Fillable Affiliate New Hire Packet and Checklist (Metropolitan State College of Denver)

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Affiliate New Hire Packet and Checklist (Metropolitan State College of Denver)

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Affiliate New Hire Packet and Checklist
Please Print your packet one sided.
Revised 3/26/2020
Complete
Form Name
Description
☐
Employee Data Sheet
Basic personal information to be entered into the MSU Denver
personnel database.
☐
Self-Identification Forms
Self-identification for governmental recordkeeping and reporting
requirements for administration of civil rights laws and regulations. You
may indicate your choice to not participate.
☐
Form W-4 Allows MSU Denver to withhold federal income tax from your pay.
☐
Direct Deposit of Payroll
Earnings Authorization
MSU Denver’s primary means of payment. Provide bank/credit union
information and attach a voided check. If you do not have checks you
can contact your bank to get a direct deposit authorization form. Many
banks have these on their website.
☐
PRWORA Form
The Personal Responsibility and Work Opportunity Reconciliation Act
(PRWORA) requires MSU Denver to report certain information on newly
hired employees to the Colorado Dept. of Human Services so that, if
applicable, child support can be more effectively enforced.
☐
Form SSA-1945 (SSA Admin.
Statement)
Acknowledgment that earnings from employment at MSU Denver are
not covered under Social Security. Instead a percentage of earnings will
go into a defined benefit plan run by PERA (Colorado Public Employees’
Retirement Association).
☐
PERA Retiree Form
PERA contribution is a requirement for all Affiliate Faculty. Please
indicate whether you are a retiree or not.
☐
PERA Beneficiary Form
Employee contribution and Employer contribution are subject to
change. Please included attachment. Beneficiaries need to be listed on
the form. Please contact PERA at 1-800-759-7372 if you have any
questions.
☐
Oath of Allegiance
Colorado law enacted in 1969, the Oath of Allegiance is required of all
faculty members and administrative professionals. Compliance with
the Oath is required and must be taken in front of a public notary. We
have notaries in our HR office.
☐
Agreement for Affiliate
Faculty
Basic agreements you are making with the university regarding the
nature of your employment.
☐
Handbook Acknowledgement
Acknowledgement of the Faculty Handbook, its location on the
University website and agreement to abide by the policies.
☐
FERPA
Agreement to abide by FERPA Regulations.
☐
Workers Compensation
Notification of Worker’s Compensation procedures. Complete
guidelines and procedures are on the HR website.
☐
Identification for the I-9
Must be original or certified copy (no scans or photocopies).
☐
Official Transcripts Requested
Submit within 30 days of hire date. We cannot accept PDFs of official
transcripts that have been sent to you.
The attached documents are provided to you as a new faculty member, as part of the on-boarding process. You may return your
printed forms in person to Human Resources during an intake session. Please direct questions by email to
jferna34@msudenver.edu or by calling 303-605-7042.
Affiliate Intake Sessions are offered Mondays at 3:00pm and Wednesdays at 9:00am and listed on the MSU Denver HR Calendar:
https://www.msudenver.edu/hr/calendar/. Please RSVP for the session you plan to attend.
Revised 1/27/2020
Employee Data Sheet
Date: __________________
900# (if known):___________________
Start Date:____________________
Hiring Department:____________________
New Employee or Returning Employee (please circle one)
First Name: MI: Last Name:
Social Security Number: Date of Birth:
Street Address: City, State, Zip:
Personal Email: Telephone Number: Cell or Home
(Please circle)
EMERGENCY CONTACT INFORMATION:
Name of Contact Telephone Number:
Street Address: (if different from above) City, State, Zip:
Citizenship Status: If Other than a United States Citizen:
Visa Type: ____________________ Country: _______________ Visa Exp. Date: ______________
Revised 1/27/2020
Equal Employment Opportunity (EEO) Gender & Ethnicity Self Disclosure Form
Di
sclosure of self-identification information is voluntary and responses will not be used in a discriminatory manner.
