Form W4 - Employee Withholding Allowance Certificate - Pennsylvania State University
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1Payroll Department
101 James M. Elliott Building
W-4
120 S. Burrowes Street
EMPLOYEE’S WITHHOLDING
State College, PA 16801
ALLOWANCE CERTIFICATE
Employer I.D. No. 24-6000376
COMPLETE ENTIRE FORM -
Complete this entire form after reading the “W-4 Information” below.
Place I-9
stamp in
this box
Suffix
PSU-ID #
Social Security Number
First Name
Middle Name
Last Name
(Jr.,Sr., I, II)
Home Street Address
Home City or Town
State
Zip Code
Taxing Authority (City, Borough, or Township)
School District
Home Phone
Work or Campus Location
County
-- Payroll Office Use Only --
Date of Birth
Office Address
Building Name
of above Address
Do you work for PSU in Pennsylvania?
If NO - What state or country do you work in for PSU?
Yes
No
Of
icial
f
Sex
Department Employed By
Type of Visa
Are you a non-resident alien
Are you a citizen of the U.S.?
Male
for US tax purposes?
Yes
No
Yes
No
Female
GURU
MARITAL STATUS
If your last name differs from that shown on your social
security card, check here. You must call 1-800-772-1213
Single
Married, but withhold at higher Single rate
Married
for a new card.
NOTE: If married, but legally separated, or spouse is a non-resident alien, check “Single” box.
WITHHOLDING ALLOWANCES
Total number of allowances you are claiming (use
IRS Publication 505
with related worksheets, as necessary)
$
Additional dollar amount, if any, you want deducted from each pay (must be in whole dollars)
FORM
I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.
(a) Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
(b) This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write EXEMPT here..........................................................................................................
..
..........
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true,
correct and complete.
Email address:
Date (Required):
Signature (Required):
W-4 INFORMATION
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 the entire form (including writing “EXEMPT” in the box in the Withholding Allowances
section) and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. 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 cannot claim exemption from withholding if your 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: (a) is age 65
or older, (b) is blind, or (c) will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not
apply to supplemental wages greater than $1,000,000.
If any of the federal withholding information is blank or incomplete, the IRS requires an employer to withhold at the single rate with zero allowances.
If the number of withholding allowances you are entitled to claim decreases to fewer than the number you claim on your current W-4, you must file a
new W-4 within 10 days.
You may be fined if, with no reasonable basis, you file a W-4 that results in less tax being withheld than is properly allowable. In addition, criminal
penalties apply for willfully supplying false or fraudulent information or failing to supply information requiring an increase in withholding.
If you have more than one job, or your spouse works, you may claim all of your allowances on one job, or you may claim some on each job, but you
may NOT claim the same allowances more than once. Your withholding will usually be more accurate if you claim all allowances on the Form W-4 for
the job with the largest wages, and claim zero on all other W-4s.
02-2017
GF5.6 W4
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