Student Employment Paperwork Packet Name:

Date:

Student ID:

Department for which I’ll be working:

Position:

Supervisor, if known:

I came in to complete my paperwork because:

The person hiring me told me to come in.

I received an e-mail instructing me to come in.

Other:

Updated 01-11-17

Form W-4 (2017) Form W-4 W-4 (2015) (2015) Form

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form Purpose. Complete FormW-4 W-4 sothat thatyour your employer Purpose. Complete Form so employer W-4 each yearthe and whenfederal your personal or can withhold the correct federal incometax taxfinancial fromyour your can withhold correct income from situation changes. pay.Consider Consider completingaanew newForm FormW-4 W-4each eachyear year pay. completing andwhen whenyour yourpersonal personal financial situation changes. and ororfinancial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the Exemption from withholding. you areexempt, exempt, Exemption from withholding. IfIfyou are form to validate it. Your exemption 2017 complete onlylines lines and77for and signexpires theform form complete only 1,1,2,2, 3,3,4,4,and and sign the February 15, 2018. See Pub. 505, Tax Withholding validateit.it.Your Yourexemption exemptionfor for2015 2015expires expires totovalidate and Estimated Tax. See February 16,2016. 2016. SeePub. Pub.505, 505,Tax TaxWithholding Withholding February 16, andEstimated Tax. can claim you as a dependent and Note: IfEstimated anotherTax. person onNote. his or her tax return, exemption Note. another personyou cancan’t claimclaim youasas dependent IfIfanother person can claim you aadependent from withholding your total income exceeds $1,050 onhis hisororher hertax taxifreturn, return, youcannot cannotclaim claim exemption on you exemption from withholding ifyour your$350 income exceeds$1,050 $1,050 and and includes moreifthan of exceeds unearned income (for from withholding income and includesinterest morethan than $350 unearnedincome income(for (for example, and dividends). includes more $350 ofofunearned example,interest interestand anddividends). dividends). example, Exceptions. An employee may be able to claim Exceptions. Anemployee employeeeven maybe able claim is Exceptions. may able totoclaim exemption fromAn withholding ifbethe employee exemptionfrom from withholding evenififthe theemployee employeeisisaa exemption withholding even a dependent, if the employee: dependent,ififthe theemployee: employee: dependent, • Is age 65 or older, age65 65ororolder, older, • •IsIsage • Is blind, or blind,oror • •IsIsblind, • Will claim adjustments to income; tax credits; or Willclaim claim adjustments income; taxreturn. credits;oror • •Will adjustments totoincome; tax credits; itemized deductions, on his or her tax itemizeddeductions, deductions,on onhis hisororher hertax taxreturn. return. itemized

The exceptions don’t apply to supplemental wages greater than $1,000,000. Basic instructions. If apply you aren’t exempt, complete Theexceptions exceptions donot not apply supplemental wages The do totosupplemental wages greater than$1,000,000. $1,000,000. the Personal Allowances Worksheet below. The greater than worksheets on page 2 further adjust your Basicinstructions. instructions.IfIfyou youare arenot notexempt, exempt,complete complete Basic withholding allowances based on itemized thePersonal Personal Allowances Worksheet below.The The the Allowances Worksheet below. deductions, certain credits, adjustments to income, worksheets on page 2 further adjust your worksheets on page 2 further adjust your or two-earners/multiple jobs situations. withholding allowancesbased based onitemized itemized withholding allowances on deductions, certain credits,adjustments adjustments income, deductions, credits, totoincome, Completecertain all worksheets that apply. However, you ortwo-earners/multiple two-earners/multiple jobs situations.For regular or jobs situations. may claim fewer (or zero) allowances. wages, withholding must be based onHowever, allowances Complete worksheets that apply. However, you Complete allallworksheets that apply. you you claimed and(or may notallowances. be a flat amount or mayclaim claimfewer fewer (or zero) allowances. Forregular regular may zero) For percentage of wages. wages,withholding withholding mustbe bebased basedon onallowances allowances wages, must youclaimed claimed andmay maynot notbe beaaflat flat amount you and amount oror head Head of household. Generally, you can claim percentage wages. percentage ofofwages. of household filing status on your tax return only if you are and pay more than 50% ofhead the Head household. Generally, you can claim head Head ofofunmarried household. Generally, you can claim ofhousehold household filing status onyour your taxreturn return only costs of keeping up a home for yourself and your of filing status on tax only ifif youare areunmarried unmarried andpay paymore morethan than50% 50%ofofSee the dependent(s) or other qualifying individuals. you and the costs501, keeping upaahome home foryourself yourself andyour your costs ofofkeeping up for and Pub. Exemptions, Standard Deduction, and dependent(s) other qualifyingindividuals. individuals.See See dependent(s) ororother Filing Information, forqualifying information. Pub.501, 501,Exemptions, Exemptions,Standard StandardDeduction, Deduction,and and Pub. Tax credits. You can take projected tax credits into Filing Information, forinformation. information. Filing Information, for account in figuring your allowable number of Taxcredits. credits.You You cantake takeprojected projected taxcredits creditsor into account Tax can into account withholding allowances. Creditstax for child dependent infiguring figuring yourallowable allowable number withholding allowances. incare your ofofwithholding allowances. expenses and thenumber child tax credit may be claimed Creditsthe forchild childorordependent dependent careexpenses expenses andthe the child Credits for care and child using Personal Allowances Worksheet below. taxcredit credit may claimed usingthe the Personal Allowances tax claimed using Allowances See Pub.may 505bebe for information onPersonal converting your other Worksheet below. SeePub. Pub. 505for forinformation informationonon Worksheet See 505 credits intobelow. withholding allowances. convertingyour yourother othercredits creditsinto intowithholding withholdingallowances. allowances. converting

