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    Payroll

    Uploaded by

    syoliphant

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Payroll

    Uploaded by

    syoliphant
    16 views2 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views2 pages

    Payroll

    Uploaded by

    syoliphant

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Payroll Department P.O. Box 32024, Lakeland, FL 33802 863.688.

    1188 ext 22311

    Payroll Information Request Form


    Name Oliphant Shateria Personnel Number:
    Last name First name Middle initial OR

    Last 4 of Social Security: & date of birth:


    Phone Number: ( )

    Work Location: Retail Support


    Store # Department

    To ensure you receive the appropriate information, please mark each box needed:

    W-2's (specify years) 2022 2021 2020 2019 2018 2017 2016

    Wage details (includes total hours worked, gross and deductions by pay week) (specify dates)

    Previously issued pay statements (max-4 statements) (specify dates)

    Other - please specify

    Payroll will process this request within five business days from the date received.

    Delivery Method - select one option


    Authorized email address to receive requested information (Required):

    o Email (released within 3-5 business days) - By marking this box, I am indicating that I have read and
    understand the below disclosures regarding the use of the email address and electronic tax document terms
    and conditions. I authorize Publix to provide the information to me at the email address provided above.
    If you complete the authorized email address above, you are validating that we can supply this information to this email
    location. You are taking the responsibility to monitor the email address, understanding your personal and/or payroll
    information will be sent to this address. Publix and the Payroll department do not take the responsibility of the users of this
    email address.

    o Mail (released within 7-10 business days). It will be mailed out to the address on record.

    If your address has changed, please complete the address change section below.

    Address change: Street

    City State Zip

    Associate's Legal Signature Date


    (Your Legal Signature is required for the request to be processed)

    You may email the completed form to: Payroll.requests@Publix.com or fax it to (863) 680-5308.
    Another option is to return it to: Publix Payroll Department P.O. Box 32024 Lakeland, FL 33802.

    FOR OFFICE USE ONLY


    MAIL EMAIL WAGE DETAILS PAY STATEMENTS W2 AUDIT
    January 2023
    Electronic Tax Document Terms and Conditions

    Withdrawal of Consent: By agreeing to these terms:

    • You may withdraw consent to receive a tax form electronically at any time by contacting the Payroll Department in
    writing at P.O. Box 32024, Lakeland, FL 33802 or payroll.requests@publix.com.
    • Publix will confirm withdrawal and the effective date in writing (electronically or in writing).
    • A withdrawal consent does not apply to previously issued tax forms.

    Paper Statement Disclosure: By choosing the option to deliver documents electronically only, you will not be furnished a
    paper tax form unless you specifically request a paper copy of the tax form.

    Scope and Duration of Consent: By agreeing to these terms, consent to receive your tax form will be limited to this single
    request.

    Notice of Terminations: By agreeing to these terms, consent to receive an electronic tax form is specifically limited to this
    request.

    Post-Consent Request for a Paper Statement: By agreeing to these terms, after giving consent to receive a tax form
    electronically, you may still receive a paper copy of the tax form by contacting the Payroll Department.

    Updating Information: E-mail addresses used for electronic delivery may be changed prior to delivery by contacting
    the Payroll Department at payroll.requests@publix.com .

    Hardware and Software Requirements: By agreeing to these terms, you are confirming that you have the hardware and
    software required to open a PDF document to access, print and retain tax forms. The tax form meets all requirements to be
    printed and attached to a federal, state or local tax return. Publix will save your tax forms for five (5) years from the original
    posting date.

    January 2023

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