Fillable NewRehire Stud Paperwork2019 fw4 2015.pdf

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1 of 2
This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq.
February 5, 2015
Pennsylvania’s State System of Higher Education
Background Clearance Certification
for Provisional Employment or Volunteering
(Under the Child Protective Services Law)
Please read this entire form carefully before completing it. This form is to be used by prospective volunteers who
reside in another state or country and employees to meet the written certification requirement to be considered as a
provisional hire or volunteer assignment. This form does not apply to volunteers who reside in Pennsylvania. In certain
limited circumstances, current employees/volunteers may need to complete this form.
Section 1. Personal Information
Full Legal Name: __________________________________________________
Date of Birth: _______________
Any former names or aliases by which you have been identified: _____________________________________________
Section 2. Instructions
If you have any question about whether to report an offense, you should report it. Failure to report may result in
disqualification for employment.
List of Reportable Offenses
A Reportable Offense enumerated under Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6344(c), consists
of one or more of the following:
1. Provisions of Title 18 of the Pennsylvania Consolidated Statutes (relating to crimes and offenses) or an equivalent
crime under the laws or former laws of the United States or one of its territories or possessions, another state, the
District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of the
Commonwealth of Pennsylvania:
Chapter 25 relating to criminal homicide
Section 2702 relating to aggravated assault
Section 2709.1 relating to stalking
Section 2901 relating to kidnapping
Section 2902 relating to unlawful restraint
Section 3121 relating to rape
Section 3122.1 relating to statutory sexual assault
Section 3123 relating to involuntary deviate sexual
intercourse
Section 3124.1 relating to sexual assault
Section 3125 relating to aggravated indecent assault
Section 3126 relating to indecent assault
Section 3127 relating to indecent exposure
Section 4302 relating to incest
Section 4303 relating to concealing death of a child
Section 4304 relating to endangering welfare of
children
Section 4305 relating to dealing in infant children
A felony offense under Section 5902(b) relating to
prostitution and related offenses
Section 5903(c) or (d) relating to obscene and other
sexual materials and performances
Section 6301 relating to corruption of minors
Section 6312 relating to sexual abuse of children
2. An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The Controlled
Substance, Drug, Device and Cosmetic Act,” committed within the preceding five-year period.
3. A founded report of child abuse within the preceding five-year period in the statewide database maintained by the
Department of Human Services.
mm/dd/yyyy
2 of 2
This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et
seq.
February 5, 2015
Section 3. No Conviction
By checking this box, I certify that I have not been convicted of any Reportable Offense or an offense similar in
nature to a Reportable Offense under the laws or former laws of the United States or one of its territories or
possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under
a former law of the Commonwealth of Pennsylvania. (See Section 2 for a list of Reportable Offenses.)
Section 4. Application for Background Checks
I certify that I have applied for the following required background clearance checks:
A rep
ort of criminal history record from the Pennsylvania State Police (PSP) or statement from the PSP that no
criminal record exists.
Cert
ification from the Pennsylvania Department of Human Services as to whether I am named in the statewide
database as a perpetrator in a pending child abuse investigation or in a founded report or indicated report of
child abuse.
A rep
ort of federal criminal history record information. I understand that I must submit a full set of fingerprints to
the PSP to obtain this report.
I fur
ther certify that I have provided copies of the completed request forms for these background clearance checks to
Pennsylvania’s State System of Higher Education. (Appropriate forms may be attached to this Certification Form.)
Section 5. Certification
By signing this form, I swear and affirm under penalty of law that the statements made in this form are true, accurate,
correct, and complete. I understand that false statements herein, including, without limitation, any failure to accurately
report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S.
§ 4904, relating to unsworn falsification to authorities.
I understand that after successful completion of the criminal background clearance process, I have a continuing
obligation to notify the Human Resources Department within seventy-two (72) hours after an arrest or conviction for an
offense defined in the “Reportable Offense” list. If I am unsure about the applicability of my arrest or conviction as a
Reportable Offense, it is my responsibility to notify the Human Resources Department for further review. I understand
that failure to disclose any arrest or conviction of a “Reportable Offense” shall be considered as non-compliance, subject
to disciplinary action, up to and including termination, and/or criminal prosecution, as applicable.