Personal Allowances Worksheet (Keep for your

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider income. making estimated payments Form Nonwage youhave haveatax alarge large amountusing Nonwage income. IfIfyou amount ofof 1040-ES, Estimated Tax for Individuals. Otherwise, nonwage income, suchas asinterest interest dividends, nonwage income, such orordividends, you may owe additional tax. If you have pension consider making estimatedtax taxpayments payments using Formor consider making estimated using Form annuityEstimated income, see Pub. 505 to findOtherwise, out if youyou should 1040-ES, Estimated Tax forIndividuals. Individuals. Otherwise, you 1040-ES, Tax for adjust your withholding on Form W-4 or W-4P. mayowe oweadditional additionaltax. tax.IfIfyou youhave havepension pensionororannuity annuity may income, see Pub. 505 to find out if you should adjust income, see Pub. 505 to find out if you should adjust Two earners or multiple jobs. If you have a your withholding onor Form W-4 W-4P. your withholding on Form W-4 ororW-4P. working spouse more than one job, figure the total number of allowances you arehave entitled Two earners multiple jobs. you have Two earners oror multiple jobs. IfIfyou aa to claim on all jobs using worksheets from only one Form working spouse morethan thanone one job, figure the working spouse orormore job, figure the W-4. Your of withholding usually will be most accurate total number ofallowances allowances youare are entitled claim total number you entitled totoclaim when all allowances are claimed on the Form onallalljobs jobsusing usingworksheets worksheetsfrom fromonly onlyone oneForm FormW-4 on for Your the highest paying job and allowances are W-4. Your withholding usually willzero bemost most accurate W-4. withholding usually will be accurate claimed on the others. See Pub. 505 for details. when allowances areclaimed claimed onthe theForm Form W-4 when allallallowances are on W-4 for thehighest highestpaying payingjob and zero allowancesalien, are see for the and zero allowances are Nonresident alien. Ifjob you are a nonresident claimed onthe theothers. others.See SeePub. Pub. 505 fordetails. details. claimed 505 for Noticeon 1392, Supplemental Form W-4 Instructions for Nonresident alien. youare arecompleting nonresident alien, Nonresidentalien. Aliens, before thisalien, form. Nonresident IfIfyou aanonresident see Notice 1392, Supplemental Form W-4 see Noticeyour 1392, Supplemental Form W-4 Check After your Form W-4 takes Instructions forwithholding. NonresidentAliens, Aliens, before Instructions Nonresident before effect, usefor Pub. 505 to see how the amount you are completing this form. completing this form. having withheld compares to your projected total tax Check your withholding. Afteryour yourForm Form W-4 takes Check your withholding. W-4 takes for 2017. See Pub. 505,After especially if your earnings effect, use$130,000 Pub.505 505to tosee seehow how theamount amount youare are effect, use Pub. the you exceed (Single) or $180,000 (Married). havingwithheld withheldcompares comparestotoyour yourprojected projectedtotal totaltax tax having Future developments. Information about any for 2015. See Pub. 505, especially if your earnings for 2015. See Pub. 505, especially if your earnings future developments Form W-4 (such as exceed $130,000affecting (Single)oror $180,000 (Married). exceed $130,000 (Single) $180,000 (Married). legislation enacted after we release it) will be posted Future developments.Information Informationabout aboutany anyfuture future Future developments. at www.irs.gov/w4. developmentsaffecting affectingForm FormW-4 W-4(such (suchasaslegislation legislation developments enactedafter afterwe werelease releaseit)it)will willbebeposted postedatatwww.irs.gov/w4. www.irs.gov/w4. enacted records.)

