Form by maclaren1

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									                 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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