Change of Personal Information
This form is used for making changes to a person’s personal information at Utah State University (USU). Personal Information is
defined as: Name, Legal Sex, Social Security Number, and Date of Birth.
Internal Revenue Service (IRS) Regulations and Penalties
USU is under obligation from the Internal Revenue Service (IRS) to ensure all students and employees have a correctly spelled name
and a correct Social Security number and that both match the IRS database. To meet IRS regulations, USU requires a copy of the
person’s Social Security card for any requested Name and/or Social Security number changes. Please note the penalty for individuals
who do not comply: “If you fail to furnish your correct SSN or ITIN to the requester, you are subject to a penalty of $50 unless your
failure is due to reasonable cause and not to willful neglect.”
(IRS form W-9S)
Part 1
Personal Information – Complete this part with your information as it now reads on your USU record
Last Name First Name Middle Name or Initial
Student ID Number
Email Address
Part 2
Requested Changes – Complete this part with the new/correct information you would like changed on your USU record
Select one or more items to change
Name Change : Documentation Required (signed social security card and government issued photo ID with updated name)
Last Name
First Name
Middle Name or Initial
Social Security Number Change : Documentation Required (signed social security card with correct number)
Social Security Number as currently listed on USU’s record (if any)
Social Security Number as shown on the Social Security card
Date of Birth Change: Documentation Required (birth certificate and government issued photo ID )
Date of Birth as currently shown on USU’s record
Month: Day:
Date of Birth as shown on the picture ID
Part 3
Agreement and Student Signature
I certify that the information provided on this form and within any attached documentation is accurate and free of alteration or
falsification. I also understand that if I choose not to provide a copy of my Social Security card, I may be fined by the United States
Internal Revenue Service (IRS).
Student Signature (required):
Part 4
A Social Security card was provided for the change(s) requested on this form.
A valid Picture ID was provided for the change(s) requested on this form.
Changes have been made as requested.
This form and related identification may be returned to the USU Registrar’s Office in Logan, UT, or to any Regional Campus (www.distance.usu.edu)
Via email (Registrar@usu.edu), fax, mail or in person.
Please visit the websites provided for mailing addresses and fax numbers. (www.usu.edu/registrar)
Phone Number
Legal Sex Change : Documentation Required (driver's license with legal sex or court order )
Legal Sex
Male
Female