Personal Allowances Worksheet (Keep for records.) Allowances Worksheet A Enter “1” for yourself if no one Personal else can claim you as a dependent . . (Keep . . for . your .your . records.) . . . . . . . . . . . A Enter“1” “1”for foryourself yourself no oneelse else canclaim claim you as dependent AA Enter ififno one aadependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AA • You’re single andcan have onlyyou oneas job; or Youare are singleand and have only one job; You single have only job; ororyour spouse doesn’t work; or B Enter “1” if: . . . B •••You’re married, have only oneone job, and Youare aremarried, married, have onlyjob one job, and yourspouse spouse does not work; or are $1,500 or less. . . . . . . BB Enter“1” “1”if:if: You only one and your not work; BB Enter wages from ahave second orjob, your spouse’s wagesdoes (or the total of or both) •••Your Yourwages wages from asecond second jobor oryour yourspouse’s spouse’s wages (or thetotal total both)are are$1,500 $1,500 less.spouse or more •Your job the ofofboth) ororless. Enter “1” for your•spouse. But,from you amay choose to enter “-0-” if wages you are(or married and have either a working C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse more Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working CC than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . .spouse . . oror . more . . C thanone onejob. job.(Entering (Entering“-0-” “-0-”may mayhelp helpyou youavoid avoidhaving havingtoo toolittle littletax taxwithheld.) withheld.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . CC than D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D Enter number dependents (other thanyour yourspouse spouse oryourself) yourself) youwill willclaim claimon on yourtax taxreturn return Enter number dependents (other than you your . . . . . . . . above) . . . . . . .. . . DD E EDD Enter “1” if youofof will file as head of household on yourortax return (see conditions under Head of household E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit .. . .. . . EE F Enter“1” “1”ififyou youhave haveatatleast least$2,000 $2,000ofofchild childor ordependent dependentcare careexpenses expensesfor forwhich whichyou youplan plantotoclaim claimaacredit credit . . . . . . FF FF (Note: Enter Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) (Note.Do Donot notinclude includechild childsupport supportpayments. payments.See SeePub. Pub.503, 503,Child Childand andDependent DependentCare CareExpenses, Expenses,for fordetails.) details.) (Note. G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. ChildTax TaxCredit Credit(including (includingadditional additionalchild childtax taxcredit). credit).See SeePub. Pub.972, 972,Child ChildTax TaxCredit, Credit,for formore moreinformation. information. GG Child • If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you your totalincome incomewill willbe beless lessthan than$65,000 $65,000($100,000 ($100,000ififmarried), married),enter enter“2” “2”for foreach eacheligible eligiblechild; child;then thenless less“1” “1”ififyou you ••IfIfyour have two total to four eligible children or less “2” if you have five or more eligible children. havetwo twototofour foureligible eligiblechildren childrenororless less“2” “2”ififyou youhave havefive fiveorormore moreeligible eligiblechildren. children. have G • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. yourtotal totalincome incomewill willbe bebetween between$65,000 $65,000and and$84,000 $84,000($100,000 ($100,000and and$119,000 $119,000ififmarried), married),enter enter“1” “1”for foreach eacheligible eligiblechild child. . . . . . GG ••IfIfyour H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)▶ ▶ H Addlines linesAAthrough throughGGand andenter entertotal totalhere. here.(Note. (Note.This Thismay maybe bedifferent differentfrom fromthe thenumber numberofofexemptions exemptionsyou youclaim claimon onyour yourtax taxreturn.) return.) ▶ HH HH Add • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. Foraccuracy, accuracy, For andAdjustments AdjustmentsWorksheet Worksheeton onpage page2.2. and complete all •••IfIfIfyou are completeall all complete youare aresingle singleand andhave havemore morethan thanone onejob jobor aremarried marriedand andyou youand andyour yourspouse spouseboth bothwork workand andthe thecombined combined you are single and have more than one job ororare married and you and your spouse both work and the combined worksheets earnings married), see the Two-Earners/Multiple Jobs Worksheet on page $50,000($20,000 ($20,000ifififmarried), married),see seethe theTwo-Earners/Multiple Two-Earners/MultipleJobs JobsWorksheet Worksheeton onpage page222toto earningsfrom fromall alljobs jobsexceed exceed$50,000 worksheets $50,000 ($20,000 earnings from all jobs exceed worksheets to avoid having too little tax withheld. that apply. avoidhaving havingtoo toolittle littletax taxwithheld. withheld. avoid thatapply. apply. that •••IfIfIfneither the above situations applies, stop here and and enter enterthe thenumber numberfrom fromline lineHHon online line5 5ofofForm Form W-4 below. neitherof theabove abovesituations situationsapplies, applies,stop stophere here W-4 below. neither ofofthe and enter the number from line H on line 5 of Form W-4 below.

}} }

{{{

{

W-4 W-4 W-4

Form Form Form

Department ofofof the Treasury Department the Treasury Department the Treasury Internal Revenue Service Internal Revenue Service Internal Revenue Service

111

✳✳

Separate here and give Form W-4 to your employer.Keep Keepthe thetop top part for your records. Separatehere hereand andgive giveForm FormW-4 W-4to toyour youremployer. employer. Keep the top part for your records. Separate part for your records.

