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U.S.A. forms for California State University Channel Islands

BROWSE CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS FORMS

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Who is authorized to receive your pay warrant in case of death? Contact
STATE OF CALIFORNIA — STATE CONTROLLER'S OFFICE
PERSONNEL OFFICE USE
your personnel office to update your designee’s name or address (Form
STD. 243). See also retirement beneficiary information on reverse side of
EMPLOYEE ACTION REQUEST
A
01 AGENCY 02 UNIT 03 KEYED BY 04 DATE KEYED
employee copy.
STD. 686 (REV. 12/2004)
CHECK ONE OR MORE BOX(ES) AND COMPLETE LISTED SECTIONS. RETURN COMPLETED FORM TO YOUR PERSONNEL OFFICE. USE BALL POINT PEN AND PRINT CLEARLY. NO CARBON REQUIRED.
Withholding
Allowance Change
SECTIONS C, E, I
03
*Address Change
04
}
SECTIONS
C, F, I
Name Change
(Attach Substantiation)
SECTIONS C, D, I
Birthdate Correction
SECTIONS C, H, I
07
B
New Employee
SECTIONS C, E, F, G, H, I
01
05
NOTE: Social Security Number and Last Name, First Name, and Middle Initial must be entered exactly as shown on Social Security card.
NAME CHANGE
01 SOCIAL SECURITY NUMBER
02 EMPLOYEE LAST NAME 03 FIRST NAME AND MIDDLE INITIAL
C
FORMER NAME (Last, First and Middle)
D
WITHHOLDING ALLOWANCE CHANGE OR NEW EMPLOYEE
***IMPORTANT*** Before completing Section E, you must read IRS Form W-4 and the applicable state tax form. (For California use Form DE-4.)
V. NONTAXABLE WAGES – Check box 09 if wages you will receive are not subject to income tax withholding.
II.SPECIAL TREATMENT OF STATE ALLOWANCES – Complete boxes 03 thru 05 if you wish your State withholding to be
different than what you claim for Federal withholding
. IF BOXES ARE NOT COMPLETED, CURRENT SPECIAL TREATMENT (IF
ANY) WILL BE CANCELLED.
03 MARITAL STATUS FOR TAX PURPOSES ONLY
(Check One)
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) NONIMMIGRANT ALIEN wages, or 3) DECEASED EMPLOYEE WAGES. Indicate reason (See General
Information on back of third page.):
III.
I hereby authorize the State Controller to deduct monthly from my wages the additional Federal and/or State tax
amount specified below. I understand that if boxes are not completed, current deductions, if any, will be cancelled.
IV.
NOTE:
E
I. FEDERAL AND STATE ALLOWANCE – For Tax Purposes Only. If no tax should be withheld, complete Part IV or V only.
01 MARITAL STATUS FOR TAX PURPOSES ONLY
(Check One)
06
FEDERAL ADDITIONAL
DEDUCTION
04
REGULAR ALLOWANCE(S)
Total you are claiming
02
TOTAL - Number of allowances
you are claiming
07
STATE ADDITIONAL
DEDUCTION
$ $
MARRIED
SINGLE
SINGLE
HEAD OF
HOUSEHOLD
05
ADDITIONAL ALLOWANCE(S)
Total you are claiming
MARRIED
08
09
ADDITIONAL DEDUCTIONS – Complete box 06 and/or 07 if you wish additional Federal and/or State tax
withheld from your wages. Part I (and Part II, if your State allowance claim differs from your Federal) must be
completed. The first deduction will be made from your earnings for the pay period in which this form is processed.
IF BOXES ARE NOT COMPLETED, CURRENT DEDUCTIONS (IF ANY) WILL BE CANCELLED.
EXEMPTION FROM WITHHOLDING – Check box 08 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 back of third page.)
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.
This exemption will automatically expire on February 15 of next year unless you file a new certification by January
31 of next year. Employers are required to notify IRS if you earn more than $200 per week.
NOTE: Employers must notify IRS if more than 10
allowances are claimed.
NOTE: Employers may be required to notify EDD if more
than 10 allowances are claimed.
ADDRESS CHANGE OR NEW EMPLOYEE *See Back of Third Page
WORK PHONE HOME PHONE
01 EMPLOYEE ADDRESS (Street, Rural Route or P.O. Box)
F
04 EMPLOYMENT LIST
02 CITY STATE 03 ZIP CODE
Check this box and enter your phone number(s) if your address is changing and your name appears on any
departmental employment list. (See back of third page.)
NEW EMPLOYEE THIS INFORMATION MAY BE USED TO LOCATE PRIOR PUBLIC EMPLOYMENT SERVICE FOR STATE SERVICE CREDITS AND/OR RETIREMENT SYSTEM BENEFITS.
G
01 LAST EMPLOYED BY CALIFORNIA STATE AGENCY
OR CAMPUS OF:
01 LAST NAME (if different)
MO YR
03 SEPARATED 04 LAST EMPLOYED BY CALIFORNIA PUBLIC AGENCY OF:
(City, County, Public School or Utility, etc.)
05 LAST NAME (if different)
MO YR
06 SEPARATED
NEW EMPLOYEE OR BIRTHDATE CORRECTION
EMPLOYEE SIGNATURE PERSONNEL OFFICE USE
MO
DAY YR
H
BIRTHDATE
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 SIGNATURE DATE
I
REVIEWER’S SIGNATURE
#
J
DATE PHONE NO.
