The University of Texas at Tyler

NON-UT TYLER STUDENT DATA FORM

Complete this form and give to your advisor or supervisor.

Have you ever attended UT TYLER? .... N

. . .D"'----
.
Social Security Number: d54 ~ ~) .-- ~ 4~ 3
-"'~.u..=.u.:=..!.=----"'!!:::~------ FirstName: JoSe-ph
Middle Name: -i--.L...::..-'-"-..U.....--------,---- Other Names: -----------.,--,------,---
(Include other names that may appear on other documentation.)

City: ___..~~.!...!....I...~L.lt,_- ___ State: frA Zip:31YQ b Texas County: _ _ _ _ __

Country: _\v.J~.SL.:_._ _ _ Home Phone: q} ~- 4 ~ Y-b 7J ~Alternate Phone: t/ d- .... ~ ~ 4- 4SS0

Birth Date: 0~/ f () / tl Place ofBirth: 54\/wf)o~ &A V~S,
Country
City State
If you are a US Citizen and were born outside the US, please explain how you became a US Citizen:

\d. t\ fJ 3 ~ (c\) s± V. 11.,\ lY\ siton 5, e.dLI

E-mail Address:

Emergency Cont;;;;1~ame: '"j;, DIN ctl.\ 1{_, Emergency Contact Phone: 91J~ ~'1{4- 4ss 0
The following information is collected for institutional, state, and federal reports, is optional and will be used in a
non-discriminatory manner, consistent with applicable civil rights laws.
Gender: o Male o Female
Ethnicity: o American Indian or Native American o Asian or Pacific Islander
o Black, Non-Hispanic o Hispanic o White, Non-Hispanic

I certify that the information on this form is complete and correct to the best of my knowledge. I agree to abide by the
policies, rules and regulations at The University of Texas at Tyler. I authorize the university to verify the information
I have provided. I further understand that this information will be relied upon by the officials of the university in
determining my admission to the program and that the submission of false information is grounds for rejection of my
application, withdrawal of an offer of acceptance, cancellation of enrollment, and/or disciplinary action.

Signature: ~ p~\. .2; l/k;L /~1~~fi?:, _ _

Date: --l....IY

Department must complete this section and fax completed form to:
UT Tyler Admissions Processing: Fax: 903-566-7068

Department:------------------ Date: _ _ _ _ _ _ _ _ __

Advisor Name ( p r i n t ) : - - - - - - - - - - - - - - Signature: _ _ _ _ _ _ _ __

 The University of Texas at Tyler
Department of Residence Life
LIMITED STAY CONTRACT
SUMMER- 2013

Name: """J"""o~ l)j fVJ-Je- lJl:. Phone Number: qIJ- -~If 1/- 6?J 4
Gender:~[\/\~---- Date of Birth: Q<g {J Q/ ~ [
Emergency Contact Information:

Name: :fvdj DIAJ~/e_ Phone Number: ~ )J.- 4~L{-. 9S9J

Relationship: M athe..r-
This On-Campus Housing Contract (the "Contract") is a contract for the Limited Stay Summer 2012 granting a license to use a room
in a University housing facility on the terms and conditions stated herein.
The "Contract Period" and "Contract Rate" as used in this Contract mean:

Summer Session Rate

REUMathCam $ 840.00

The "Contract Rate" for Summer 2013 Session are for a bedroom in a 4-bedroom apartment at Patriot Village. The "Contract Rate" does not include
meal plan.

l/We the undersigned Guest and Guarantor, if applicable, certify that Ilwe have read in full the separate document entitled On-Campus Residence
Contract Terms and Conditions and understand and agree that the terms of that document are incorporated into this contract and both documents
constitute the "Contract." I!We acknowledge that University Regulations may be found in the UT Tyler Student Affairs Manual of Policies and
Procedures, the UT Tyler Handbook of Operating Procedures, the Residence Life Handbook, the Rules and Regulations of the Board of Regents of
The University of Texas System, and the Administrative Rules of The University of Texas System, and agree to abide to them. l/We acknowledge
that the Department of Residence Life will not grant the license described herein unless personal guarantee of payment of all charges or obligations
under the Contract is made. I!We, jointly and severally, further agree to pay all charges arising under the Contract and any extension thereof when
due and in accordance with the regulations of The University of Texas at Tyler, together with all fees and other reasonable costs for the collection of
any amount not paid when due.
A guest under the age of eighteen (18) years is required to have this Contract signed by a parent, guardian or other person
of legal responsibility as the Guarantor. The execution of this contract by Student and Guarantor, if applicable, constitutes
acceptance of the Contract.

Guest's Signature: ~ Yi W. JJt

Guest's E-mail address: d.. ;tu 1 Cvf(n
CONTRCT GUARANTOR: equired if student is under 18 years)

Guarantor's Name ( P R I N T ) : - - - - - - - - - - - - - - - - - - - Signature:

Page 5 of5
 On-Campus Housing Contract
Limited Stay Contract Addendum
2012-2013

The Addendum to the 2012-2013 On-Campus Housing Contract allows a resident to use a room
for a period of time less than an academic semester. Residents who sign the Addendum are
subject to all conditions of the Summer 2013 On-Campus Housing Contract (including UT Tyler
Residence Life Policies), except as noted below:

1. The occupancy period is defined by the Resident and UT Tyler Residence Life.

2. UT Tyler reserves the right to terminate a Limited Stay Contract Addendum without
cause and with no less than 15 days notice.

