Leeward Community College
Student Employee Summer FICA Exemption Questionnaire
Name _____________________________________ Department ________________________
Please answer the following questions until instructed to stop. Turn in this form to your supervisor.
1. Are you graduating in Spring? Yes _____ No _____
If yes, from which campus ______________________________________________
2. Will you be working during the Summer? Yes _____ [Continue] No _____ [Stop]
3. Will you be a non-resident alien attending the University of Hawaii on an F-1, J-1, M-1, Q-1
visa performing services in accordance with the primary purpose of the visa’s issuance?
Yes _____ [Stop] (“N”) No _____ [Continue]
4. Will you be attending Summer School? Yes _____ [Continue] (“N”) No _____ [Stop] (“K”)
Which campus will you be attending? _____________________________________
Please indicate which session(s) you will be attending (check all that apply).
Summer I _______ Summer II _______
Cross term _______ indicate dates _____/_____/_____ to _____/_____/_____
I certify the above answers are correct and that I will notify my supervisor immediately if my status
should change in anyway.
_______________________________________________ ______________________
Student’s Signature Date
_______________________________________________ ______________________
Supervisor’s Signature Date
Please return completed form to the Human Resources Office.