Fillable Spar-2014 CSU Student Payroll Action Request

Fill Online, Printable, Fillable, Blank Spar-2014 CSU Student Payroll Action Request Form

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

Spar-2014 CSU Student Payroll Action Request

On average this form takes 20 minutes to complete

The Spar-2014 CSU Student Payroll Action Request form is 2 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 81 other fields

Country of origin: US
File type: PDF

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

BROWSE CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS 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
 
CSU STUDENT PAYROLL
ACTION REQUEST
OFFICE USE ONLY
C
02 CITY 03 ZIP CODE
01 EMPLOYEE ADDRESS (Street, P.O. Box or Rural Route)
STATE
THIS IS CARBONLESS PAPER.
PRINT CLEARLY. USE BALLPOINT PEN.
See instructions on reverse of this form before completing.
01 AGENCY 03 CLASS
A
02 UNIT
04 SERIAL
01 SOCIAL SECURITY NUMBER 02 EMPLOYEE LAST NAME 03 FIRST NAME AND MIDDLE INITIAL
D
BIRTHDATE SEX ETHNIC CODE
For ethnic codes, see Section G of instructions.
Enter appropriate code in space at the left.
F
E
M or F
Mo. Day Yr. (Enter Code)
G
STATE OF CALIFORNIA¦ CONTROLLER'S OFFICE
STD. 457 (REV. 10/2008)
TYPE OF TRANSACTION
CHECK ALL APPROPRIATE BOXES AND
B
COMPLETE LISTED SECTIONS
NEW EMPLOYEE INFORMATION
(C thru I, K, L)
WITHHOLDING ALLOWANCE CHANGE
A98
E03
(C, H, I)
ADDRESS CHANGE (C, D, I)
E04
NAME CHANGE (C, I) (ATTACH
E05
SUBSTANTIATION) NAME WAS
BIRTHDATE CHANGE (C, E, I)
SSA NUMBER CHANGE (C, I)
E07
105
SSA NO. WAS
(ATTACH SUBSTANTIATION)
445
ETHNIC CORRECTION (C, G, I)
CAMPUS USE ONLY
DESIGNEE CHANGE (C, I, K)
WITHHOLDING ALLOWANCE CERTIFICATE ***IMPORTANT*** Before completing Section H you must read IRS Form W-4 or W-4A and state tax Form DE-4.
EXEMPTION FROM WITHHOLDING - Complete box 06 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 or II.
(See General Information - fourth page.)
FEDERAL AND STATE ALLOWANCES
III.
H
If no tax should be withheld, complete Part III or IV only.
MARITAL STATUS (Check One)
FOR TAX PURPOSES ONLY
01
TOTAL
ALLOWANCES
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.
02
06
MARRIED
SINGLE
NOTE: Employers may notify IRS if more than 10 allowances are claimed.
If you are not having income tax withheld this year but expect to have
a tax liability next year, you must file a withholding allowance claim by
December 1st of this year.
II.
SPECIAL TREATMENT OF STATE ALLOWANCES
This exemption will automatically expire on February 15th of next year
unless you file a new certification by January 31st of next year.
Complete boxes 03 thru 05 if you wish your California state withholding
to be different than what you claim for federal withholding.
MARITAL STATUS (Check One)
FOR TAX PURPOSES ONLY
Employers are required to notify IRS if you earn more than $200 per week.
03
HEAD OF
HOUSEHOLD
NONTAXABLE WAGES-Complete box 07 if wages you will receive are not
subject to income tax withholding. (See General Information-fourth page.)
SINGLE
MARRIED
IV.
REGULAR
ALLOWANCES
ADDITIONAL
ALLOWANCES
I claim that the wages I will be receiving from the State are either 1)
MINISTER OF A CHURCH, 2) NONRESIDENT ALIEN wages, or 3)
Deceased Employee Wages. Indicate reason:
________________________________________________________
07
04
05
NOTE: Employers may be required to notify EDD if more than 10
allowances are claimed.
NONRESIDENT ALIEN
I.
EMPLOYEE CERTIFICATION
I
I certify the above information is true and that I have read IRS Form W-4 or W-4A and state Form DE-4. Under the penalties of perjury, I certify that the num-
ber of withholding exemptions and allowances claimed does not exceed the number to which I am entitled. If claiming exemption from withholding, I certify I
incurred no tax liability for last year and I anticipate 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. If completing Section K,
SIGNATURE
DATE
I hereby revoke any previous designation. If completing Section L, I hereby subscribe
�
to the oath of allegiance or declaration of permission to work.
CSU REPRESENTATIVE SIGNATURE
J
I authorize the State Controller to take the action indicated hereon and do certify that