__________
___________________________________________ _____________________________________
Signature Date
mm/dd/yyyy
LOCK HAVEN UNIVERSITY OF PA
Student Application for New Employment or Fund Center Change
*Student may not begin work until employment paperwork is complete
It is the policy of the PASSHE that you cannot work until you have a social security number
If your address changes at any time, please notify Student Payroll
Name
PERNR# - Completed by Payroll
Social
Security
Number
Local or
Cell
Telephone Number
Date
of
Birth
P
U.S.
Citizen
lease mark
t
h
e
appropriat
e
box.
Resident
or
Nonresident
Alien
(Every calendar year you must complete Statement of Citizenship in the International
Office. You will not be put on the payroll until all paperwork is completed.)
Gender:
Male
Female
Check
here
if
you
are
a
veteran
Currently enrolled in classes at Lock Haven University
I
declare
that
this
statement,
to
the
best
of
my
knowledge,
is
true
and
correct.
Falsifying hours
worked will result in IMMEDIATE TERMINATION of Student Employment
Student
Sign
a
ture
Date
LHUP E-
mail
address
NOTE TO SUPERVISORS: Students may work no more than 20
hours per week during the semesters. Prior
approval must be obtained, in writing, from Department of Student Affairs to work more than 20 hours.
Students may work 37.5 hours per week, a maximum of 7.5 in a day, during summer and scheduled breaks provided
there are sufficient monies in your department fund center.
Completed paperwork is to be forwarded to Student Payroll Office, EC J207. Students may not begin
working until the student and supervisor receive an email from payroll saying they are cleared to work.
1. ______________________________ _______________
Department Date
__ __ __ __ __ __ __ __ __ __.__ __ __ __ __
10 digit Fund Center
(Grant WBS)
2.
_____________________________
Supervisor - Printed Name
Supervisor - Signature
________________________________
Hi
re Date
mm/dd/yyyy
mm/dd/yyyy
LOCAL EARNED INCOME TAX
RESIDENCY CERTIFICATION FORM
DCED-CLGS-06 (1-11)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT
GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES
EMPLOYEE INFORMATION - PERMANENT RESIDENCE LOCATION
TO EMPLOYERS/TAXPAYERS:
This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.
This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.
NAME (Last, FIrst, Middle Initial)
FIRST LINE OF ADDRESS (If PO Box, please include actual street address)
SECOND LINE OF ADDRESS
CITY STATE ZIP CODE DAYTIME PHONE NUMBER
CERTIFICATION
SIGNATURE OF EMPLOYEE DATE
PHONE NUMBER EMAIL ADDRESS
MUNICIPALITY (City, Borough, Township)Write Municipality name and &LUFOH Municipality type
COUNTY PSD CODE3D\UROO8VH2QO\ TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION - EMPLOYMENT LOCATION
EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN
FIRST LINE OF ADDRESS (
I
If PO Box, please include actual street address)
SECOND LINE OF ADDRESS
CITY STATE ZIP CODE PHONE NUMBER
MUNICIPALITY (City, Borough, Township)
COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE
For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,
please refer to the Pennsylvania Department of Community & Economic Development website:
www.newPA.com
Select Get Local Gov Support, >Municipal Statistics
Personnel # or last 4 digits of SS#Personnel # or last 4 digits of SS#
Lock Haven University of Pennsylvania - Main Campus
401 N. Fairview St.
Lock Haven
PA
17745
570-484-2032
Lock Haven City
Clinton
1
8
0
1
1
8
1.0%
Form W-4 (2019)
Future developments. For the latest
information about any future developments
related to Form W-4, such as legislation
enacted after it was published, go to
www.irs.gov/FormW4.
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider
completing a new Form W-4 each year and
when your personal or financial situation
changes.
Exemption from withholding. You may
claim exemption from withholding for 2019
if both of the following apply.
• For 2018 you had a right to a refund of all
federal income tax withheld because you
had no tax liability, and
• For 2019 you expect a refund of all
federal income tax withheld because you
expect to have no tax liability.
If you’re exempt, complete only lines 1, 2,
3, 4, and 7 and sign the form to validate it.
Your exemption for 2019 expires February
17, 2020. See Pub. 505, Tax Withholding
and Estimated Tax, to learn more about
whether you qualify for exemption from
withholding.