Employee’s Withholding AllowanceCertificate Certificate Employee's Withholding Withholding Allowance Allowance Certificate Employee's ▶ are entitled to claim certain number ofallowances allowances or exemption from withholding ▶▶Whether Whetheryou youare areentitled entitledto toclaim claimaaacertain certainnumber numberofof allowances exemption from withholding Whether you oror exemption from withholding isisis

OMB No. 1545-0074 OMB No. 1545-0074 OMB No. 1545-0074

2017 2015 2015

subject review by the IRS. Your employer may berequired requiredtoto tosend send acopy copy this form the IRS. subjectto reviewby bythe theIRS. IRS.Your Youremployer employermay maybe be required send this form the IRS. subject totoreview aacopy ofofof this form tototo the IRS. Your first name and Last name Your social security number Your first name andmiddle middleinitial initial Lastname name Your social security number Your first name and middle initial Last 22 2 Your social security number

Home address (number route) Home address (numberand andstreet streetororrural ruralroute) route) Home address (number and

Single Married Married, but withhold at higher Single rate. Single Married Married, but withhold higher Single rate. 333 Single Married Married, but withhold atathigher Single rate. Note:If IfIfmarried, married, but legally separated, orspouse spouse a nonresident alien, check the “Single” Note. married, but legally separated, nonresident alien, check the“Single” “Single” box.box. Note. but legally separated, ororspouse isisaisanonresident alien, check the box.

City town, state,and andZIP ZIPcode code City ororor town, state, City town, state, and ZIP code

your last name differs from that shown onon your social security card, yourlast last name differs from that shown your social security card, name differs from that shown on your social security card, 444 IfIfIfyour ▶▶ ▶ check here. You must call 1-800-772-1213 for replacement card. check You must call 1-800-772-1213 for aareplacement card. checkhere. here. You must call 1-800-772-1213 for a replacement card.

Totalnumber numberof allowancesyou youare areclaiming claiming(from (fromline lineHHabove orfrom from the applicable worksheet on page Total number ofofallowances allowances worksheet on page 2)2)2) 55 5 555 Total claiming (from line aboveor fromthe theapplicable applicable worksheet on page Additionalamount, amount,ifififany, any,you youwant wantwithheld withheldfrom fromeach eachpaycheck Additional amount, any, 666 Additional withheld from each paycheck . .. . .. . .. . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 6$$ $ Iclaim claimexemption exemptionfrom fromwithholding withholdingfor for2015, 2015,and andIIIcertify certifythat meet both the following conditions for exemption. exemption from conditions for exemption. 777 I Iclaim for 2017, and certify thatI Imeet meetboth bothofof ofthe thefollowing following conditions for exemption. •Last Lastyear yearII had Ihad hadaaaright righttotoaarefund refundof ofall allfederal federalincome incometax taxwithheld withheldbecause because no tax liability, and year right tax liability, and ••Last of all federal income tax withheld becauseI Ihad Ihad hadno no tax liability, and •This Thisyear yearII expect Iexpect expectaaarefund refundof allfederal federalincome incometax taxwithheld withheldbecause because have no tax liability. year refund ofofall no tax liability. ••This all federal income tax withheld becauseI Iexpect I expect expecttoto tohave have no tax liability. ▶▶▶ 77 If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . 7

✳✳ ✳✳

Under penalties perjury,II declare Ideclare declarethat thatII Ihave haveexamined examinedthis thiscertificate certificateand, and, the best my knowledge and belief, correct, and complete. Under penalties ofofperjury, perjury, that and belief, ititisitistrue, correct, and complete. Under penalties of have examined this certificate and,toto tothe thebest bestofof ofmy myknowledge knowledge and belief, istrue, true, correct, and complete. Employee’ssignature signature Employee’s

signature ▶ ✳✳ Employee’s (This form not validunless unlessyou yousign signit.) it.) ▶ (This form not valid unless you sign it.) ▶ (This form isisis not valid 8

88

Employer’sname nameand andaddress address(Employer: (Employer:Complete Completelines lines88and and10 10only onlyififsending sendingtotothe theIRS.) IRS.) Employer’s Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

ForPrivacy PrivacyAct Actand andPaperwork PaperworkReduction ReductionAct ActNotice, Notice,see seepage page2.2. For For Privacy Act and Paperwork Reduction Act Notice, see page 2.

✳✳

▶▶ Date Date Date ▶

Officecode code(optional) (optional) 10 10 Employer Employeridentification identificationnumber number(EIN) (EIN) 9 9Office 9 Office code (optional) 10 Employer identification number (EIN) Cat.No. No.10220Q 10220Q Cat. Cat. No. 10220Q

FormW-4 W-4(2015) (2015) Form Form W-4 (2017)

Page 2

Form W-4 (2017)

Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state 1 and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . $12,700 if married filing jointly or qualifying widow(er) 2 Enter: $9,350 if head of household . . . . . . . . . . . $6,350 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to 5 Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .

{

6 7 8 9 10

}

Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

1

$

2

$

3 4

$ $

5 6 7 8 9

$ $ $

10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here. Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .

