Section Security

SECTION I (ALL FIELDS REQUIRED)

PLEASE TYPE OR PRINT CLEARLY

1. Name (Last,First, MI) 2. Social Security or EMPL ID Number 3. Address

4. City, State, Zip Code

5. Personal Email 6. Phone (Please include area code) SECTION II (Required)

7. Select Type of Form Needed

W-2

8. Indicate Years Needed

Year(s) Year(s) Year(s)

SECTION III

9. A Duplicate form is requested for the following reason(s): __ Never Received __ Misplaced Form(s) __ Forms Destroyed SECTION IV

10. A Corrected form is requested for the following reason(s): (Please check all that apply) __ Incorrect SSN (Enclose copy of your SS Card)

__ Incorrect or misspelled name (Enclose copy of your SS Card) __ Incorrect amount- (Please include box number or line number and attach an explanation) __ Other- (Please attach an explanation)

SECTION V

11. __ Send Form to Address Below __ Email Form to Address Below __ Fax Form to Number Below Mailing Address (Please Include Area Code) Fax Number

Email

12. Signature w/ Notary (Required): Date Requested: Contact Us:

Email: ***********@****.***

Send Request To:

P.F. Chang's China Bistro

Mail Stop: W2 Inquiries

8377 E Hartford Dr, Ste 200

Scottsdale, AZ 85255 Notary Signature

Notary Stamp

My Commission Expires

Date Received:

Date Processed:

Departmental Use Only:

TO REQUEST CORRECTED FORM, COMPLETE Section IV, Lines 10 - 12 TO REQUEST DUPLICATE FORM,COMPLETE Section III, LINE 9,THEN SKIP TO Section V, Lines 11-12 Request for Duplicate or Corrected Tax Form

(P.F. Chang's China Bistro Employees/Former Employees Only) Disbursements Form DUPREQ (Rev.-March 2019)

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