UNIVERSITIES SPACE RESEARCH ASSOCIATION
Stipend / Scholarship Vendor Form

To be completed by Recipient (recipient acceptance required)

Name of Recipient:

First/Given:

Middle:

Last/Family/Surname:

Social Security Number:

Address Line 1:

Address Line 2:

Address Line 3:

City: State: Zip:

Country:

Tax Documents &
Direct Deposit slips
will be mailed to
this address.

Citizenship

Recipient is a:

US Citizen
Resident Alien
Non-resident Alien : Visa Type:

Country of Origin:

Select the country of which the recipient claims residency under that country's tax laws.

Payment Method

Stipend Election - Stipend "S" vendor number

Scholarship Election - Scholarship "T" vendor number, must meet the requirements of the USRA program to qualify. Program not available to non-resident aliens or high school students.

Travel Authorized - S & T vendor numbers

Acceptance

I understand that stipend/scholarship payments are subject to IRS regulations and may be reported to the IRS as taxable income. I selected the address to where the 1099, 1042-S, or scholarship letter will be sent if required. Indicate acceptance of this appointment by selecting "I agree" below and clicking the "Submit" button. No payments will be issued until this form is complete including acceptance of this agreement by the recipient.

I agree I do not agree

UNIVERSITIES SPACE RESEARCH ASSOCIATION Stipend / Scholarship Vendor Form

UNIVERSITIES SPACE RESEARCH ASSOCIATION
Stipend / Scholarship Vendor Form