General Instructions
If you aren’t exempt, follow the rest of
these instructions to determine the number
of withholding allowances you should claim
for withholding for 2019 and any additional
amount of tax to have withheld. For regular
wages, withholding must be based on
allowances you claimed and may not be a
flat amount or percentage of wages.
You can also use the calculator at
www.irs.gov/W4App to determine your
tax withholding more accurately. Consider
using this calculator if you have a more
complicated tax situation, such as if you
have a working spouse, more than one job,
or a large amount of nonwage income not
subject to withholding outside of your job.
After your Form W-4 takes effect, you can
also use this calculator to see how the
amount of tax you’re having withheld
compares to your projected total tax for
2019. If you use the calculator, you don’t
need to complete any of the worksheets for
Form W-4.
Note that if you have too much tax
withheld, you will receive a refund when you
file your tax return. If you have too little tax
withheld, you will owe tax when you file your
tax return, and you might owe a penalty.
Filers with multiple jobs or working
spouses. If you have more than one job at
a time, or if you’re married filing jointly and
your spouse is also working, read all of the
instructions including the instructions for
the Two-Earners/Multiple Jobs Worksheet
before beginning.
Nonwage income. If you have a large
amount of nonwage income not subject to
withholding, such as interest or dividends,
consider making estimated tax payments
using Form 1040-ES, Estimated Tax for
Individuals. Otherwise, you might owe
additional tax. Or, you can use the
Deductions, Adjustments, and Additional
Income Worksheet on page 3 or the
calculator at www.irs.gov/W4App to make
sure you have enough tax withheld from
your paycheck. If you have pension or
annuity income, see Pub. 505 or use the
calculator at www.irs.gov/W4App to find
out if you should adjust your withholding
on Form W-4 or W-4P.
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
Personal Allowances Worksheet
Complete this worksheet on page 3 first to
determine the number of withholding
allowances to claim.
Line C. Head of household please note:
Generally, you may claim head of household
filing status on your tax return only if you’re
unmarried and pay more than 50% of the
costs of keeping up a home for yourself and
a qualifying individual. See Pub. 501 for
more information about filing status.
Line E. Child tax credit. When you file your
tax return, you may be eligible to claim a
child tax credit for each of your eligible
children. To qualify, the child must be under
age 17 as of December 31, must be your
dependent who lives with you for more than
half the year, and must have a valid social
security number. To learn more about this
credit, see Pub. 972, Child Tax Credit. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line E of the worksheet. On
the worksheet you will be asked about your
total income. For this purpose, total income
includes all of your wages and other
income, including income earned by a
spouse if you are filing a joint return.
Line F. Credit for other dependents.
When you file your tax return, you may be
eligible to claim a credit for other
dependents for whom a child tax credit
can’t be claimed, such as a qualifying child
who doesn’t meet the age or social
security number requirement for the child
tax credit, or a qualifying relative. To learn
more about this credit, see Pub. 972. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line F of the worksheet. On
the worksheet, you will be asked about
your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Allowance Certificate
▶
Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
2019
1 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3
Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
4
If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.
▶
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 5
6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6
$
7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . .
▶
7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
▶
Date
▶
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete
boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of
employment
10 Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 10220Q
Form W-4 (2019)
LOCKHAVENUNIVERSITYOFPENNSYLVANIA
ETHNICITY/RACEINFORMATION
Aracialidentificationcodeisanintegralpartofthepersonnelrecordsofeveryemployeeat
LockHavenUniversity.Allinformationisconfidential.
Pleaseprovideaccurateinformation.
1. WHATISYOURETHNICITY?(SelectOneOption)
HispanicorLatino
PersonsofCuban,Mexican,PuertoRican,SouthorCentralAmericanorotherSpanish
cultureororigin,regardlessofrace.
NotHispanicorLatino
2. WHATISYOURRACE?(Selectoneormore)
AmericanIndianorAlaskaNative
PersonshavingoriginsinanyoftheoriginalpeoplesofNorthandSouthAmerica
(includingCentralAmerica).
Asian
PersonshavingoriginsinanyoftheoriginalpeoplesoftheFarEast,SoutheastAsia,or
theIndiansubcontinen t,including,forexample,Cambodia,China,India,Japan,Korea,
Malaysia,Pakistan,thePhilippineIslands,Thailand,andVietnam.
