BRIDGEWATER STATE UNIVERSITY. Preferred Name*: (if applicable)

Transcription

1 BRIDGEWATER STATE UNIVERSITY First Name: Last Name: ~ Middle Name: Preferred Name*: (if applicable) Date of Birth: Social Security Number: J ' Marital status: o Single o Married Sex: o Male o Female o Divorced o Widowed Citizenship: o canadian o Mexican Citizen o Non-Resident Alien o Other o Resident Alien/US Permanent Resident o US Citizen ---- c.c..:.cc.:: :_; :_ ~ ; Ethnicity: o Hispanic or Latino o Not Hispanic or Latino i Race: o American Indian/ Alaska Native o Asian o Black o cape Verdean o Native Hawaiian/ Pacific Islander _:: c:_.:. : :_c o Middle Eastern/North --'---~.:=c.:_ African o c c_::_:_: White ;! Veteran Status: o Not a Veteran o Active Wartime/Campaign Badge Veteran o Not a Protected Veteran o Protected Veteran Cell Phone: (required for campus emergency notifications) Home Phone: Home Address: Address: City: i State:. ZIP Code: Mailing Address: (if different) - -,,,_,, v City: 1 State:... EMPI.C>Yfl!EtfflNFC>RMATIC>N : ZIP Code: : Position Appointed To: 'Hire Date:,"'~i- a - ="-' A.-,v,~~'<-- C;;,d,-»- AOmA< A - ) I : Department: _LBuil~in.r. EMERGENCY CONTACT. Name: 'Address:. City: State: ZIP Code: : Phone: Secondary Phone: (Optional) ' Relationship: : IMPORTANT:. Please notify Human Resources of any changes in the information listed above. ---'-----'-----'-----'---~-<.... 'A preferred first name is a name that you commonly use that is different from your legal first name. (Example: A transgender employee has the legal first name ''Jennifer" but goes by the name "Jason". This employee's preferred first name is "Jason".) Some records, such as paychecks or employee documents, that require the use of a legal name, will not change to preferred name. However, whenever posslb!e, preferred name wtll be used.

2 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 0MB No 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. Address (Street Number and Name) Apt. Number City or Town ZIP Code Date of Birth (mmlddlyyyy) U.S, Social Security Number Employee's E~mai! Address Employee's Telephone Number [DJ [D I 1111 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): D 1. A citizen of the United States D 2. A noncitizen national of the United States (See instructions) D 3. A lawful permanent resident {Alien Registration Number/USCIS Number}: D 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "NIA" in the expiration date field. (See instructions) Aliens authorized to work must provide onfy one of the fallowing document numbers to complete Form 1-9: An Alien RegistraUon Number/USCJS Number OR Form 1~94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: OR 2. Form 1-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: QR Code - Section 1 Do Not Write In This Space 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 Signature of Preparer or Translator I Today's Date (mmlddlyyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Fonn J.9 07/17/17 N Page I ofj

3 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-9 0MB No List A Identity and Employment Authorization Expiration Date (if any)(mmlddlyyyy) OR Expiration Date (if any)(mmlddlyyyy) AND List C Employment Authorization Expiration Date (if any)(mmlddlyyyy) Additional Information QR Code- Sections 2 & 3 Do Not Write ln This Space Expiration Date (if any)(mmldd/yyyy) Expiration Date (if any)(mmldd/yyyy) Certification: I attest, under penalty of perjury, that (1) I have examined the document(s} presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mmldd/yyyy): (See Instructions for exemptions) Signature of Employer or Authorized Representative Today's Date /mmlddlyyyy) Title of Employer or Authorized Representative Last Name of Errp!oyer or Authorized Representative Flrst Name of Errployer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) C. If theernployee's previous grant of emptoymen\ailthorlzation has explted, provide the Jnfonrtation.for the do umen( O'feC!llp\that establishes continuing employment authorization In th.e space provided betow. Expiration Date (if any) /mmlddlyyyy) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mmldd/yyyy) Name of Employer or Authorized Representative Fann /17/17 N Page 2 of3

4 LISTS OF ACCEPT ABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List Band one selection from List C. 6. LIST A LIST B LIST C Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization AND 1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye 3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary stamp or temporary INS AUTHORIZATION printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms 1-766) DS-1350, FS-545, FS-240) 5. For a nonimmigrant alien authorized 3. School ID card with a photograph 3. Original or certified copy of birth to work for a specific employer Voter's registration card certificate issued by a State, because of his or her status: county, municipal authority, or U.S. Military card or draft record territory of the United States a. Foreign passport; and bearing an official seal Military dependent's ID card b. Form 1-94 or Form l-94a that has the following: U.S. Coast Guard Merchant Mariner 4. Native American tribal document (1) The same name as the passport; Card 5. U.S. Citizen ID Card (Form 1-197) and Native American tribal document (2) An endorsement of the alien's 6. Identification Card for Use of nonimmigrant status as long as Driver's license issued by a Canadian Resident Citizen in the United that period of endorsement has government authority States (Form 1-179) not yet expired and the proposed employment is not in For persons under age 18 who are 7. Employment authorization document issued by the conflict with any restrictions or unable to present a document Department of Homeland Security limitations identified on the form. listed above: Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form l-94a indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI School record or report card Clinic, doctor, or hospital record Day-care or nursery school record Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I /17 N Page3of3