Ge
nder:
Female Male
Et
hnicity (select one):
Hispanic/Latino, Chicano, Cuban, Puerto Rican, Mexican American
Non-Hispanic/Latino
Ra
ce (regardless of answer above, select all that apply):
American Indian or Alaskan Native – A person having origins in any of the original peoples of North and South
America (including Central America), and who maintain cultural identification through tribal affiliation or community
recognition.
Asian – A person 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 – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
White, Anglo, Caucasian – A person having origins in any of the original peoples of Europe, Middle East, or North
Africa.
Revised 1/27/2020
Voluntary Self-Identification of Veteran Status:
Disclosure is voluntary and responses will not be used in a discriminatory manner
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as
amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to
take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans;
(3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the
appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to
measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
These classifications are defined as follows:
I am not a Veteran.
I am not a protected veteran.
A “disabled veteran” is one of the following:
• A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who
but for the receipt of military retired pay would be entitled to compensation) under laws
administered by the Secretary of Veterans Affairs; or
• A person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such
veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
• Date of Separation:
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S.
military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been
authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S.
military, ground, naval or air service, participated in a United States military operation for which an Armed Forces
service medal was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment
Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you
may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty
if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment
and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
EMPLOYEE SIGNATURE: DATE:
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signature
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Vol
untary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
0B
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
0F
i
To help us measure how well we are doing, we are asking you to tell us if
you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If
you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
1BHow do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disa
bilities include, but are not limited to:
Please check one of the boxes below:
☐
YES, I HAVE A DISABILITY (or previously had a disability)
☐
NO, I DON’T HAVE A DISABILITY
☐
I DON’T WISH TO ANSWER
__________________________ __________________
Your Name Today’s Date
•
3B
Blindness
•
4B
Autism
•
5B
Bipolar disorder
•
6B
Post-traumatic stress disorder (PTSD)
•
7B
Deafness
•
8B
Cerebral palsy
•
9B
Major depression
•
10B
Obsessive compulsive disorder
•
11B
Cancer
•
12B
HIV/AIDS
•
13B
Multiple sclerosis (MS)
•
14B
Impairments requiring the use of a wheelchair
•
15B
Diabetes
• 16BEpilepsy
•
17B
Schizophrenia
• 18BMuscular
dystrophy
•
19B
Missing limbs or
partially missing limbs
•
20B
Intellectual disability (previously called mental
retardation)
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signature
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Vol
untary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
2B
Reasonable Accommodation Notice
Federal
law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at
www.dol.gov/ofccp.
PU
BLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
a
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a
Give Form W-4 to your employer.
a
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
a
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld .....
a
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
a
$
Multiply the number of other dependents
by $500 . . . .
a
$
Add the amounts above and enter the total here .............
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b) Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here .....................
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
F
Employee’s signature (This form is not valid unless you sign it.)
F
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)
Metropolitan State University of Denver
84-0559160
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signature
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Form W-4 (2020)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption from withholding. You may claim exemption from
withholding for 2020 if you meet both of the following
conditions: you had no federal income tax liability in 2019 and
you expect to have no federal income tax liability in 2020. You
had no federal income tax liability in 2019 if (1) your total tax on
line 16 on your 2019 Form 1040 or 1040-SR is zero (or less
than the sum of lines 18a, 18b, and 18c), or (2) you were not
required to file a return because your income was below the
filing threshold for your correct filing status. If you claim
exemption, you will have no income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both of the conditions above by writing “Exempt”
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1a, 1b, and 5. Do not complete any other steps. You will
need to submit a new Form W-4 by February 16, 2021.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to
additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also be
checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be cut
in half for each job to calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may be withheld, and this extra amount will be
larger the greater the difference in pay is between the two jobs.
F
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for
determining the amount of the child tax credit and the credit
for other dependents that you may be able to claim when
you file your tax return. To qualify for the child tax credit, the
child must be under age 17 as of December 31, must be
your dependent who generally lives with you for more than
half the year, and must have the required social security
number. You may be able to claim a credit for other
dependents for whom a child tax credit can’t be claimed,
such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 972, Child
Tax Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2020 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
Form W-4 (2020)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 ..................... 1
$
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a ....................... 2a
$
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b .............................
