January 2016

Dear LHUP Student Employee:

lp}\1\\\11111/Uff?P ... LOCK HAVEN UNIVERSITY

As a new student employee, there are several steps that must be completed prior to beginning employment at Lock Haven

University. Please know that you will not be able to begin your employment, or be paid for time worked, until all of the

steps below are completed:

l. All information requested on the student employment forms is personal information. If you need assistance in determining the correct information needed to complete any of these documents, please contact your parent, legal guardian, accountant, or someone who is familiar with your personal situation. Department timekeepers do not have knowledge of your personal information to complete these forms.

2. Training on the use of E-time (the process by which you will be entering your hours worked for payroll) is available at the Office of Human Resources. If you require training on the process to enter time in E-time, please contact the Office of Human Resources at 570-484-2230. If you are unable to log on to E-Time, please call the Computing Center Hotline at 570-484-2286.

You will not have access to E-time until all your paperwork is completed and returned to the payroll office. Once this step is complete you will have access to enter your hours via E-time at https://po11al.passhe.edu/ irj/po1tal. Your login will be your full LHU email address and your password will be temp!xOO xOO (x=your middle initial & OO=the last two digits of your SSN).

3. Effective January I, 2015, in accordance with Act 153 of 2014 (HB 43 5), all student employees are required

to complete the following background clearances PRIOR to beginning employment: Act 34, Pennsylvania

Criminal Record Clearance; Act 151 , Child Abuse Clearance; and Act 114, Federal Bureau oflnvestigations

(FBI) Criminal Background Checks. Employment is contingent upon completion of a satisfactory

background investigation. Employment cannot begin until the student, supervisor, and timekeeper

receive an email from LHU Student Employment indicating a student is cleared for employment.

4. Student Employees should contact Judy Saxon - Student Payroll at 570-484-2230 or jsaxon@lhup.edu to apply for appropriate background clearances. You will receive an email with directions to complete each background clearance. Students who believe they already possess the required clearances should also contact Judy Saxon.

5. Appointment is provisional for a single 90 day period provided the enclosed "Arrest/Conviction Report and Certification Form" is returned accompanied by all other required employment documents.

Sincerely,

~M_~-t(,(~ Deana Hill

Associate Vice President of Human Resources

Lock Haven University • Lock Haven, PA 17745

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This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Pennsylvania’s State System of Higher Education Background Clearance Certification

for Provisional Employment or Volunteering (Under the Child Protective Services Law)

Please read this entire form carefully before completing it. This form is to be used by prospective volunteers who reside in another state or country and employees to meet the written certification requirement to be considered as a provisional hire or volunteer assignment. This form does not apply to volunteers who reside in Pennsylvania. In certain limited circumstances, current employees/volunteers may need to complete this form.

Section 1. Personal Information

Full Legal Name: __________________________________________________ Date of Birth: ____/____/_______

Any former names or aliases by which you have been identified: _____________________________________________

Section 2. Instructions

If you have any question about whether to report an offense, you should report it. Failure to report may result in disqualification for employment.

List of Reportable Offenses

A Reportable Offense enumerated under Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6344(c), consists of one or more of the following:

1. Provisions of Title 18 of the Pennsylvania Consolidated Statutes (relating to crimes and offenses) or an equivalentcrime under the laws or former laws of the United States or one of its territories or possessions, another state, theDistrict of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of theCommonwealth of Pennsylvania:

Chapter 25 relating to criminal homicide Section 2702 relating to aggravated assault Section 2709.1 relating to stalking Section 2901 relating to kidnapping Section 2902 relating to unlawful restraint Section 3121 relating to rape Section 3122.1 relating to statutory sexual assault Section 3123 relating to involuntary deviate sexual

intercourse Section 3124.1 relating to sexual assault Section 3125 relating to aggravated indecent assault Section 3126 relating to indecent assault

Section 3127 relating to indecent exposure Section 4302 relating to incest Section 4303 relating to concealing death of a child Section 4304 relating to endangering welfare of

children Section 4305 relating to dealing in infant children A felony offense under Section 5902(b) relating to

prostitution and related offenses Section 5903(c) or (d) relating to obscene and other

sexual materials and performances Section 6301 relating to corruption of minors Section 6312 relating to sexual abuse of children

2. An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The ControlledSubstance, Drug, Device and Cosmetic Act,” committed within the preceding five-year period.

