Request For 1095c Form - Greenville County Schools
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1Return to:
Greenville County Schools
Benefits – 1095‐C Request
Fax 864.355.0490
Email benefits@greenville.k12.sc.us
Greenville County Schools
Request for IRS 1095‐C Copy
Active GCS Employees are required to use the GCS Document Self Service
System for reprints and additional copies of 1095‐C forms
Copies may not be emailed to non‐GCS email addresses
PLEASE PRINT
Please reissue a 1095‐C form for the tax year(s) ending _____________________
Name ________________________________________________________________________________
Social Security # _______________________________________________________________________
___
I would like my 1095‐C form mailed to the following address:
Street ________________________________________________________________________________
City _________________________________________ State ____________ Zip Code _______________
___
I would like to pick up my 1095‐C form from the Central Office (Benefits Department)
The Form 1095‐C form is requested for the following reason:
___
Never Received
___
Misplaced or Destroyed
___
Incorrect information (explain below)
___
Other (Explain) __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Note: You will not be called to pick‐up your 1095‐C form. Forms not picked up within 1 week will be
destroyed.
Signature
Date
For Benefits Use ONLY
Date Received __________________________Original form remailed ____________________________
Duplicate form reissued __________________Processed by ____________________________________
Revised 3/24/2016
h:\request for 1095.doc
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Parent category: Business