the action is appropriate. I have reviewed the completion of this document and where
SIGNATURE
DATE
appropriate, witnessed the subscription to the oath of allegiance or declaration of
�
permission to work.
DISTRIBUTION: BLUE - Personnel/Payroll Division; PINK/YELLOW - Campus Copies; GREEN - Employee
Print
Clear
________________________________________________________
I
105
445
STATE OF CALIFORNIA¦ CONTROLLER'S OFFICE
STD 457 (REV. 10/2008)
TYPE OF TRANSACTION
CHECK ALL APPROPRIATE BOXES AND
B
COMPLETE LISTED SECTIONS
NEW EMPLOYEE INFORMATION
(C thru I, K, L)
WITHHOLDING ALLOWANCE CHANGE
A98
E03
(C, H, I)
ADDRESS CHANGE (C, D, I)
E04
NAME CHANGE (C, I) (ATTACH
SUBSTANTIATION) NAME WAS
E05
(ATTACH SUBSTANTIATION)
BIRTHDATE CHANGE (C, E, I)
SSA NUMBER CHANGE (C, I)
SSA NO. WAS
E07
ETHNIC CORRECTION (C, G, I)
CAMPUS USE ONLY
DESIGNEE CHANGE (C, I, K)
CSU STUDENT PAYROLL
ACTION REQUEST
OFFICE USE ONLY
C
02 CITY 03 ZIP CODE
01 EMPLOYEE ADDRESS (Street, P.O. Box or Rural Route)
STATE
THIS IS CARBONLESS PAPER.
PRINT CLEARLY. USE BALLPOINT PEN.
See instructions on reverse of this form before completing.
01 AGENCY 03 CLASS
A
02 UNIT
04 SERIAL
01 SOCIAL SECURITY NUMBER 02 EMPLOYEE LAST NAME 03 FIRST NAME AND MIDDLE INITIAL
D
E
BIRTHDATE SEX ETHNIC CODE
For ethnic codes, see Section G of instructions.
Enter appropriate code in space at the left.
F
M or F
Mo. Day Yr. (Enter Code)
G
III.
EXEMPTION FROM WITHHOLDING - Complete box 06 if you are eligible
H
I.
FEDERAL AND STATE ALLOWANCES
to claim exemption from withholding. No Federal or State income tax will
01
If no tax should be withheld, complete Part III or IV only.
be withheld from your wages. DO NOT COMPLETE PARTS I or II.
MARITAL STATUS (Check One)
(See General Information - fourth page.)
06
FOR TAX PURPOSES ONLY
I claim exemption from withholding because of no tax liability: Last
SINGLE
MARRIED
ALL income tax withheld, AND this year I do not expect to owe any
ALLOWANCES
year I did not owe any income tax and had a right to a full refund of
NONRESIDENT ALIEN
02
TOTAL
income tax and expect to have a right to a full refund of ALL income
tax withheld.
NOTE: Employers may notify IRS if more than 10 allowances are claimed.
If you are not having income tax withheld this year but expect to have
a tax liability next year, you must file a withholding allowance claim by
II.
SPECIAL TREATMENT OF STATE ALLOWANCES
December 1st of this year.
Complete boxes 03 thru 05 if you wish your California state withholding
This exemption will automatically expire on February 15th of next year
to be different than what you claim for federal withholding.
unless you file a new certification by January 31st of next year.
03
MARITAL STATUS (Check One)
Employers are required to notify IRS if you earn more than $200 per week.
FOR TAX PURPOSES ONLY
HEAD OF
SINGLE
MARRIED
IV.
NONTAXABLE WAGES-Complete box 07 if wages you will receive are not
04
HOUSEHOLD
ADDITIONAL
subject to income tax withholding. (See General Information-fourth page.)
ALLOWANCES
REGULAR
05
07
I claim that the wages I will be receiving from the State are either 1)
ALLOWANCES
MINISTER OF A CHURCH, 2) NONRESIDENT ALIEN wages, or 3)
Deceased Employee Wages. Indicate reason:
NOTE: Employers may be required to notify EDD if more than 10
allowances are claimed.
WITHHOLDING ALLOWANCE CERTIFICATE ***IMPORTANT*** Before completing Section H you must read IRS Form W-4 or W-4A and state tax Form DE-4.
EMPLOYEE CERTIFICATION
I certify the above information is true and that I have read IRS Form W-4 or W-4A and state Form DE-4. Under the penalties of perjury, I certify that the num-
ber of withholding exemptions and allowances claimed does not exceed the number to which I am entitled. If claiming exemption from withholding, I certify I
incurred no tax liability for last year and I anticipate 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. If completing Section K,
SIGNATURE
DATE
I hereby revoke any previous designation. If completing Section L, I hereby subscribe
�
to the oath of allegiance or declaration of permission to work.
CSU REPRESENTATIVE SIGNATURE
I authorize the State Controller to take the action indicated hereon and do certify that
SIGNATURE
the action is appropriate. I have reviewed the completion of this document and where