3. A founded report of child abuse within the preceding five-year period in the statewide database maintained by theDepartment of Human Services.

2 of 2

This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Section 3. No Conviction

By checking this box, I certify that I have not been convicted of any Reportable Offense or an offense similar in nature to a Reportable Offense under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of the Commonwealth of Pennsylvania. (See Section 2 for a list of Reportable Offenses.)

Section 4. Application for Background Checks

I certify that I have applied for the following required background clearance checks:

A report of criminal history record from the Pennsylvania State Police (PSP) or statement from the PSP that no criminal record exists.

Certification from the Pennsylvania Department of Human Services as to whether I am named in the statewide database as a perpetrator in a pending child abuse investigation or in a founded report or indicated report of child abuse.

A report of federal criminal history record information. I understand that I must submit a full set of fingerprints to the PSP to obtain this report.

I further certify that I have provided copies of the completed request forms for these background clearance checks to Pennsylvania’s State System of Higher Education. (Appropriate forms may be attached to this Certification Form.)

Section 5. Certification

By signing this form, I swear and affirm under penalty of law that the statements made in this form are true, accurate, correct, and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

I understand that after successful completion of the criminal background clearance process, I have a continuing obligation to notify the Human Resources Department within seventy-two (72) hours after an arrest or conviction for an offense defined in the “Reportable Offense” list. If I am unsure about the applicability of my arrest or conviction as a Reportable Offense, it is my responsibility to notify the Human Resources Department for further review. I understand that failure to disclose any arrest or conviction of a “Reportable Offense” shall be considered as non-compliance, subject to disciplinary action, up to and including termination, and/or criminal prosecution, as applicable.

_____________________________________________________ _____________________________________ Signature Date

LOCK HAVEN UNIVERSITY OF PA Student Application for New Employment or Fund Center Change

*Student may not begin work until employment paperwork is completeIt is the policy of the PASSHE that you cannot work until you have a social security number

If your address changes at any time, please notify Student Payroll

Name

PERNR# - Completed by Payroll

Social Security Number

Date of Birth Local or Cell Telephone Number

Beginning Date of Employment

PU.S. Citizen

lease mark the appropriate box.

Resident or Nonresident Alien (Every calendar year you must complete Statement of Citizenship in the International Office. You will not be put on the payroll until all paperwork is completed.)

Gender: Male Female

Check here if you are a veteran

Currently enrolled in classes at Lock Haven University

I declare that this statement, to the best of my knowledge, is true and correct. Falsifying hours worked will result in IMMEDIATE TERMINATION of Student Employment Student Signature Date

LHUP E-mail address

NOTE TO SUPERVISORS: Students may work no more than 20 hours per week during the semesters. Prior approval must be obtained, in writing, from Department of Student Affairs to work more than 20 hours. Students may work 37.5 hours per week, a maximum of 7.5 in a day, during summer and scheduled breaks provided there are sufficient monies in your department fund center.

Completed paperwork is to be forwarded to Student Payroll Office, EC J207. Delay in submitting paperwork will result in student not being paid in a timely manner.

1. ______________________________ _______________ Department Date

__ __ __ __ __ __ __ __ __ __.__ __ __ __ __ 10 digit Fund Center (Grant WBS)

2. _____________________________Supervisor - Printed Name Supervisor - Signature

_____________________________

LOCAL EARNED INCOME TAXRESIDENCY CERTIFICATION FORM

DCED-CLGS-06 (1-11) COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT

GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES

EMPLOYEE INFORMATION - PERMANENT RESIDENCE LOCATION

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.