1

2 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 5 6 7 8 9

Enter the number from line 2 of this worksheet . . . . . . . . . . 4 Enter the number from line 1 of this worksheet . . . . . . . . . . 5 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1 Married Filing Jointly

6 7 8

$ $

9

$

Table 2 All Others

Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 7,001 - 14,000 14,001 - 22,000 22,001 - 27,000 27,001 - 35,000 35,001 - 44,000 44,001 - 55,000 55,001 - 65,000 65,001 - 75,000 75,001 - 80,000 80,001 - 95,000 95,001 - 115,000 115,001 - 130,000 130,001 - 140,000 140,001 - 150,000 150,001 and over

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

$0 - $8,000 8,001 - 16,000 16,001 - 26,000 26,001 - 34,000 34,001 - 44,000 44,001 - 70,000 70,001 - 85,000 85,001 - 110,000 110,001 - 125,000 125,001 - 140,000 140,001 and over

0 1 2 3 4 5 6 7 8 9 10

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

If wages from HIGHEST paying job are— $0 - $75,000 75,001 - 135,000 135,001 - 205,000 205,001 - 360,000 360,001 - 405,000 405,001 and over

Enter on line 7 above $610 1,010 1,130 1,340 1,420 1,600

All Others If wages from HIGHEST paying job are— $0 - $38,000 38,001 - 85,000 85,001 - 185,000 185,001 - 400,000 400,001 and over

Enter on line 7 above $610 1,010 1,130 1,340 1,600

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103. The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Form WH-4

State Form 48845 (R2 / 8-08)

State of Indiana

Employee’s Withholding Exemption and County Status Certificate This form is for the employer’s records. Do not send this form to the Department of Revenue. The completed form should be returned to your employer.

Full Name _______________________________________________________ Home Address ________________________________

✳

Social Security Number or ITIN __________________________

City _______________________

State ______

Zip Code ______________________

Indiana County of Residence as of January 1: ________________________________________

(See instructions)

Delaware County Indiana County of Principal Employment as of January 1: _______________________________

(See instructions)

___________________________________________________________________________ How to Claim Your Withholding Exemptions 1. You are entitled to one exemption. If you wish to claim the exemption, enter “1” .............................................................................. Nonresident aliens must skip lines 2 through 6. See instructions

___________

2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1” ...................................................

___________

3. You are allowed one (1) exemption for each dependent. Enter number claimed ...............................................................................

___________

4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or (b) if you and/or your spouse are legally blind.

□

□

□

□

or blind Spouse is 65 or older or blind Check box(es) for additional exemptions: You are 65 or older Enter the total number of boxes checked ...........................................................................................................................................

___________

5. Add lines 1, 2, 3, and 4. Enter the total here ..................................................................................................................................... ► 6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions).................................................. ► 7. Enter the amount of additional state withholding (if any) you want withheld each pay period ...........................................................

$ __________

8. Enter the amount of additional county withholding (if any) you want withheld each pay period .........................................................

$ __________

✳

I hereby declare that to the best of my knowledge the above statements are true.

✳

Signature: ______________________________________________________________________

Date: __________________________

Instructions for Completing Form WH-4

This form should be completed by all resident and nonresident employees having income subject to Indiana state and/or county income tax. Print or type your full name, Social Security number or ITIN and home address. Enter your Indiana county of residence and county of principal employment as of January 1 of the current year. If you did not live or work in Indiana on January 1 of the current year, enter “not applicable” on the line(s). If you move to (or work in) another county after January 1, your county status will not change until the next calendar tax year. Nonresident alien limitation. A nonresident alien is allowed to claim only one exemption for withholding tax purposes. If you are a nonresident alien, enter “1” on line 1, then skip to line 7. You are considered to be a nonresident alien if you are not a citizen of the United States and do not meet the green card test and the substantial presence test (get Publication 519 from www.irs.gov for information about these tests). All other employees should complete lines 1 through 7. Lines 1 & 2 - You are allowed to claim one exemption for yourself and one for your spouse (if he/she does not claim the exemption for him/herself). If a parent or legal guardian claims you on their federal tax return, you may still claim an exemption for yourself for Indiana purposes. You cannot claim more than the correct number of exemptions; however, you are permitted to claim a lesser number of exemptions if you wish additional withholding to be deducted. Line 3 - Dependent Exemptions: You are allowed one exemption for each of your dependents based on state and federal guidelines. To qualify as your dependent, a person must receive more than one-half of his/her support from you for the tax year and must have less than $1,000 gross income during the tax year (unless the person is your child and is under age 19 or under age 24 and a full-time student at least during 5 months of the tax year at a qualified educational institution). Line 4 - Additional Exemptions. You are also allowed one exemption each for you and/or your spouse if either is 65 or older and/or blind. Line 5 - Add the total of exemptions claimed on lines 1, 2, 3, and 4. Enter the total in the box provided. Line 6 - Additional Dependent Exemptions. An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a son, stepson, daughter, stepdaughter and/or foster child. Lines 7 & 8 - If you would like an additional amount to be withheld from your wages each pay period, enter the amount on the line provided. NOTE: An entry on this line does not obligate your employer to withhold the amount. You are still liable for any additional taxes due at the end of the tax year. If the employer does withhold the additional amount, it should be submitted along with the regular state and county tax withholding. You may file a new Form WH-4 at any time if the number of exemptions increases. You must file a new Form WH-4 within 10 days if the number of exemptions previously claimed by you decreases for any of the following reasons: (a) you divorce (or are legally separated from) your spouse for whom you have been claiming an exemption or your spouse claims him/herself on a separate Form WH-4; (b) someone else takes over the support of a dependent you claim or you no longer provide more than one-half of the person’s support for the tax year; or (c) the person who you claim as an exemption will receive more than $1,000 of income during the tax year. Penalties are imposed for willingly supplying false information or information which would reduce the withholding exemption.

