FICA (SOCIAL SECURITY & MEDICARE) EXEMPTION FORM
Q
UAL
L
I
I
F
F
I
I
E
E
D
S
S
TUDE
E
NTS
S
WORKI
I
NG
F
F
OR
L
L
I
I
B
B
E
E
RTY
U
NI
I
VE
E
RS
S
I
I
TY
Q
UA D TUD NT WORK NG OR RTY
U
N V R TY
DO
NOT
HAVE
E
TO
P
P
AY
F
F
I
I
CA
TAXE
E
S
S
DO NOT HAV TO AY
CA
TAX
Check the box that applies:
EXEMPT from FICA taxes (Do not withhold from paycheck)
Students enrolled and regularly attending classes qualify for exemption from FICA taxes.
During summer break you will be subject to the FICA tax and will be automatically changed
to Non-Exempt unless you notify Human Resources that you are enrolled in summer classes.
If you are a nonresident alien international student you can be exempt from FICA taxes all
year.
NON-EXEMPT from FICA taxes (Withhold from paycheck)
You do not qualify to claim exempt or want FICA taxes to be withheld.
I have indicated my FICA tax status above. I understand that if at any point during the fall or
spring semesters my student status changes from that of a regularly attending student, my
FICA exemption must be changed. I understand that it is my responsibility to notify Student
Employment in the Human Resources Office of this change.
Name (Print)
Signature
Date