5 Form W-4 { 2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal Income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to va!ldate It. Your exemption for 2017 expires February 15, See Pub. 505, Tax Withholding and Estimated Tax. Note: If another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, The exceptions don't apply to supplemental wages greater than $1,000,000. Basic instructions. lf you aren't exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding al!owances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only lf you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and FIiing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withhold!ng allowances. Credits for child or dependent care expenses and the child tax credit may be claimed Nonwage income. If you have a large amount of nonwage income, such as Interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. lf you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually wiu be most accurate when all allowances are claimed on the Fann W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially!f your earnings exceed $130,000 {Slngle) or $180,000 {Married). ls blind, or Future developments. Information about any future Will claim adjustments to income; tax credits; or using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other developments affecting Form W-4 (such as legislation enacted after we release 1t) will be posted itemized deductions, on his or her tax return. credits Into withholding allowances. at gov/w4. Personal Allowances Worksheet (Keep for your records.) A B C D E F G H Enter "1" for yourself if no one else can claim you as a dependent, You're single and have only one job; or } Enter "1" if: You're married, have only one job, and your spouse doesn't work; or B { Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. {Entering "-0-" may help you avoid having too little tax withheld.). C Enter number of dependents (other than your spouse or yourself) you will claim on your tax return. D Enter "1 11 if you will file as head of household on your tax return {see conditions under Head of household above) E Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. 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 have two to four eligible children or less "2" if you have five or more eligible children. 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. G 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 For accuracy, [ complete all worksheets that apply. If you plan to itemize or claim adjustments to Income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line Hon line 5 of Form W-4 below Separate here and give Form W--4 to your employer. Keep the top part for your records Employee's Withholding Allowance Certificate 0MB No Form W 4 Department of the Treasury -., Whether you are entitled to claim a certain number of allowances or exemption from withholding ls ~@17 Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. Your first name and middle initial Last name 2 Your social security number A Home address {number and street or rural route) 3 D Single D Married O Married, but withhold at higher $Ingle rate. City or town, state, and ZIP code Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single» box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card..,_ D 5 Tota! number of allowances you are claiming {from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck 7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liab;:;ile,it,; c... If you meet both conditions, write "Exempt" here.. -., 7 Under penalties of perjury, 1 declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee's signature (fhls form is not valid unless you sign it.)., 8 Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) Date., For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Form W-4 (2017)

6 ~~:~:II name... -~~S~~~H-U~E~S- EMPLOYEE'S WITH::~a~::u~:::PTI~~ ~~~TIFl~~TE... Rev 1112 {~ J Print home address.....,...,,...,.,,...,... City......,... State...,... Zip.... Employee: Fite this form or Fonn W-4 with your empk>yer. Othetwise, Massachusetts Income Taxes wil! be withheld from your wages Without e)(emptions. Employer: Keep this certificate with your records. If the employee is believed to have claimed excessive exemptions, the Massachusetts Department of Revenue should be so advised HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS 1. Your personal exemption. Write the figure "1." If you are age 65 or over or wm be before next year, write "2" 2. If married and if exemption for spouse is allowed, wr!te the figure "4." If your spouse is age 65 or over or will be before next year and if otherwise qualified, write "5.~ See Instruction C Write the number of your quallfled dependents. See Instruction Add the number of exemptions which you have claimed above and write the total. 5. Additional withholding per pay period under agreement wlth employer$ A D Check if you will file as head of household on your tax return. B, D Check if you are blind. C. D Check if spouse is blind and not subject to withholding. D. D Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual Income will not exceed $8,000. EMPLOYER: DO NOT withhold If Box D Is checked. I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. Dale.., Slgned.... THIS FORM MAY BE REPRODUCED THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE A. Number. If you claim more than the correct number of exemptions, civil and criminal penalties may be Imposed. You may claim a smaller number of exemptions. tt you do not file a certificate, your employer must withhold on the basis of no exemptions. lf you expect to owe more income tax than will be withheld, you may either claim a smaller number of exemptions or enter into an agreement with your employer to have additional amounts withheld. You should claim the total number of exemptions to which you are entitled to prevent excessive overwithholding, unless you have a significant amount of other income. If you work tor more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer. If you are married and if your spouse is subject to withholding, each may claim a personal exemption. B. Changes. You may file a new certificate at any time if the number of exemptions increases. You must file a new certificate within 1 0 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son's income indicates that you will not provide over half of his support for the year, you must file a new certificate. C. Spouse. If your spouse is not working or if she or he is working but not claiming the personal exemption or the age 65 or over exemption, general~ ly you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemp tions for your spouse or for any dependents that will not be claimed on your annual tax return. If claiming a wife or husband, write "4" in line 2. Using "4" is the withholding system adjustment for the $4,400 exemption for a spouse. D. Dependent(s). You may claim an exemption in line 3 for each individual who qualifies as a dependent under the Federal Income Tax Law. In addition, if one or more of your dependents will be under age 12 at year end, add "1" to your dependents total for line 3. You are not allowed to claim "federal withholding deductions and adjustments'' under the Massachusetts withholding system. If you have Income not subject to withholding, you are urged to have additional amounts withheld to cover your tax liability on such income. See line 5. IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