BlackorAfricanAmerican
PersonshavingoriginsinanyoftheblackracialgroupsofAfrica.
NativeHawaiianorPacificIslander
PersonshavingoriginsinanyoftheoriginalpeoplesofHawaii,Guam,Samoa,orother
Pacificislands.
White/Caucasian
PersonshavingoriginsinanyoftheoriginalpeoplesofEurope,theMiddleEast,or
NorthAfrica.
Signature______________________________________Date_______________
mm/dd/yyyy
Undergraduate Student Employment Practices
Lock Haven University of PA
In accordance with the Board of Governors Policy, 1983-10, Lock Haven University of PA [hereafter the
University or LHUP] has established undergraduate student employment practices for Campus
Employment and Federal Work Study [FWS] employment. Students receiving financial aid who are
interested in Federal Work Study may be granted those funds through the Student Financial Services [SFS]
Office located in Ulmer Hall. Students may identify both Campus Employment and FWS employment
opportunities through LHUP website.
General Guidelines
Students earn minimum wage and are permitted to work up to 20 hours per week during the
academic year.
Students may work up to 20 hours during the academic year and 37.5 hours per week during the
summer and scheduled breaks.
It is recommended that first year students be limited to no more than 15 hours per week during the
academic year.
Students cannot be assigned to work directly for any family members.
Students may not work for more than two fund centers, and the total combined hours worked
cannot exceed 20 hours during the academic year and 37.5 hours during the summer.
Special permission to work more than 20 hours per week may be requested through the Vice
President of Student Affairs, Ulmer Hall.
No student may work more than 7.5 hours in a single day.
Students must be enrolled for at least six credits each semester as a regular LHU student.
Students seeking employment for the summer must be enrolled either for a summer session or for
the next fall session.
Students returning to work in the same office need not complete the employment application
process again unless there is a change in fund center.
Students may identify employment opportunities through the following website:
http://www.lockhaven.edu/career/
Any student enrolled at the University may be employed through Campus Employment.
Campus Employment is funded through established fund centers and is subject to budget
restrictions. A fund center is assigned a specific amount of student employment funding at the
beginning of the fall semester which can be used to fund as many students as funding permits.
The fund center supervisor is responsible for monitoring the number of hours students are
assigned. Exceptions may be granted by the Vice President of Student Affairs for students who
wish to exceed the maximum number of hours per week.
Student employment forms for LHUP students are available on the LHUP web site.
Students must complete the required employment forms, which should then be given to their
department supervisor/timekeeper for review and signature. Supervisors/timekeepers must review
all forms for completeness. Supervisors/timekeepers shall forward all completed forms to the
Human Resources Office.
No student may begin working until they receive an email from Human Resources indicating they
are cleared to work, the supervisor will be copied. The cleared to work email will be sent after all
forms are completed, signed, reviewed and all registrations for clearances have been provided.
I, ________________________________________ (print name), affirm that I have read and
understand the above guidelines and agree to abide by them.
__________________________________________ __________________
Signature of LHUP Student Employee Date
mm/dd/yyyy
State System of Higher Education
The System Works for Pennsylvania
Tired of going to the bank or waiting in line to cash your check?
Introduce yourself to Direct Deposit.
How Direct Deposit works: The State System of Higher Education notifies your Financial Institution electronically
of the funds to be deposited on your behalf. Your Financial Institution records this transaction into an account of
your choice, creating immediate access on the day of deposit. You receive an earnings statement documenting this
payment.
¾ It’s convenient - saves you a trip to the bank.
¾ It’s faster - most banks post the funds to your account at the beginning
of the day’s business on payday allowing immediate access.
¾ It’s safer - Direct Deposit eliminates the worry of a lost or stolen paycheck.
¾ It’s confidential - funds are automatically processed and you can instruct the
bank to apply them to your savings or checking account.
Sign up today by completing the form below and contacting your Human Resource Office.
---------------------------------------------------------------------------------------------------------------------
Direct Deposit Authorization
Name___________________________
SAP PERNR # Completed by Payroll ________________
I hereby authorize the State System of Higher Education to (check one) ___ Start ___ Change ___ Stop total bi-
weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings and loan
association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2) accepts electronic
funds transfer. Payroll will notify you if the institution you choose does not qualify.
