Request For 1095c Form - Greenville County Schools

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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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