Fillable B C EMPLOYEE ACTION REQUEST D A (California)

Fill Online, Printable, Fillable, Blank B C EMPLOYEE ACTION REQUEST D A (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

B C EMPLOYEE ACTION REQUEST D A (California)

On average this form takes 14 minutes to complete

The B C EMPLOYEE ACTION REQUEST D A (California) form is 2 pages long and contains:

  • 2 signatures
  • 14 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATE OF CALIFORNIA – STATE CONTROLLER’S OFFICE
EMPLOYEE ACTION REQUEST
STD. 686 (REV 12/2020)
***IMPORTANT*** Before completing Section E, you must read the instructions on Internal Revenue Service (IRS) Form W-4 and the applicable state tax form. (For California, use Form DE-4)
WITHHOLDING CHANGE OR NEW EMPLOYEE
NOTE: Social Security Number and Last Name, First Name, and Middle Initial must be entered exactly as shown on Social Security card.
I claim that the wages I will be receiving from the State are either a 1) MINISTER OF A CHURCH in the exercise
of his/her ministry, 2) NONRESIDENT ALIEN wages, or 3) DECEASED EMPLOYEE WAGES. Indicate reason
(See General Information on reverse)
III. ADDITIONAL DEDUCTIONS – Part I and Part II must be completed. Complete box(es) 11 and/or 12 if you wish
additional Federal and/or State tax withheld from your wages. IF BOXES ARE NOT COMPLETED, CURRENT DEDUCTIONS
(IF ANY) WILL BE CANCELLED. The first deduction will be made from your earnings for the pay period in which this form
is processed. Must be a dollar amount.
I hereby authorize the State Controller to deduct monthly from my wages the additional Federal and/or State tax amount
specified below.
NOTE: This exemption will automatically expire on February 15 of next
year unless you file a new certification by January 31 of next year.
Who is authorized to receive your pay warrant in case of death? Contact your
personnel office to update your designee's name or address (Form STD. 243).
PERSONNEL OFFICE USE
Withholding
Allowance Change
SECTIONS C, E, I
*Address Change
}
SECTIONS
C, F, I
Name Change
(Attach substantiation)
SECTIONS C, D, I
Birthdate Correction
SECTIONS C, H, I
A
NAME CHANGE
D
B
New Employee
SECTIONS C, E, F, G, H, I
E
I. FEDERAL WITHHOLDING – If no tax should be withheld, complete box 03, Part IV or V only.
06
ADDRESS CHANGE OR NEW EMPLOYEE
*See reverse.
C
F
04 EMPLOYMENT LIST
By writing/typing EXEMPT, I claim exemption from withholding because of no tax liability: Last year I did not owe
any income tax and had a right to a full refund of ALL income tax withheld, AND this year I do not expect to
owe any income tax and expect to have a right to a full refund of ALL income tax withheld.
<
CHECK ONE OR MORE BOX(ES) AND COMPLETE LISTED SECTIONS.
RETURN COMPLETED FORM TO YOUR PERSONNEL OFFICE. USE BALLPOINT PEN AND PRINT CLEARLY.
02 MARITAL STATUS FOR TAX PURPOSES ONLY
V. NONTAXABLE WAGES – Check box 14 if wages you will receive are not subject to income tax withholding.
(See reverse, employee copy)
NONRESIDENT ALIEN
(FRONT)
01 03 04 05 07
01 AGENCY
02 UNIT 03 KEYED BY 04 DATE KEYED
01 SOCIAL SECURITY NUMBER 02 EMPLOYEE LAST NAME 03 FIRST NAME AND MIDDLE INITIAL
FORMER NAME (Last, First, and Middle)
01
SINGLE
MARRIED
11
FEDERAL
ADDITIONAL DEDUCTION
12
STATE
ADDITIONAL DEDUCTION
IV. EXEMPTION FROM WITHHOLDING
– Write/type EXEMPT in box 13 if you are eligible to claim exemption from
withholding. No Federal or State income tax will be withheld from your wages. DO NOT COMPLETE PARTS I, II, OR III.
(See General Information on reverse.)
II. STATE ALLOWANCES - If no tax should be withheld, complete Part IV or V only.
08 MARITAL STATUS FOR TAX PURPOSES ONLY (Check one)
MARRIED
(ONE INCOME)
SINGLE OR MARRIED
(WITH TWO OR MORE INCOMES)
HEAD OF
HOUSEHOLD
REGULAR ALLOWANCE(S)
Total you are claiming
ADDITIONAL ALLOWANCE(S)
Total you are claiming
14
01 EMPLOYEE ADDRESS (Street, Rural Route, or P.O. Box)
02 CITY
09
10
STATE
03 ZIP CODE
WORK PHONE HOME PHONE
G
01 LAST EMPLOYED BY CALIFORNIA STATE AGENCY
OR CAMPUS OF:
02 LAST NAME (if different)
MO
YR
03 SEPARATED
04 LAST EMPLOYED BY CALIFORNIA PUBLIC AGENCY OF:
(City, County, Public School, Utility, etc.)
05 LAST NAME (if different)
MO
06 SEPARATED
YR
NEW EMPLOYEE - THIS INFORMATION MAY BE USED TO LOCATE PRIOR PUBLIC EMPLOYMENT SERVICE FOR STATE SERVICE CREDITS AND/OR RETIREMENT SYSTEM BENEFITS
NEW EMPLOYEE OR
BIRTHDATE CORRECTION
EMPLOYEE SIGNATURE
PERSONNEL OFFICE USE
MO DAY
BIRTHDATE
YR
H
REVIEWER'S SIGNATURE
DATE PHONE NUMBER
I certify that the above information is true and correct and that I have read the IRS Form W-4 and the applicable State form. Under the