Financial Institution’s Name___________________________
Transit Routing Number______________________________
Account Number____________________________________
Type of Account____________________________________ (Checking or Savings)
Effective with pay date of_____________________________
I have an established account at the Financial Institution indicated above, and authorize the State System of Higher
Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries in error to my
(our) account(s) indicated above. I have provided a copy of a voided check (see attached) solely for the purpose of
verifying my account number and the Financial Institution’s routing number. My authorization will remain in effect
until revoked by me in writing or I terminate my employment with the State System of Higher Education.
Date_______________________ Signature________________________________________
Co-Signature (If Joint Account)________________________________________
I:\Payroll\BEH\Direct Deposit Authorization
mm/dd/yyyy
mm/dd/yyyy
LO
CAL
SERVIC
ES
TAX
–
EXE
MPTION
CERTIFICATE
2018
Tax Year
APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX
A
cop
y
of
thi
s
a
pp
licatio
n
for
exemption
fro
m
the
Local
Se
rv
ices
Ta
x
(LST)
,
an
d
all
necessary
suppo
rtin
g
do
cument
s,
mu
s
t
be
com
p
leted
an
d
presente
d
to
your
employe
r
AND
to
the
political
su
bdivisi
on
le
vy
i
ng
the
Local
Services
Ta
x
for
the
m
unicipalit
y
or
sc
hoo
l
dist
r
ict
in
wh
ic
h
you
ar
e
pr
ima
r
ily
em
p
loyed
.
This
application
for
exempti
on
fro
m
the
Local
Services
Ta
x
mu
s
t
be
s
igne
d
an
d
d
a
te
d.
No
exemption
will
be
approved
until
p
r
op
er
documentation
has
been
received.
Name:
Addr
ess:
City
/State:
So
c
Sec
#:
Phon
e
#:
Zip:
REASON FOR EXEMPTION
1._______ MULTIPLE
EMPLOYERS:
Attach
a
co
py
of
a
cu
rr
ent
pay
state
ment
fro
m
your
principal
employe
r
that
shows
the
name
of
the
emplo
y
e
r,
the
le
ng
th
of
the
pa
yr
oll
p
eriod
an
d
the
amount
of
Local
Se
r
vice
s
Ta
x
withheld.
List all
empl
oy
er
s
on
the
rever
s
e
side
of
this
fo
rm
.
You
must
notify
your
other
employers
of
a
change
in
principal
place
of
employment
within
two
weeks
of
the
change.
2.
______
EXPECTED
TOTAL
EARNED
INCOME
AND
NET
PROFI
T
S
FROM
ALL
SOURCE
S
WITHIN
City
of
Lock
Haven
(municipalit
y
or
s
chool
district)
WILL
BE
LE
SS
THAN
$ 12,000.00
:
Attach
copie
s
of
your
last
pa
y
statements
or
your
W-2
for
the
yea
r
pr
io
r.
If
you
are
self-em
p
loy
e
d,
p
lease
atta
ch
a
c
opy
of
your
PA
Sche
d
ule
C,
F,
or
RK
-1
for
the
pr
ior
yea
r.
3._______
ACT
I
VE
D
UTY
M
ILITARY
EXEMPTION:
Please
attach a
c
opy
of
your
or
de
rs
directin
g
you
to
active
du
t
y
statu
s.
Ann
ual
t
raining
is
no
t eligible
for
exemptio
n.
You
are
req
u
i
r
ed
to
advise
the
ta
x
of
fice
whe
n
you
are
dis
c
ha
rg
ed
fro
m
active
du
t
y
statu
s.
4._______
MI
LITARY
D
ISABILITY
EXEMPTI
ON
:
Please
attach
co
py
of
your
d
ischa
rg
e
or
de
rs
an
d
a
state
ment
fro
m
the
Un
ited
States
Vetera
ns
Ad
mi
n
istrator
documenting
your
disab
ilit
y.
Onl
y
100%
perma
n
ent
disabilities
are
r
ec
ogn
ize
d
for
this
exemptio
n.
