TO: Social Security Administration DATE: FROM: GIVEN NAME: FAMILY NAME: DATE OF BIRTH: Purdue University requires all employees to provide their Social Security Number for tax reporting purposes. In such a case that I leave the University without first providing this information, I authorize the University to obtain my number from the Social Security Administration. Please fax my Social Security Number to: Nonresident Tax Administrator Tax Department Purdue University 401 S. Grant St. West Lafayette, IN 47907-1064 Phone Number: 765-494-1697 FAX Number: 765-496-1392 Signature of Employee ***COMPLETED BY SOCIAL SECURITY ADMINISTRATION ONLY*** Social Security Number: ***Note to Purdue University Business Offices: Please send this completed form to TAX/FREH. DO NOT fax this form to the Social Security Administration. INSTRUCTIONS This form must be completed by all employees that are applying for a social security number. Please complete all yellow highlighted fields. This includes first name, last name, date of birth, and signature. Turn in the completed form to the Tax Department with the Glacier documents.
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