penalties of perjury, I certify that the number of withholding exemptions and allowances claimed on this certificate does not exceed the
number to which I am entitled. If claiming exemption from withholding, I certify that I incurred no tax liability for last year and that I
anticipate that I will incur no liability this year. I authorize my employer via the State Controller's Office to refund any overcollection
of current/prior year Social Security and Medicare taxes; I certify that I shall not claim a tax refund or credit for these overcollections.
EMPLOYEE'S SIGNATURE DATE
J
I
@
@
Check this box and enter your phone number(s) if your address is changing and your
name appears on any departmental employment list. (See reverse.)
04
HIGHER WITHHOLDING
(Must be Y or N. See reverse)
05
07
HEAD OF
HOUSEHOLD
13
03
EXEMPT FROM FEDERAL WITHHOLDING -
Write/type EXEMPT in box 03 if you are eligible to claim
exemption from Federal withholding.
03
(See reverse)
CLAIM DEPENDENTS
AMOUNT MUST BE A WHOLE NUMBER
OTHER INCOME
NOT FROM JOBS
DEDUCTIONS
Reset Form
Print Form
click to sign
signature
click to edit
click to sign
signature
click to edit
STATE OF CALIFORNIA – STATE CONTROLLER’S OFFICE
EMPLOYEE ACTION REQUEST
STD. 686 (REV 12/2020)
(REVERSE)
BENEFICIARIES FOR PRE-RETIREMENT SURVIVOR BENEFITS
For information regarding CalPERS beneficiaries for Survivor Benefits, please go to www.calpers.ca.gov, and use the search engine to locate information on Beneficiary Designations.
RESTORATION OR PURCHASE OF RETIREMENT SERVICE CREDIT
You may be eligible to increase your CalPERS service credit through a service credit purchase and the more service credit you have at retirement, the higher your monthly benefit may be. Information on the purchase or redeposit
of retirement service credit may be obtained by visiting the CalPERS website at www.calpers.ca.gov.
PRIVACY NOTIFICATION
The Information Practices Act of 1977 (California Civil Code Section 1798.17) and the Federal Privacy Act (5 USC 552a, subd. (e)(3)) require this notice to
be provided when collecting personal information from individuals.
The information you are asked to provide on this form is requested by the Office of the State Controller, Personnel/Payroll Services Division. The
information will be used by the State Controller’s Office for personnel, payroll, retirement, and health benefits processing.
Furnishing the information requested on this form is mandatory except for Prior Public Employment (Section G). Furnishing prior public employment
information is voluntary. Noncompliance in providing your social security number and name will result in refusal of employment. Failure to furnish
other requested information may result in inaccurate determination of credit for State service, payroll calculations, retirement, and/or health benefits.
Legal references authorizing the maintenance of this information by the State Controller’s Office include: Federal Internal Revenue Code (26 USC
Sections 3402(a), 6011, 6051, and 6109) and the regulations thereto; Federal Public Health and Welfare Code (42 USC Section 403); and California
GENERAL TAX INFORMATION
IF YOU ARE A NONRESIDENT ALIEN PER INTERNAL REVENUE SERVICE (IRS) NOTICE 2005-76, check the Nonresident Alien box. If you have questions as to whether you should mark this box, you should contact your human
resources office.
IF YOU ARE EXEMPT FROM STATE WITHHOLDING ONLY, but not exempt from federal and state, contact your personnel office for special instructions.
IF YOU ARE EXEMPT FROM FEDERAL WITHHOLDING ONLY, Write/type EXEMPT in box 03 if you are eligible to claim exemption from federal withholding. No Federal income tax will be withheld from your wages.
IF YOU WILL RECEIVE NONTAXABLE WAGES, please indicate the reason on your withholding claim in the space provided. The reason must be one of the following:
a. “Minister of the church in the exercise of his / her ministry” – employed by the State of California as a Chaplain.
b. “Nonresident Alien per Tax Treaty” (indicate on claim: “Exempt per Article ________ of treaty between United States and (Country).”) Tax Treaty must cite exemption from both Federal and State personal income tax to qualify for
this exemption.
c. “Deceased Employee Wages” – agency administrative action.
IF YOU HAVE ANY QUESTIONS REGARDING YOUR ELIGIBILITY UNDER ANY OF THE ABOVE REASONS, you should contact your local Internal Revenue Service office or the Employment Tax District Office of the Employment