2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c .......... 2c
$
3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. ..... 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) ......................... 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up to $10,000), and medical expenses in excess of 10% of your income ........ 1 $
2 Enter:
{
• $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately
}
........ 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information . . . 4
$
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 ........... 5 $
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 with no other entries on the form; 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.
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 W-4 (2020)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870
$10,000 - 19,999
220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070
$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900
$30,000 - 39,999
900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100
$40,000 - 49,999
1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220
$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220
$60,000 - 69,999
1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220
$70,000 - 79,999
1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240
$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180
$150,000 - 239,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250
$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170
$260,000 - 279,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770
$280,000 - 299,999
2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370
$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970
$320,000 - 364,999
2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840
$365,000 - 524,999
2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280
$525,000 and over
3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040
$10,000 - 19,999
940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830
$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110
$30,000 - 39,999
1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310
$40,000 - 59,999
1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080
$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060
$80,000 - 99,999
2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060
$100,000 - 124,999
2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620
$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370
$150,000 - 174,999
2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120
$175,000 - 199,999
2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230
$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$250,000 - 399,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$400,000 - 449,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540
$450,000 and over
3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040
$10,000 - 19,999
830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440
$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850
$30,000 - 39,999
1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140
$40,000 - 59,999
1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380
$80,000 - 99,999
1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380
$100,000 - 124,999
2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870
$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620
$150,000 - 174,999
2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370
$175,000 - 199,999
2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980
$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$250,000 - 349,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$350,000 - 449,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200
$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240
Direct Deposit Authorization Agreement
COMPANY
NAME: Metropolitan State University of Denver COMPANY ID: 84-0559160
I hereby authorize MSU Denver, hereinafter called COMPANY, to initiate credit entries and to
initiate, if necessary, debit entries and adjustments for any credit entries in error to my
Checking Savings account (select one) indicated below at the depository named below,
hereinafter called DEPOSITORY, to credit and/or debit the same to such account.
BANK DEPOSITORY
NAME:
ROUTING
NUMBER:
ACCOUNT
NUMBER:
This authorization is to remain in full force and effect until COMPANY has received written
notification from me of its termination in such time and such manner as to afford COMPANY
and DEPOSITORY a reasonable opportunity to act on it.
NAME: 90_#:
(PLEASE PRINT)
Work Telephone
Number:
Home/Cell Phone
Number:
DATE: SIGNED:
NOTE: ALL WRITTEN CREDIT AUTHORIZATIONS SHOULD PROVIDE THAT THE RECEIVER
MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE
MANNER SPECIFIED IN THE AUTHORIZATION.
Employee Type:
Full-Time: Faculty,
Administrators, Classified Staff
Part-time Faculty Admin/Classified Hourly
PLEASE ATTACH VOIDED CHECK
OR
BANKING INSTITUTION
LETTER
PRWORA Form
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, known as
welfare reform, require all employers to report certain information on their newly hired employees to a
designated state agency within time parameters.
For additional information, visit the U.S. Department of Health and Human Services, Administration for Children
and Families website:
http://www.acf.hhs.gov/programs/css/resource/new-hire-reporting-answers-to-employer-questions
PLEASE PRINT LEGIBLY IN BLACK OR BLUE INK:
Name:
Social Security Number:
Address:
City, State, Zip:
For Human Resources:
Hire Date:
TO: Colorado Department of Human Services
FROM: Metropolitan State University of Denver
P.O. Box 173362, Campus Box 47
Denver, CO 80217-3362
Federal Employer I.D. Number: 84-0559160
Form SSA-1945 (01-2013)
Destroy Prior Editions
Social Security Administration
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name
Employee ID#
Employer Name
Employer 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 $395.50. 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 www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf
or hard of hearing call the TTY number 1-800-325-0778, 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
PERA INFORMATION
As a result of Senate Bill 04-257, effective July 1, 2005, PERA employers are required to
begin paying employer contribution salaries paid to PERA retirees. To ensure that we have
correct information on our employee population, please complete this form and return it with
your contract to the Office of Human Resources. If you have questions, please contact the Office
of Human Resources at 6-3120.
