Long Beach Community College District
Duplicate W-2 Request Form
Payroll Office
4901 East Carson Street
Long Beach, CA 90808, G-2
Telephone:
Classified:
Academic:
(562) 938-4464
(562) 938-4466
(562) 938-4463
Fax:
(562) 938-4959
Please type or print legibly:
The Year(s) Requested:
Date of Request:
Employee Name:
Social Security #
Current Mailing Address:
Street Address:
City
State
Zip Code
Disposition of Duplicate W-2:
Mail to the Above Address
Fax to
(
Hold in the Payroll Office for Pick Up
)
The Duplicate W-2 Form is requested for the following reason:
Never Received
Misplaced or Destroyed
Social Security # or Name Is Incorrect
Other (please explain)
Employee Signature
Date:
NOTE: As processing a duplicate W-2 may take several days, please do
not make your request on the day that you need it.
For Payroll Office use only
Employee ID:
Duplicate W-2 issued on:
LBCCD / Fiscal Services
Processed by:
Revised: February 2010