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Instructions: 1. 2. 3.

BALL STATE UNIVERSITY PAYROLL & EMPLOYEE BENEFITS Student Employee Authorization for Direct Deposit

Fill in the form. You may establish direct deposit for up to 2 financial institutions. Return on campus to CAREER CENTER (Lucina 220) If mailing the form send it to: Career Center, 2000 W. University Ave., Muncie, IN 47306 (DO NOT SEND IN CAMPUS MAIL)

BSU ID: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ Last Name ________________________________ First Name _____________________________ M.I. _________ Choose only one: START direct deposit

to the financial institution(s) noted below

STOP direct deposit send to payroll BEFORE closing your account

CHANGE my current direct deposit by stopping any and all authorizations now in force by me and replacing with the financial information listed below.

NOTE: You may designate direct deposit by either percent or amount, but not both. This direct deposit information will be used to distribute ALL PAYROLL payments from Ball State University.

1)

Financial Institution: ______________________________________________________ Bank Routing Number: _____________________________________________________ Bank Account Number: _____________________________________________________

Complete only 1 of the following:

Checking _________percent (%) OR

Savings $ _________Amount

Only complete if you elect to designate the remaining portion of your direct deposit to a second financial institution or another account.

2)

Financial Institution: ______________________________________________________ Bank Routing Number: _____________________________________________________ Bank Account Number: _____________________________________________________

Complete only 1 of the following:

Checking

Savings

I hereby authorize Ball State University to deposit my payroll amounts automatically to my account at the financial institution(s) indicated above. I understand that the very earliest I can expect my checking or saving account(s) to be credited will be on payday. I further understand that if I change or terminate my account(s) without notifying Ball State payroll in writing my pay may be delayed.

Signature: ______________________________________________________

Date: ____________________________

FOR ACCOUNTING PAYMENTS (i.e. EMPLOYEE TRAVEL, EXPENSE REIMBURSEMENTS, FINANCIAL AID, ETC) FOLLOW THE LINK BELOW TO A SECURE SITE TO ENTER YOUR BANK INFORMATION FOR THE ACCOUNTING DEPARTMENT. https://www.bsu.edu/webapps2/frsachs/

Important Information Regarding Your Retirement Savings B A L L

S T A T E

U N I V E R S I T Y

2 0 1 5

WHAT IS A 403(b) PLAN?

TAKING THE INITIATIVE

A 403(b) plan is a tax-deferred retirement plan for employees of certain tax-exempt, governmental organizations or public education institutions. An employer may sponsor a 403(b) plan to provide a benefit to its employees to save for retirement on a tax-deferred basis. Contributing to a 403(b) plan may help to give you peace of mind through financial security during your retirement. Participation in the 403(b) plan sponsored by the University is completely voluntary. You may contribute a portion of your pay to the 403(b) plan as a pretax contribution or an after-tax (Roth) contribution in order to save toward your retirement. If you are already contributing to the 403(b) plan, now may be the perfect time to think about increasing your contributions.

Contributing to the 403(b) plan can help you take control of your future retirement needs. Other sources of retirement income, including state pension plans and, if applicable, Social Security, often do not adequately replace a person’s salary upon retirement. The 403(b) plan can be a great way to provide you with additional income at retirement.

WHO IS ELIGIBLE TO CONTRIBUTE TO A 403(b) PLAN? All University employees are eligible to participate in the University’s 403(b) plan except students performing services that are exempt from FICA and non-resident aliens who receive no earned income from the University which constitutes U.S. source income. WHAT ARE THE BENEFITS OF CONTRIBUTING TO A 403(b) PLAN? LOWER YOUR TAXES You may make pre-tax contributions to the 403(b) plan. This means that you are taxed on a lower amount of income. For example, if your federal marginal income tax rate is 25%, and if you contribute $100 a month to the 403 (b) plan, you have reduced your federal income taxes by nearly $25. In effect, your $100 contribution costs you only $75. You will realize similar tax savings based on your state income tax rate. The tax savings can grow with the size of your contributions to the plan.

TAX-DERERRED GROWTH Interest and earnings on your contributions to the 403(b) plan grow tax-free until you withdraw them from the plan. The compounding interest on your contributions to the 403(b) plan can allow your account to grow more quickly than saving money in a savings account where interest and earnings are generally taxed each year.

