Request to Change Student Record Information
The University of Texas at Tyler
Office of the Registrar
3900 University Blvd, STE 230 Tyler, TX 75799
Revised: 10/30/2019
Notice about Information Laws and Practices
With few exceptions, you are entitled on your request to be informed about the information The University of Texas at Tyler collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information.
Under Section 559.004 of the Texas Government Code, you are entitled to have The University of Texas at Tyler correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in The University of Texas System
Business Procedures Memorandum 32. The information that The University of Texas at Tyler collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of
information are kept for different periods of time.
SOCIAL SECURITY NUMBER GENERAL MANDATORY DISCLOSURE
Disclosure of your Social Security Number (SSN) may be required of you in order for The University of Texas at Tyler to complete your request, as mandated by State law (Texas Education Code Ch. 61). Further disclosure of your SSN is governed by the Public
Information Act (Chapter 552 of the Texas Government Code) and other applicable laws.
Photo ID and Acceptable Documentation Required
Student ID Number: ________________________________________ Date: _______________________
Printed Name: ____________________________________________________________________________
(As it currently appears in your student records)
Graduation Term: ________________________________________
Name Changes: (Please print legibly, exactly as you wish your name to appear. Attach two forms of documentation from the list
below that support the requested name change and provide a valid government or UT Tyler-issued photo ID. All documents must be
original or notarized certified copies.)
• Social Security card
• Current, valid U.S. Armed Forces (any branch) identification
card
• Marriage license/certificate bearing the filing stamp from the
county or parish in which the document was issued
• Court order granting a name change; must be signed by the
presiding judge and embossed with the appropriate county filing
stamp
• Current, valid U.S. passport
• Current, valid home country passport (International students
only)
• Divorce decree that explicitly grants a name restoration/change;
must be signed by the presiding judge and embossed with the
appropriate county filing stamp
• Certificate of Naturalization
_____________________________ _____________________________ __________________________
Last Name First Name Middle Name
_______________________________________________________________________________________________________________________________________
Address Changes: (Please print legibly and provide a valid government or UT Tyler-issued photo ID)
___________________________________________________________ ________________________
Address Apt #/Suite
__________________________________________ ___________ ________________________
City State Zip Code
Use this Address for: □ Home □ Mailing □ Diploma
____________________________________________________________________________________________________________________________________________________________________________________
Telephone Number Changes: (Please print legibly and provide a valid government or UT Tyler-issued photo ID)
(__________) ________ - _____________ List this number as: □ Cell □ Home □ Business
By my signature below I certify that I have read and understand the relevant policy information on the Office of the Registrar’s website
for the change requested. I confirm that all documents submitted with this form are original or certified copies, and that all information is
up-to-date.
______________________________________________________________________ __________________
Student Signature/PIN Date
Verified Photo ID: _________ Two Valid Original Documentation Provided (Name Change Only): _________
myUTTyler Updated: _________ ImageNow Updated: _________ Notification Sent: _________
OIP Notified (International Students Only): _________
