W-2 RE-ISSUANCE REQUEST FORM 
 
NOTE: There is a 24 hour processing period on all requests * ID must be presented when picking up 
* There is a $15.00 fee for any re-issuance of duplicate W-2 VI forms 
 
 
Date: _________________ 
 
EMPLOYEE INFORMATION 
 
 
Name: __________________________________ 
 
 
 
Employee Number: __________________________________ 
 
Telephone Number: __________________________________ 
 
SSN: __________________________________ 
 
Email Address: __________________________________ 
 
Job Title: __________________________________ 
 
Activity Site: __________________________________ 
 
Address: __________________________________ 
 
 
Employee Signature: ____________________________ 
 
 
FOR HR OFFICE USE ONLY 
Prepared By: ________________________ 
Date Issued: ________________________ 
Comments: ___________________________________________________________________________ 
_____________________________________________________________________________________ 
_____________________________________________________________________________________ 
 
 
Knud Hansen Complex Bldg. A • 1303 Hospital Ground, Suite 1 • St. Thomas, Virgin Islands 00802-6472 • (340) 774-0930  
3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980