This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last, FIrst, Middle Initial)

FIRST LINE OF ADDRESS (If PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE

PHONE NUMBER EMAIL ADDRESS

MUNICIPALITY (City, Borough, Township) Write Municipality name and Circle Municipality type

COUNTY PSD CODE Payroll Use Only TOTAL RESIDENT EIT RATE

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN

FIRST LINE OF ADDRESS (IIf PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough, Township)

COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,

please refer to the Pennsylvania Department of Community & Economic Development website:

www.newPA.com

Select Get Local Gov Support, >Municipal Statistics

Form W-4 (2018)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.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. You may claim exemption from withholding for 2018 if both of the following apply.• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. 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 might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20181 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2018, 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 liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

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.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

LOCK HAVEN UNIVERSITY OF PENNSYLVANIA 

ETHNICITY/RACE INFORMATION 

A racial identification code is an integral part of the personnel records of every employee at Lock Haven University.  All information is confidential. 

Please provide accurate information. 

1. WHAT IS YOUR ETHNICITY? (Select One Option)

Hispanic or Latino 

Persons of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. 

Not Hispanic or Latino 

2. WHAT IS YOUR RACE? (Select one or more)

American Indian or Alaska Native 

Persons having origins in any of the original peoples of North and South America (including Central America). 

Asian 

Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. 

Black or African American 

Persons having origins in any of the black racial groups of Africa. 

Native Hawaiian or Pacific Islander 

Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands. 

White/Caucasian 

Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. 

Signature______________________________________ Date_______________ 

Student Employment Practices Lock Haven University of PA

In accordance with the Board of Governors Policy, 1983-10, Lock Haven University of PA [hereafter the University or LHUP] has established undergraduate student employment practices for Campus Employment and Federal Work Study [FWS] employment. Students receiving financial aid who are interested in Federal Work Study may be granted those funds through the Student Financial Services [SFS] Office located in 223 Ulmer Hall. Students may identify both Campus Employment and FWS employment opportunities through LHUP website.

General Guidelines

• Students earn minimum wage and are permitted to work up to 20 hours per week during theacademic year.

• Students may work up to 20 hours during the academic year and 37.5 hours per week during thesummer and scheduled breaks.

• It is recommended that first year students be limited to no more than 15 hours per week during theacademic year.

• Students cannot be assigned to work directly for any family members.• Students may not work for more than two fund centers, and the total combined hours worked

cannot exceed 20 hours during the academic year and 37.5 hours during the summer.• No student may work more than 7.5 hours in a single day.

• Students must be enrolled for at least six credits each semester as an undergraduate studentor three credits as a graduate student..• Students seeking employment for the summer must be enrolled either for a summer session or forthe next fall session.

• Students returning to work in the same office need not complete the employment applicationprocess again unless there is a change in fund center.

• Students may identify employment opportunities through the following website:http://www.lhup.edu/students/student_resources/career_services/

• Any student enrolled at the University may be employed through Campus Employment.• Campus Employment is funded through established fund centers and is subject to budget

restrictions. A fund center is assigned a specific amount of student employment funding at thebeginning of the fall semester which can be used to fund as many students as funding permits.

• Student employment forms for LHUP students are available on the LHUP web site.

• Students must complete the required employment forms, which should then be given to theirdepartment supervisor/timekeeper for review and signature. Supervisors/timekeepers mustreview all forms for completeness. The I-9 form instructions must be followed, and theappropriate documents must be copied and attached to the completed employment forms. Yoursupervisor/timekeeper will review/copy the I-9 doucments for you.

• No student may begin working until all forms are completed, signed, and reviewed and thesupervisor/timekeeper has submitted them to the Human Resources Office for processing.

I, ________________________________________ (print name), affirm that I have read and understand the above guidelines and agree to abide by them.

__________________________________________ __________________ Signature of LHUP Student Employee Date

State System of Higher Education The System Works for Pennsylvania

Tired of going to the bank or waiting in line to cash your check? Introduce yourself to Direct Deposit.

How Direct Deposit works: The State System of Higher Education notifies your Financial Institution electronically of the funds to be deposited on your behalf. Your Financial Institution records this transaction into an account of your choice, creating immediate access on the day of deposit. You receive an earnings statement documenting this payment.

It’s convenient - saves you a trip to the bank.It’s faster - most banks post the funds to your account at the beginning

of the day’s business on payday allowing immediate access. It’s safer - Direct Deposit eliminates the worry of a lost or stolen paycheck. It’s confidential - funds are automatically processed and you can instruct the

bank to apply them to your savings or checking account.