7 Social Security Administration Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name Employee ID# Em p Io ye r Name Commonweal th of Mass. Em p Io ye r ID# Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $ This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, "Windfall Elimination Provision." Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow( er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, "Government Pension Offset." For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at You may also call toll free , or for the deaf or hard of hearing call the TTY number , or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits. Signature of Employee Date Form SSA-1945 ( ) Destroy Prior Editions

8 BRIDGEWATER STATE UNIVERSllY Social Security Card Employee's Responsibilities Upon first date of employment: 1. Employee who has a social security card shall show it to the employer. 2. If employee has a social security card, but doesn't have it on his/her person and knows the number and exactly how the name reads, employee can provide the employer with number/name as it appears on cards. 3. If employee has put in an application for a new social security card and has a receipt from the Social Security Administration, employee shall show said receipt to employer. 4. If employee is unable to furnish a receipt or the receipt does not include the social security number, he/she will need to complete: Full Name: Present Address: Date of Birth: Employee's Sex: I understand and agree that it is my sole responsibility to verify the accuracy of my social security number prior to receiving a paycheck. If I provide an incorrect number, I accept full responsibility in the event that taxes and deductions are applied to the incorrect number. Employee's Signature Date My name (as it appears on my social security card) is: Please Print Clearly My social security number is: Please Print Clearly

9 SECTION 1: Employee Infonnation PAYROLL AUTHORIZATION FOR DIRECT DEPOSIT INTO EMPLOYEE'S ACCOUNT/ACCOUNTS TREASURER AND RECEIVER GENERAL Employee Name: Employee I.D:. SECTION 2: Direct Deposit Infonnation (fill in as necessarv) Instructions: Direct deposits are distributed to accounts in order oftbe priority starting with priority' I'. The total of the percentages cannot exceed 100%. Designate one (and only one) account to receive any excess funds left over after all direct deposits are processed. Check 'Partial Allowed?' to allow the direct deposit amount to be less than the amount entered in the 'Amount' or 'Percent ofnet Pay' fields. If you are adding a new account please list this along with all existing accounts in the order of priority. Percent of Excess? Partial Checking/ Priority Amount Net Pay (check one) Allowed? *Routing# Account# Savings LIA** NEW CHANGE DEL*** $ or % D D D D D D 2 $ or % D D D D D D 3 $ or % D D D D D D 4 $ or % D D D D D D 5 $ - or % D D D D D D 6 $ or % D D D D D D 7 $ or % D D D D D D 8 $ or % D D D D D D 9 $ - or % D D D D D D 10 $ or % D D D D D D SECTION 3: Sign and Return to Your Payroll Coordinator I choose to receive my bi-weekly payroll advice through the Commonwealth Pay Info website (available 24 hours). No bi-weekly paper copy will be issued to me by my employer D Check box if any of the total of any of the above direct deposits go directly to a foreign bank or if the entire amount is forwarded from a domestic bank to a foreign bank I hereby authorize my employer, through the State Treasurer, to deposit my net pay and/or distributions to the fmancial institution(s) listed above. My employer, through the State Treasurer, is also authorized to debit any over deposit or error, which it has caused to be made to my account. The State Treasurer or the employee may cancel this authorization any time with proper notice to the Personnel/Payroll Office. In the absence of bank documentation, my signature certifies the Transit #(s) and Account #(s) indication above are correct as shown. Employee Signature: * ** *** Revised 9/24109 NOTE: to find the routing numbers, contact your financial institution for help. LEAVE ALONE DELETE Date: Employee Work Phone: Please return your completed fonn to: Bridgewater State University Payroll Office 13 I Summer Street, Boyden Hall 103 Bridgewater, MA 02325