White — Personnel/Payroll Services Div. Yellow — Personnel Pink — Employee
Clear
Print
STATE OF CALIFORNIA — STATE CONTROLLER'S OFFICE
EMPLOYEE ACTION REQUEST
STD. 686 (REV. 12/2004) (REVERSE, EMPLOYEE COPY)
INFORMATION FOR EMPLOYEES COVERED BY THE PUBLIC EMPLOYEES’ RETIREMENT SYSTEM (PERS)
You are entering into membership in the Public Employees’ Retirement System (PERS) 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.
BENEFICIARIES FOR DEATH BENEFITS
1. STATUTORY BENEFICIARIES – If you should die while in employment covered by PERS and you do not name other beneficiaries, death benefits will be paid to your survivors in the following order:
a. Your spouse (husband or wife) or domestic partner.
b. If you have no spouse or domestic partner, your children (share and share alike).
c. If you have no spouse, domestic partner, or children, your parents (share and share alike).
d. If you have none of the above, the benefits will be paid to your estate. If your estate will not be probated, payment will be made to next of kin as provided by law.
2. NAMING DIFFERENT BENEFICIARIES – If you wish, you may at any time name different beneficiaries or change the order of those listed as statutory. To do so, you must file with PERS, a Beneficiary Designation (State
Form STD. 241), obtainable from your personnel office. DO NOT FILE FORM STD. 241 IF THE STATUTORY BENEFICIARIES LISTED IN ITEM NO. 1 ARE SATISFACTORY.
Each time you have a change in marital or domestic partnership status, or you acquire a child by birth or adoption, the Public Employees’ Retirement Law will automatically revoke any previously named beneficiaries and establish
statutory beneficiaries as listed in Item No. 1. If the statutory beneficiaries are not satisfactory, you must file a form STD. 241 to reflect your desired change.
RESTORATION OR PURCHASE OF RETIREMENT SERVICE CREDIT
If you were a former member of the Public Employees’ Retirement System (PERS) and withdrew your contributions, you have the right to redeposit those funds as a member of the first-tier retirement plan and restore your previous
service; or your previous state service can be restored at no cost if you are a member of the second-tier plan and you have elected to have all past service credited to your account. You may also have the right to receive retirement
service credit for state employment in which you were not a PERS member. Additional retirement service credit will in most cases increase your potential retirement benefits. Information on restoration or purchase of retirement
service credit may be obtained by writing to the Public Employees’ Retirement System, Member Services Division -- 832, P.O. Box 942704, Sacramento, CA 94229-2704.
GENERAL INFORMATION
TAXES
EARNED INCOME CREDIT (EIC)
IF YOU ARE EXEMPT FROM EITHER FEDERAL OR STATE WITHHOLDING, but not exempt from both, contact your
personnel office for special instructions.
You may be entitled to an income tax refund or credit from the Internal Revenue Service (IRS) if you meet
certain eligibility requirements relating to your annual income and family size. You have the option of receiving
IF YOU WILL RECEIVE NONTAXABLE WAGES, please indicate the reason on your withholding claim in the space
advance payments of the earned income credit each month or claiming the credit on Form 1040 or 1040A, your
provided. The reason must be one of the following:
annual tax return, and receiving the credit when you file. To find out more information about the credit, contact
a. “Minister of the church in the exercise of his ministry” -- employed by the State of California as a Chaplain.
your personnel/payroll office or IRS at 1-800-829-1040. To request advance EIC payments, you must complete a
b. “Nonimmigrant Alien per Tax Treaty” (indicate on claim: “Exempt per Article ________ of treaty between United States and
Form W-5, Earned Income Advance Payment Certificate. The W-5 is available at your local IRS office or can be
(Country) .”) Tax Treaty must cite exemption from both Federal and State personal income tax to qualify for this exemption.
ordered by calling 1-800-829-3676.
c. "Deceased Employee Wages"--agency administrative action.
ADDRESS CHANGE
If you have any questions regarding your eligibility under any of the above reasons, you should contact your local Internal Revenue
IF YOU HAVE A U.S. SAVINGS BOND DEDUCTION and the address of the registered owner is changing,
Service Office or the Employment Tax District Office of the Employment Development Department.
you must complete a new United States Savings Bonds Purchase/Payroll Deduction Authorization, STD. 242.
EMPLOYEES WITH TWO OR MORE CONCURRENT JOBS WITH THE STATE OF CALIFORNIA. The allowances
IF YOU HAVE OTHER DEDUCTIONS, you must change your address with the deduction company. This
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
form does not affect an address change with deduction companies.
does not include the California Agricultural Associations, the University of California or Legislative employees.
IF YOUR NAME APPEARS ON ANY DEPARTMENTAL EMPLOYMENT LIST (Open, Promotional,
IF YOUR NORMAL LOCATION OF EMPLOYMENT IS NOT IN CALIFORNIA and you are a California State employee,
Reemployment, etc.), and your address is changing, check Box 04 and enter your phone number(s) in Section F.
you may be eligible to have income tax for another state withheld from your wages under the reciprocity provisions required by G.C.
Your department will update the appropriate list(s) with this information.
1170.5. Contact your personnel office for additional information.
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 your 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
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 Personnel Administration, 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.
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