Development Department.
EMPLOYEES WITH TWO OR MORE CONCURRENT JOBS WITH THE STATE OF CALIFORNIA. The allowances you claim on this form will be used for tax withholding purposes for all wages paid under the Uniform State Payroll
System. The Uniform State Payroll System includes all California State Agencies (except as noted below) and the California State Universities. It does not include the California Agricultural Associations, the University of California,
or Legislative employees.
IF YOUR NORMAL LOCATION OF EMPLOYMENT IS NOT IN CALIFORNIA and you are a California State employee, you may be eligible to have income tax for another state withheld from your wages under the reciprocity
provisions required by G.C. 1170.5. Contact your personnel office for additional information.
ADDRESS CHANGE
IF YOU HAVE DEDUCTIONS, you must change your address with the deduction company. This form does not affect an address change with deduction companies.
IF YOUR NAME APPEARS ON ANY DEPARTMENTAL EMPLOYMENT LIST (Open, Promotional, Reemployment, etc.), and your address is changing, check Box 04 and enter your phone number(s) in Section F. Your department
will update the appropriate list(s) with this information.
INFORMATION FOR EMPLOYEES COVERED BY THE CALIFORNIA PUBLIC EMPLOYEES’ RETIREMENT SYSTEM (CalPERS)
You are entering into membership in the California Public Employees’ Retirement System (CalPERS) which provides you and your fellow State employees with retirement and other benefits. Member contributions, those
contributions made by the State of California, and the interest earned on investments provide for service retirement, disability retirement, and death benefits. An information booklet is available from your personnel office. The
booklet describes your particular benefit coverage in detail.
Government Code Sections 12470 through 12479 and 16391 through 16395; California Unemployment Insurance Code Section 13020; delegated
authority from the State Personnel Board; and delegated authority from the Trustees of the California State University.
Certain items of information furnished on this form may be transferred to the following governmental or private agencies where authorized by
law; State Personnel Board, Department of Human Resources, Trustees of the California State University, Employment Development Department,
Department of Social Services, Department of Finance, Public Employees’ Retirement System, employing State agencies and campuses, Social
Security Administration, Federal Internal Revenue Service, California State Franchise Tax Board, other State income tax bureaus and other
governmental entities when required by State or Federal law, organizations for which deductions are authorized by law, and collective
bargaining organizations.
Employees have the right to review their own personal information maintained by the State Controller’s Office unless access is exempted by law.
Contact: Personnel/Payroll Services Division, State Controller’s Office, P.O. Box 942850, Sacramento, CA 94250-5878.
FEDERAL
NEW ITEMS, EFFECTIVE 2020
For important information regarding these items , you must read the Internal Revenue Service (IRS) Form W-4.
04. HIGHER WITHHOLDING (TWO JOB INDICATOR - STEP 2(C) ON THE IRS 2020 FORM W-4):
Y- YES TO HIGHER WITHOLDING
N - NO TO HIGHER WITHOLDING
05. CLAIM DEPENDENTS: Enter the annual amount to be claimed. This is the amount for the child tax credit
and the credits for other dependents that may be claimed on your tax return.
06. OTHER INCOME (NOT FROM JOBS): Enter the total dollar amount of other estimated income for the year,
if any. This does not include income from other jobs. This may include, interest dividends and retirement
income.
07. DEDUCTIONS: Enter the resulting amount from the Deductions Worksheet on the IRS Form W-4, if you
expect to claim deductions other than the basic standard deductions on the current year's tax return.
STATE
MUST BE COMPLETED, EFFECTIVE 2020
For important information regarding these items , you must read Employment Development Department (EDD)
Form DE-4.
09. REGULAR ALLOWANCES: Total Number of Allowances you are claiming.
10. ADDITIONAL ALLOWANCES: If you expect to itemize deductions on your California income tax return, you
can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated
deductions may entitle you to claim one or more additional withholding allowances.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

B C EMPLOYEE ACTION REQUEST D A (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document