3. Housing rate $105.00/week for 8 weeks =$840.00

Payment terms: Yl =$420.00 due June 5
Yl =$420.00 due July 3

Contract Period: June 3. 2013-July 27. 2013

GuestName: ~O~~h DiNoc±~\e, I[.

I0I RO~Ax-1 out cJ-
Mailing address:

City: So.. v{)y noC\..-h State:

Guest phone number: 5ld_- 4~ Y~ bJali

Guest email address:jcL y131t(i) sh, lL no s±roo~~·edu
By signing this Limited Stay Contract Addendum I agree to all the terms and conditions in the
On-Campus Housing Contract and I have read and understood the Residence Life 2012-2013
Handbook at this link: http://www.uttyler.edu/housinglfiles/Residence%20Lifehandbook.pdf.

Guest Signature: FJ= We 1'1< Date: 0 \11 I~I r~

Guest of: College of Arts & Sciences

Contact Person: Jennifer McLoud-Mann Email: jmcloud@uttyler.edu

 THE UNIVERSITY OF TEXAS AT TYLER
DIRECT DEPOSIT AUTHORIZATION
This direct deposit form is used for both University employees and vendors of the University. Please read the form carefully and fill in
the boxes that apply to you as an employee 7
to your vendor company.
MARK ONE: New Setup V __ . Change Bank_ Cancel Direct Deposit_
PAYEE IDENTIFICATION:

AUTHORIZATION FOR DIRECT DEPOSIT SETUP:

I authorize The University of Texas at Tyler to deposit my payments from the University to my financial institution electronically.
further understand that the University will reverse any payments made to my account in error. As a University employee, I understand
I will receive my earning statements electronically, which will require access to the UT Direct system. This authorization is to remain
in full force and effect until University has received written notification of its termination at such time and in such manner as to afford
University and Bank a reasonable opportunity to act on the termination.

I also agree to comply with the National Automated Clearing House Association's rules and the University's rules for electronic
payments at all times.

FINANCIAL INSTITUTION (Completion by your financial institution is recommended.)

Note: If your financial, institution does not complete this section, please return form with a voided check.
For University employees only: If you prefer to electronically deposit funds to a CREDIT UNION or an INVESTMENT
ACCOUNT, please contact your financial institution for proper electronic funds transfer routing instructions.
Financial Institution Name(?<lr(l
City $o.,Vo.,.n
Phone Numbe9 \ ~_ ~ S
Routing Transit Number

Ob roo
Representative Name
s~ Savin s

Representative Signature (Optional) Date

Note: Alterations to the routing number, account number, and/or type of account must be initialed by the financial institution representative or the payee.
*Disclosure of your Social Security Number is required. Your Social Security Number will be used to help the University administer the
state's tax laws and for other purposes. This disclosure requirement has been adopted under the Federal Privacy Act of 1974 (5) U.S.C.A.
sec. 552a (note) (West 1977) and the Tax Reform Act of 1976 (42 U.S.C.A. sec. 405(c)(2)(C) (West 1992). With few exceptions, under TEXAS
GOVERNMENT CODE ANN. sec. 559.003 (1) (2) & (3) (Vernon Supp. 1992), you are entitled to request to be informed about the information
that the University collects, under Sections 552.021 and 552.023 of the Government Code, you are entitled to receive and review the
information, and under Section 559.004 of the Government Code, you are entitled to have the University correct information about you that is
incorrect. See Op Texas Attorney General No. H-1255(1978).

FOR UNIVERSITY USE ONLY

Form W-9
(Rev. January 2011)
Request for Taxpayer Give Form to the
requester. Do not
Department of the Treasury Identification Number and Certification send to the IRS.
Internal Revenue Service

0 C Corporation 0 S Corporation 0 Partnership 0 TrusVestate

D Exempt payee
0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ~ --------------------------------

address (optionaQ

Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose I Employer identification number
number to enter.

1@111 Certification
m-11111111
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign Signature of
Here u.s. person ~ Date~
3
General lnstructi Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester's form if it is substantially similar
Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
noted.
Definition of a U.S. person. For federal tax purposes, you are
Purpose of Form considered a U.S. person if you are:
A person who is required to file an information return with the IRS must • An individual who is a U.S. citizen or U.S. resident alien,
obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or
example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States,
you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate), or
of debt, or contributions you made to an IRA.
• A domestic trust (as defined in Regulations section 301. 7701-7).
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or
requester) and, when applicable, to: business in the United States are generally required to pay a withholding
tax on any foreign partners' share of income from such business.
1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W-9 has not been received, a
number to be issued), partnership is required to presume that a partner is a foreign person,
2. Certify that you are not subject to backup withholding, or and pay the withholding tax. Therefore, if you are a U.S. person that is a
3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United
payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S. trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners' share of
effectively connected income.

Cat. No. 10231X Form W-9 (Rev. 1-2011)