I am not a retiree.
I am a PERA retiree and currently receiving a monthly benefit.
I am receiving a retirement benefit from another retirement plan other than PERA.
Plan Name:
Print Name Date
________________________________
Signature
Name - Print
OATH OF ALLEGIANCE
“I
solemnly swear or affirm that I will uphold the Constitution of the United
States and the Constitution of the State of Colorado, and I will faithfully
perform the duties of the position upon which I am about to enter.”
Signature Date
Notary Public
Under 1969 C.R.S. §22-61-104, the Oath of Allegiance is required of all employees in teaching positions. Any person employed to teach who
is a citizen of a nation other than the United States shall not be required to take the oath.
The Oat
h of Allegiance shall be administered by any person authorized to administer oaths in the State of Colorado. This includes judges,
court clerks, and notaries public. Metropolitan State University of Denver Human Resource personnel are notary public.
Attention: Please do not
sign
oath unless you are in the presence of a
Colorado notary.
AGREEMENT FOR AFFILIATE FACULTY
I understand that, in consideration of my execution of the Agreement, the Department Chairman, Director, or
Program Coordinator may arrange for me to teach classes on a temporary basis and recommend that I be
appointed, but agree and acknowledge that the final authority concerning my employment rests with the President
of the University and its Board of Trustees.
I understand that if enrollments do not warrant my employment as a part-time (Affiliate) faculty member; should
the budget for the University not be sufficient to justify my retention; or should the efficient use of regular faculty
members or other part-time faculty members with previous teaching experience at the University require it, I will
not receive a part-time agreement for the entire semester, but shall be compensated only for the time actually
spent performing services for the University. The determination concerning the above conditions shall be at the
sole discretion of the University through the Provost / Vice President for Academic and Student Affairs.
In the event that this appointment is subsequently terminated by the University prior to the completion of services
required, remuneration shall be based upon services actually performed at the then current rate for pay for affiliate
faculty.
This Agreement in no way commits Metropolitan State University of Denver to offer employment to me during
any given term during any given fiscal year.
Some key guidelines to note are faculty are required to meet each class session as scheduled, including the class
scheduled for the Final Exam, and post grades. College policy requires that ALL ABSENCES BE REPORTED
TO THE DEPARTMENT CHAIR AND ASSISTANT CHAIR, before they occur if possible. Specific and
additional requirements will be outlined within each department.
This Agreement is designed to clarify my relationship with the University pending acceptance by the President for
Metropolitan State University of Denver of the recommendation for my employment as a part-time faculty
member.
______________________________________ _______________________________________
Signature Date
Revised 1/29/2020
Faculty Handbook Acknowledgement Form
I acknowledge that Metropolitan State University of Denver Faculty Handbook is available to me on the
University’s website: https://www.msudenver.edu/hr/policies/handbooksmanualsrules/
I understand that I am responsible for adhering to the policies and agree to abide by the procedures set
forth in the handbook and understand that they may be revised from time to time.
Name: ________________________________________________________________________
Signature: _____________________________________________________________________
Date:______________________________ Dept.:_______________________________
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Metropolitan State University of Denver
Confidentiality Agreement – Federal Educational Rights and Privacy Act
Rev 01/01/2019
Federal Educational Rights and Privacy Act (FERPA)
FERPA is a federal law protecting the privacy of a student’s educational records and applies to any educational
institutions that receive funds under any program administered by the U.S. Department of Education. Violation to
FERPA would result to the University losing the ability to provide financial aid to our students.
FERPA rights belong to the student at a postsecondary institution regardless of age. Student applies to all
students—including continuing education students, students auditing a class, distance education students, and
former students.
Metropolitan State University of Denver maintains educational records for each student who has enrolled at the
University. Under the Family Education Rights and Privacy Act of 1974, 20 USC 1232g, and the implementing
regulations published at 34 CFR part 99, each eligible student has the right to:
1. Inspect and review his/her educational records;
2. Request the amendment of the student’s education records to ensure that they are not inaccurate,
misleading or otherwise in violation of the student’s privacy or other rights;
3. Consent to the extent that FERPA authorizes disclosure without consent (see Nondisclosure and
Exceptions in the University catalog under Student’s Rights and Responsibilities.
