Request For Students Taxpayer Identification Number
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1Registar’s Office
University Park, IL 60484
708.534.4500
Fax: 708.534.1640
REQUEST FOR STUDENT’S TAXPAYER IDENTIFICATION NUMBER
(Substitute Form W-95)
This form is used to collect a student’s identifying number to file Form 1098-T, Tuition Statement,
with the IRS to furnish a statement to the student. This would be the social security number (SSN)
or individual taxpayer identification number (ITIN).
Please return completed and signed form (parts I and II, or part III), in person or by mail to:
Governors State University
Office of the Registrar, C1300
1 University Parkway
University Park, IL 60484
Part I — Student Identification
_________________________________________________________________________________________
Name of Student
Student ID number
_________________________________________________________________________________________
Address
_________________________________________________________________________________________
City, State, Zip
Taxpayer ID number (SSN or ITIN) ___ ___ ___ — ___ ___ — ___ ___ ___ ___
Part II — Signature
I certify that the number shown on this form is my correct identification number
_________________________________________________________________________________________
Signature
Date
Part III — Refusal: check one box and print and sign name
I am a foreign national/nonresident alien and do not have a social security number or individual
taxpayer identification number. I do not plan to file an income tax return in the U.S.
I do not wish to provide my taxpayer identification number to GSU at this time. I understand that I
may be subject to an IRS fine of $50 for failure to do so. I further understand that the IRS will not
be able to use the Form 1098-T filed by GSU to confirm my eligibility for certain education tax
benefits without my taxpayer identification number.
_________________________________________________________________________________________
Signature
Date
Print Name ______________________________________________________________________________
PA12052014
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Parent category: Legal