Sign up today by completing the form below and contacting your Human Resource Office. ---------------------------------------------------------------------------------------------------------------------

Direct Deposit Authorization

Name___________________________ SAP PERNR # Completed by Payroll ________________

I hereby authorize the State System of Higher Education to (check one) ___ Start ___ Change ___ Stop total bi-weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings and loan association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2) accepts electronic funds transfer. Payroll will notify you if the institution you choose does not qualify.

Financial Institution’s Name___________________________ Transit Routing Number______________________________ Account Number____________________________________ Type of Account____________________________________ (Checking or Savings)

Effective with pay date of_____________________________

I have an established account at the Financial Institution indicated above, and authorize the State System of Higher Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries in error to my (our) account(s) indicated above. I have provided a copy of a voided check (see attached) solely for the purpose of verifying my account number and the Financial Institution’s routing number. My authorization will remain in effect until revoked by me in writing or I terminate my employment with the State System of Higher Education.

Date_______________________ Signature________________________________________

Co-Signature (If Joint Account)________________________________________

I:\Payroll\BEH\Direct Deposit Authorization

LOCAL SERVICES TAX – EXEMPTION CERTIFICATE 2018

Tax Year

APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX

A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax for the municipality or school district in which you are primarily employed.

This application for exemption from the Local Services Tax must be signed and dated.

No exemption will be approved until proper documentation has been received.

Name: Address:

City/State:

Soc Sec #: Phone #:

Zip:

REASON FOR EXEMPTION

1._______ MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal

employer that shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld. List all employers on the reverse side of this form. You must notify

your other employers of a change in principal place of employment within two weeks of the

change.

2. ______ EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES

WITHIN City of Lock Haven (municipality or school

district) WILL BE LESS THAN $ 12,000.00 : Attach copies of your last pay statements or

your W-2 for the year prior.

If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior

year.

3._______ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to

active duty status. Annual training is not eligible for exemption. You are required to advise the

tax office when you are discharged from active duty status.

4._______ MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a

statement from the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this exemption.

EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the

portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by the

tax collector to withhold the tax.

Tax Office: City of Lock Haven Address: 20 E. Church St.

City/State: Lock Haven, PA

Phone #: 570-893-5621

Zip: 17745

IMPORTANT NOTE TO EMPLOYERS 1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers

and self-employment) in their municipality is less than $12,000 when the combined rate exceeds $10.00.

2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the

income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999.

3. Contact the tax office where your business worksites are located to obtain this information.

LST Exemption 10-07

Employment Information: List all places of employment for the applicable tax year. Please list your

PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self

employed, write SELF under Employer Name column.

1. PRIMARY EMPLOYER 2. 3.

Employer Name Lock Haven University

Address 301 W. Church St.

Address 2

City, State Zip Lock Haven, PA

Municipality Lock Haven

Phone 570-484-2230

Start Date 1/1/18

End Date 12/31/18

Status (FT or PT) PT

Gross Earnings

4. 5. 6. Employer Name

Address

Address 2

City, State Zip

Municipality

Phone

Start Date

End Date

Status (FT or PT)

Gross Earnings

PLEASE NOTE:

All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX.

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND

ATTACHED TO THIS FORM IS TRUE AND CORRECT:

SIGNATURE: DATE:

LST Exemption 10-07

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

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.

STATEMENT OF CITIZENSHIP STATUS and TAXATION Pennsylvania State System of Higher Education

March 25, 2008 1 of 3

__________________________________ University Tax Year 20_______

In order to comply with the applicable provisions of the U.S. Internal Revenue Code, the information requested on this form is necessary for the University to determine the correct rate of Federal tax withholding.

DIRECTIONS: 1. Permanent U.S. resident immigrant, complete sections A,B,C, D and F, and attach a photo copy of your alien

registration card (green card). 2. All others, complete entire form, and attach a copy of your I-94 (Arrival and Departure Record) and your work

authorization paper work (DS-2019/IAP-66, I-20, Notice of Action, Employment Authorization Card).