4. File a complaint under 34 CFR 99.64, concerning alleged failures by the University to comply with the
requirements of FERPA, with the Family Compliance Office, U.S. Department of Education.
As a staff or faculty member at MSU Denver, it is your responsibility to oversee and uphold the rights of FERPA
grants to our students. Basic guidelines include:
• Do not display any personally identifiable data or information which includes, but is not limited to
student’s name, the name of the student’s parent or other family members, the address of the student
or student’s family, a personal identifier such as SSN, student number or biometric record. Other
indirect identifiers such as the student’s date of birth, place of birth, mother’s maiden name, or other
information alone or in combination that is linked to a specific student.
• Student educational records are considered confidential and cannot be released without the student’s
prior written consent.
• As a student worker, staff, or faculty member, you are given access to student educational records for
the sole purpose of performing your job. It is your responsibility to protect educational records
whenever they are used and regardless of the medium in which they are accessed.
• Do not use anyone else’s username or password or allow anyone to use yours. Log out of Banner when
not in use and lock your computer when you walk away.
• When in doubt, do not give it out. Do not hesitate to call the Office of the Registrar at 303-556-3991 for
any FERPA guidance.
I have read and agree to the above responsibilities regarding FERPA regulations:
Name: _____________________________________________
Signature: __________________________________________
900#_________________________
Date: _________________________
Metropolitan State University of Denver
Worker’s Compensation Policy
EMPLOYEE NOTIFICATION OF WORKER’S COMPENSATION PROCEDURES*
I, (Print or type name), have
been notified by my employer/supervisor of the Worker’s Compensation Procedures. In the
event I am involved in a work related injury or illness, I understand that MSU Denver has
designated medical facilities that serve as approved medical providers for all work related
injuries or illnesses. I understand that if I do not receive medical care for work related injuries
or illnesses from the designated clinic or an approved 24-hour after care facility, or any
specialists to which they refer me, EXCEPT IN THE CASE OF A SERIOUS EMERGENCY; I
could be financially responsible for payment of that care.
I have received the above referenced procedures and have been informed that authorization is
required from my employer before I seek medical care for non-emergency, work related injuries
or illnesses.
Signature Date
*Submit to Human Resources after signature.
*Required
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Revised 1/30/20
How to Request Official Transcripts:
To maintain accreditation, we require transcripts for all degrees obtained. Future teaching
assignments will be prohibited if we do not receive official transcripts.
What are official transcripts?
• Paper: Issued to MSU Denver, mailed directly to MSU Denver.
• Paper: Issued to student, delivered to MSU Denver in an unopened envelope.
• PDF transcripts: Issued to MSU Denver received by MSU Denver via another institution.
• Transcripts that are foreign must go through an evaluation completed by a professional
transcript evaluation service. In order to be official, the report must arrive at MSU in a sealed
envelope from the originating agency.
What are not official transcripts?
• PDF transcripts that have been forwarded from outside the institution (example: PDF transcripts
issued to student, student forwards to MSU Denver). Forwarding transcripts makes them
unofficial.
• Paper, issued to student or recipient other than MSU Denver presented to MSU Denver in an
opened envelope.
• Copies of transcripts: paper, or electronic.
When requesting paper transcripts please have them mailed to:
MSU Denver
Human Resources
Attn: Jordan Fernandes
P.O. Box 173362, Campus Box 47
Denver, CO 80217
If requesting electronic/pdf transcripts please have them sent to:
Jordan Fernandes: affiliates@msudenver.edu
If you are working for the College of Business, please send your transcripts to:
MSU Denver
College of Business
Attn: Nanette Wilmot
P.O. Box 173362, Campus Box 13
Denver, CO 80217
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Affiliate New Hire Packet and Checklist (Metropolitan State College of Denver)

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Completed 18 September 2020

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