EMPLOYER:
Onc
e
you
receive
this
Exemption
Certificate,
you
shall
not
withhold
the
Local
Services
Tax
for
the
portion
of
the
calendar
year
for
which
this
certific
ate
applies,
unless
you
are
otherwise
notified
or
instructed
by
the
tax
collector
to
withhold
the
tax.
Ta
x
Office:
Cit
y of
Lock
Have
n
Addr
ess:
20
E
.
Churc
h
St
.
City
/State:
Lock
Have
n, PA
Phon
e
#:
570-893-5621
Zip:
17745
IMPORTANT NOTE TO EMPLOYERS
1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers
and self-employment) in their municipality is less than $12,000 when the combined rate exceeds $10.00.
2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the
income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999.
3. Contact the tax office where your business worksites are located to obtain this information.
LST Exemption 10-07
Employment Information: List all places of employment for the applicable tax year. Please list your
PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self
employed, write SELF under Employer Name column.
1. PRIMARY EMPLOYER 2. 3.
Employer
Name
Lock Haven University
Address
301 W. Church St.
Address
2
City
,
State
Zip
Lock Haven, PA
Municipality
Lock Haven
Phone
570-484-2230
Start
Date
1/1/18
End
Date
12/31/18
Status
(FT
or
PT)
PT
Gross
Earnings
4.
5.
6.
Employer
Name
Address
Address
2
City
,
State
Zip
Municipality
Phone
Start
Date
End
Date
Status
(FT
or
PT)
Gross
Earnings
PLEASE
NOTE:
All
information
received
by
the
Tax
Collector
is
considered
to
be
CONFIDENTIAL
and
is
on
l
y
used
for
official
purposes
relating
to
the
collection,
administration
and
enforcement
of
the
LOCAL
SERVICES
TAX.
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND
ATTACHED TO THIS FORM IS TRUE AND CORRECT:
SIGNATURE: DATE:
LST Exemption 10-07
mm/dd/yyyy
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
LOCK HAVEN UNIVERSITY APPLICANT ACKNOWLEDGEMENT AND
CONSENT FOR CRIMINAL BACKGROUND CHECK
1. _______________________________________ hereby acknowledge and consent to the following:
(PRINT NAME)
2.
I have applied for a position with Lock Haven University and have been advised that all university employees
are required to satisfy the requirements of the Pennsylvania Child Protective Services Law (CPSL).
3. I acknowledge that CPSL requires a Pennsylvania State Police Criminal History Report, Pennsylvania Department
of Human Services Child Abuse History Clearance and a Federal Bureau of Investigation Criminal History Report.
4.
I further acknowledge that I will provide the original Federal Bureau of Investigation Criminal History Report
(fingerprint report) to Human Resources at Lock Haven University.
5.
I will use the provided payment code to submit my Pennsylvania Department of Human Services Child Abuse
History Clearance report electronically, which will allow Lock Haven University access to the final report.
6.
I understand that Human Resources at Lock Haven University will run the Pennsylvania State Police Criminal
History report (e-PATCH) on my behalf and I am providing the following information for them to do so.
Full Name (print) _________________________________________________________________
Date of Birth _________________________________________________________________
Full Social Security Number _________________________________________________________________
Aliases and/or Maiden Name _________________________________________________________________
Race _________________________________________________________________
Race is a required field in the Pennsylvania State Police application for the Criminal History Report. Failure to provide race on
this form will result in race being reported as unknown to the Pennsylvania State Police.
7.
I understand that CPSL permits (but does not require) Lock Haven University to hire me on a provisional basis
for an approved time period not to exceed ninety (90) days.
8.
I understand that during any authorized period of provisional employment/participation, I will not be
permitted to work alone with children and must work in the immediate vicinity of a permanent Lock Haven
University employee.
9.
I understand that Lock Haven University may immediately terminate my provisional employment/participation
should the Pennsylvania State Police, Pennsylvania Department of Human Services and/or the Federal Bureau
of Investigation be unable to provide the required reports within the approved provisional period.
_____________________________________________ _________________________________________
SIGNATURE DATE
_____________________________________________ __________________________________________
E-MAIL ADDRESS T
ELEPHONE NUMBER
APPLICANT FOR:
FACULTY STAFF STUDENT EMPLOYMENT VOLUNTEER DEPARTMENT: ________________
Approved by University Legal Counsel April 13, 2015
mm/dd/yyyy
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