POSSIBLE TAX CREDITS If you contribute to the 403(b) plan, you may be able to receive a tax credit, which could reduce your overall federal income tax paid for the year. Please contact your tax advisor to learn more. ROTH 403(b) OPTION You may also choose to contribute a portion of your pay to the 403(b) plan on an aftertax (Roth) basis. If you wait at least five years before taking a distribution of your after-tax (Roth) account and meet certain other requirements, you can request a distribution of your entire account tax-free. HOW MUCH CAN YOU CONTRIBUTE TO A 403(b) PLAN? You may elect to contribute up to $18,000 of your pay to the 403(b) plan in 2015. (If you are age 50 or older, or will attain age 50 by the end of the calendar year, you may also elect to contribute up to an additional $6,000 of your pay to the 403(b) plan in 2015.) HOW TO ENROLL IN THE PLAN You must first select an investment provider with which to invest your contributions. Once you have opened an account with an investment provider, you should submit a 403(b) and 457(b) Plan Salary Reduction Agreement (SRA) to the Office of Payroll & Employee Benefits indicating the percentage of pay you would like to contribute to the 403(b) plan. A list of approved investment providers under the 403(b) plan and a SRA for making your elections can be found on the Payroll & Employee Benefits website at www.bsu.edu/benefits by clicking Benefits>>Saving for Retirement.

P L A N

H I G H L I G H T S

INVESTMENT CHOICES You can contact the approved investment providers under the 403(b) plan for a comprehensive listing of the investment options offered by each investment provider. DISTRIBUTIONS FROM THE PLAN You or your beneficiary can take a distribution from the 403(b) plan at the earlier of: 1.

Retirement

2.

Total disability

3.

Death of participant

4.

Termination of employment

5.

Attainment of age 59 ½

Your investment provider will provide you with the distribution paperwork. LOANS Loans are limited to one at a time from all investment providers combined. You may borrow up to ½ of your balance up to a maximum of $50,000. Contact your investment provider for more information. GENERAL PLAN INFORMATION To obtain additional information about the 403(b) plan, please contact the Office of Payroll & Employee Benefits at 765-285-8461 or [email protected]. Plan Name: Ball State University Tax Deferred Annuity Plan Plan Administrator: Ball State University

Updated 11/11/14

BALL STATE UNIVERSITY

“Universal Availability Notice” Acknowledgement for Participation in the University’s 403(b) Plan I,

, acknowledge that I have received a (Please print name.)

copy of the University's “Important Information Regarding Your Retirement Savings" document for participation in the university's 403(b) Tax Deferred Annuity Plan, as well as a summary description of the university's other voluntary Roth 403(b) and 457(b) retirement plans. I also understand that if I am interested in enrolling in any of these voluntary retirement plans or if I have any questions regarding these plans that I am to contact the Office of Payroll and Employee Benefits at (765) 285-8461 for assistance.

Employee Signature

Date

Employee (Student) I.D.

CONFIDENTIALITY AND INFORMATION ACCESS EMPLOYEE AGREEMENT 1. INTRODUCTION This Confidentially and Information Access Employee Agreement must be read, understood, and signed by all employees who either access or may encounter Ball State University confidential information as a part of their assigned duties. Questions which arise during the course of employment may be directed to your immediate supervisor, Career Center, or the Office of Information Security Services. Employees signing this agreement should keep a copy for their records.

2. CONFIDENTIAL INFORMATION DEFINED Ball State University is dedicated to safeguarding and maintaining the confidentiality, integrity, and availability of our student, employee, and organizational information. “Confidential Information” includes all of this information that is personally identifiable and non-public. I understand Confidential Information may be paper-based, electronic, or stored or transmitted in some other form, and that examples of Confidential Information include, but are not limited to: a. Academic information, such as grades and class schedules b. Bank and credit card account information, income, credit history, and consumer report information c. Disciplinary or employment records or related information d. Loan information, including loan applications and loan servicing, collection and processing e. Money wiring and other electronic funds transfers f. Other non-public personally identifiable information relating to a financial transaction g. Social Security Numbers, driver’s license numbers, or similar identification codes or numbers h. Student account balance information, financial aid information I understand the existence of information in one publicly available format does not imply approval to disclose it in another format. For example, I understand certain student directory information (such as telephone numbers and mailing addresses) may appear in the printed Ball State University Directory, however disclosure of the same information in another format such as an electronic file requires separate approval from the appropriate Data Steward. I will contact my supervisor or the Office of Institutional Effectiveness for help in determining the appropriate Data Steward for particular university data when dealing with Confidential Information if I am unsure how to proceed.