A. PERSONAL INFORMATION:

Name (last, first, middle) Date of Birth Local Phone # Candidate for a degree? YES NO

Street address while in U.S. Street address in country of residence

City City Province

State Zip Code Country Postal Code

B. EMPLOYMENT INFORMATION:

Faculty / Staff Employee Student Worker (limited to 20 hours per week during the academic year)

C. SOCIAL SECURITY INFORMATION:

Have you applied for a Social Security Number (SSN)?

Yes - My number is _______ - ______ - _______

No have not applied. (In order work and be paid you are required to have a SSN. (Your university payroll office can direct you to the university representative who can assist you with this requirement. Please notify the Payroll office in writing when you receive your number.)

PRIVACY NOTIFICATIONS:

Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security Number is mandatory. Disclosure of the Social Security Number is required pursuant to sections 6011 and 6051 of Subtitle F of the Internal Revenue Code and with Regulation 4, Section 404.1256, Code of Federal Regulations under Section 218, Title II of the Social Security Act, as amended. The Social Security Number is used to verify your identity. The principal uses of the number shall be to report (1) state and federal income taxes withheld, (2) Social Security contributions, (3) state unemployment and Workers' Compensation earnings, and (4) earnings and contributions to participating retirement systems.

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D. CITIZENSHIP AND VISA INFORMATION:

Citizen of (Country) Resident of (Country)

What country issued you a passport? Passport Number What is the primary purpose of your visit to the US?

Is this your first visit to the U.S.? Yes No If no, please list all entries into the U.S. and the previous non-visitor visa types (F1, J1, H1-B):

Date of Entry into U.S. Date of Exit from U.S. Visa Type

Most recent U.S. entry date:

Visa type on I-94: Expiration date of I-94: Intended length of stay in U.S. (if known):

E. DETERMINATION OF FEDERAL TAX WITHHOLDING STATUS. (To be completed by alien.)

Follow directions for each test.

Test 1: “Exempt Individual” Days for Substantial Presence Check any applicable statement:

I have a Type A visa or Diplomatic or Consular status.

I have a J-1 visa and I was in the U.S. as a teacher, trainee, researcher, or student on a J-1 or F-1 visa for less than 2 calendar years of the preceding six years.

I am a student on an F-1 or J-1 visa and have been in the U.S. for five or fewer calendar years.

I am a student on an F-1 or J-1 visa and have been in the U.S. for more than five calendar years, and I have established with the IRS that I do not plan to reside in the U.S. when my education is completed. (Attach IRS notification letter)

If you marked any box, you are a nonresident alien for tax purposes. Please complete “Test 2” completely but instead of performing the calculation enter ZERO in the far right column, otherwise calculate the days.

STATEMENT OF CITIZENSHIP STATUS and TAXATION Pennsylvania State System of Higher Education

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� Option: I elect to be treated as a U.S. citizen for income tax purposes. This election can be made as soon as I arrive in the United States. This will allow me to complete a W-4 like any U.S. citizen for federal withholding, and will make me subject to social security/Medicare taxes immediately. (Students may be exempt from FICA through the 218 Agreement.)

F. SIGNATURE:

I declare under the penalties of perjury that this statement, to the best of my knowledge and belief, is true and correct.

___________________________________________ Signature

______________________ Date

Department Contact:_________________________________________ Contact’s Phone #: ____________________

ATTACH ALL OF THE FOLLOWING DOCUMENTS:

All Nonresident Aliens in the U.S. under a visa � Completed Earned Income Questionnaire � Completed Form I-9 (1st time hired & thereafter upon

expiration of documents)� Completed Form W-4 � I-94� DS-2019/IAP-66 or I-20 � Copy of Social Security card � Copy of Passport & Visa Stamp

Green Card Holders � Completed Earned Income Questionnaire � Completed Form I-9 (1st time hired & thereafter upon

expiration of documents)� Completed Form W-4 (when hired, then optional

changes by employee)� Green Card (I1797/I1797Ad � Copy of Social Security card

Please forward this form and the requested documents to the Payroll Office.

Test 2: Substantial Presence Test (SPT)

I have been present in the US during the current and the previous two years as follows:

Enter year Visa Type

Date Entered US

Date Departed US

Number of Days in US

Computation of SPT

Current Year x 1 =

1st Preceding Year x 1/3 =

2nd Preceding Year x 1/6 =

Total Days: