION If paying by Credit Card or Payroll Deduction you may fax to 212 669-4928 www. NYC. gov/payroll Office of Payroll Administration W-2 Adjustment Unit One Centre Street Room 200N New York NY 10007 Payroll Number Agency Name Agency Telephone W-2 Coordinator Name If known EMPLOYEE SECTION M. I. FIRST EMPLOYEE LAST SOCIAL SECURITY NUMBER DAYTIME TELEPHONE Mandatory for DoEd employees CHECK HERE IF THIS AN AGENCY ADDRESS STREET ADDRESS MAILING ADDRESS Address to which copies of documents STATE BOROUGH / CITY / TOWN will be mailed ZIP CODE 4 Enter the year s of your request. YEAR TAX YEAR S REQUESTED Requested by W -2 Employee Signature 3RD PARTY DISABILITY Other Authorized Person 1127 STATEMENT Relationship Signature FEE CALCULATION - Enter quantity and total NUMBER OF ITEMS FEE PER Duplicate W-2 Request Forms X PAYMENT METHOD - Select method of payment Cash Not Accepted TOTAL Payroll Deduction A fee of 5 is charged for each copy of a W-2 or 1127 more than three years old. Fees do not apply to copies of documents of active employees of NYCHA NYCERS TRS Police Pension Fund or the Water Authority. Credit Card Type Certified Check Money Order Please make certified check or money order payable to City of New York Office of Payroll Administration FOR ACTIVE EMPLOYEES ONLY Employee Authorization for Payroll Deduction MasterCard Not accepted by fax or mail Complete section below for Credit and Debit Cards VISA Discover Debit Card American Express CREDIT CARD ACCOUNT NUMBER Cardholder Name EXPIRATION DATE Print name as it appears on card FOR OPA USE ONLY Request for copies received by processed by MONTH DAY Initial Please Print Items Mailed.

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