3. PROTECTION OF CONFIDENTIAL INFORMATION Protection of Confidential Information requires the following minimum standards, which I agree as a condition of my continued employment: a. Download or Transmission of Confidential Information: I will not download or extract Confidential Information to removable storage devices such as compact discs or flash drives, or transmit such information to any non-university system including personally owned systems or entity without explicit approval to do so from my supervisor or the appropriate Data Steward and the Office of Information Security Services. b. Access to Confidential Information: I will safeguard and maintain the confidentiality of all Confidential Information at all times and will only access, use, or disclose Confidential Information necessary to preform my assigned duties. I will disclose such information to other individuals or organizations only for legitimate University business, research, or academic purposes, and only after I have received prior approval to do so from my supervisor or the appropriate Data Steward. c. Desktop and Laptop Computer Security: I will maintain the security of any computer or device I use to access or store Confidential Information to the best of my ability including the use of passwords, protected “screen savers”, approved antivirus and anti-spyware software, and other measures as may be required by Information Technology Security procedures available at http:// www.bsu.edu/security. If I am uncertain as to how to secure my computers or devices I will obtain the necessary help to ensure they are protected. Ball State University Confidentiality and Information Access Agreement Rev: 07/29/2013 page 1 of 2

CONFIDENTIALITY AND INFORMATION ACCESS EMPLOYEE AGREEMENT 3. PROTECTION OF CONFIDENTIAL INFORMATION (continued) d. Servers and Vendors: I understand implementing servers on or off-campus requires compliance with a separate set of procedures available at http://www.bsu.edu/security. I will not implement servers or hosted systems before contacting the Office of Information Security Services to ensure alignment with applicable hosting procedures. e. Duty to Protect Passwords: I understand passwords used to access university systems are Confidential Information and that I am responsible for access assigned to me. I will not disclose my university passwords for any reason absent the approval of the Office of Information Security Services. In the event I suspect my password has been lost or stolen I will immediately notify the IT Helpdesk (765-285-1517) or Computer Operations (765-285-1549) so that my password may be disabled or reset. f. Duty of Renounce Access: In the event my duties and responsibilities or job assignment changes or my employment with the university ceases I affirm that I will maintain the confidentiality, integrity and availability of all Confidential Information and will promptly notify the appropriate systems administrator or other authority so that my access may be properly adjusted or removed. g. Reporting An Information Security Breach Or Policy Violation: In the event I suspect a security breach or inappropriate disclosure of Confidential Information my first action will be to immediately notify either the Office of Information Security Services (765-285-4390), the Office of University Compliance (765-285-5162), or IT Computer Operations after-hours support (765-2851419). I will then review the official procedures for Reporting an Information Security Incident or Suspected Violation and will take any additional subsequent steps required. h. Appropriate Use of Technology: I understand the Information Technology Users’ Privileges and Responsibilities policy governs my usage and I agree to abide by the terms of this policy regarding the appropriate use of all technology and information systems at Ball State University. i. Security Monitoring and Testing Software or Hardware: I will not use software, tools, or techniques (human, technical, or otherwise) designed or intended to break, exploit, or test the security of university technology resources without explicit written approval from the Office of Information Security Services. j. Audit & Security Review of BSU Information Systems: I understand I have no personal expectation of privacy in any computer or storage system owned, maintained, or utilized by Ball State University. I further understand the university audits, logs, reviews, and utilizes information stored on or passing through information systems for legal or administrative purposes, and that the university may not provide notification of such access or usage. k. Sanctions: I understand violations of this Agreement may result in disciplinary action up to and including termination of employment, suspension and loss of privileges, termination of authorization to Confidential Information, as well as legal sanctions.

PLEASE REFER ANY QUESTIONS RELATED TO THIS AGREEMENT TO YOUR SUPERVISOR OR THE CAREER CENTER. By signing this Agreement, I acknowledge that I have read and fully understand and agree to comply with all of its terms and conditions. I also understand my current access may be revoked and I may be denied future access to university information unless I sign, date and return this Agreement in a timely manner.

Employee’s Signature _________________________________________________

Date ____________________________

Employee’s Printed Name ______________________________________________

Date ____________________________

Employee (student) ID _________________________________________________

Please Return This Completed Agreement To The Career Center. Ball State University Confidentiality and Information Access Agreement Rev: 07/29/2013 page 2 of 2

USCIS Form I-9

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

OMB No. 1615-0047 Expires 08/31/2019

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section Information and Attestation (Employees complete Section of Form I-9later no later Section1. 1. Employee Employee Information and Attestation (Employees mustmust complete and and signsign Section 1 of 1Form I-9 no than the first but not not before before accepting accepting aa job job offer.) offer.) than the firstday dayof ofemployment, employment, but Last Name (Family Name)

Apt. Number

Address (Street Number and Name) Date of Birth (mm/dd/yyyy)

Middle Initial

First Name (Given Name)

U.S. Social Security Number -

Other Last Names Used (if any) State

City or Town

ZIP Code

Employee's Telephone Number

Employee's E-mail Address

-

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States

✳

2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident

(Alien Registration Number/USCIS Number):

4. An alien authorized to work

until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions) QR Code - Section 1 Do Not Write In This Space

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number: Country of Issuance: Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer Certification one):and signed if Section 1 is prepared by a person other than the Preparerand/or and/or Translator Translator Certification (To(check be completed I did not use a preparer or translator. employee.)

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Today's Date (mm/dd/yyyy)

Signature of Preparer or Translator Last Name (Family Name) Address (Street Number and Name)

First Name (Given Name) City or Town

State

ZIP Code

Employer Completes Next Page

Employer Completes Next Page Form I-9 11/14/2016 N

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