J
DATE
appropriate, witnessed the subscription to the oath of allegiance or declaration of
�
permission to work.
DESIGNEE FOR STATE WARRANT(S)
01 DESIGNEE FIRST NAME AND INITIAL
02 LAST NAME 03
RELATIONSHIP
K
05 DESIGNEE ADDRESS (Street, P.O. Box, or Rural Route)
06 CITY AND STATE
07 ZIP CODE
OATH OF ALLEGIANCE/DECLARATION OF PERMISSION TO WORK Complete Part I or Part II
L
PART I - OATH OF ALLEGIANCE
I, _________________________________________________________, do solemnly swear (or affirm) that I will support and defend the Constitution of the
United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the
Constitution of the United States and the Constitution of the State of California; that I take this obligation freely without any mental reservation or purpose of
evasion; and that I will well and faithfully discharge the duties upon which I am about to enter. I hereby subscribe to this oath by signing in Section I above.
PART II - DECLARATION OF PERMISSION TO WORK
If "NO", I hereby certify that I have permission to work in this country and have
declared any restrictions placed upon me in this regard by the United States
government to the appointing power.
YES
I am a lawful permanent resident noncitizen of the United
States.
NO
DISTRIBUTION: BLUE - Personnel/Payroll Division; PINK/YELLOW - Campus Copies; GREEN - Employee
STATE OF CALIFORNIA¦ CONTROLLER'S OFFICE
CSU STUDENT ACTION REQUEST
STD. 457 (REV. 10/2008)
GENERAL INFORMATION
PRIVACY NOTIFICATION
The Information Practices Act of 1977 (California Civil Code § 1798.17) and the Federal
Privacy Act (5 USC 552a, subd. (e)(3)) require this notice 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. Furnishing the information
requested on this form is mandatory. Noncompliance in providing your Social Security
Number and name will result in refusal of employment.
Information requested on this form is used for personnel, payroll and related
processing. Legal references authorizing the maintenance of this information by the
State Controller's Office include: Federal Internal Revenue Code (26 USC §§ 3402(a),
6011, 6051, 6109) and the regulations thereto; federal Public Health and Welfare
Code (42 USC § 403); California Government Code §§ 12470 through 12479 and
16391 through 16395; California Unemployment Insurance Code § 13020; 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: Trustees, The California
State University, Employment Development Department, Department of Social Ser-
vices, 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 agencies when required by state or federal law, and
organizations for which deductions are authorized by law.
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,
Post Office Box 942850, Sacramento, California 94250-5878.
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,
Legislative employees, or the Universities of California.
IF YOU DO NOT COMPLETE SECTION H. If you are new to State service and you fail
to complete Section H, you will be treated (for withholding tax purposes) as a single
person claiming no allowances (Section 3402(c) and Section 3402(1) of the Internal
Revenue Code).
If you are returning to State service and you fail to complete Section H and you have
received within the past year, earnings paid under the Uniform State Payroll System,
taxes will be withheld from your wages based on the allowances you previously claimed.
IF YOU ARE EXEMPT FROM EITHER FEDERAL OR STATE WITHHOLDING
but not
exempt from both, contact your personnel/payroll office for special instructions for
completing Section H.
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 officer.
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 a Church"- employed by the State of California as a Minister of a
Church
b. "Nonresident Alien per Tax Treaty"
(Indicate on claim: "Exempt per Article
of treaty between the 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"- campus 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.
STUDENT PAYROLL ACTION REQUEST INSTRUCTIONS
Read all instructions before completing this form. Use pen and print all entries. Sign your name in Section I. Retain the
4th (Green) copy for your records. If you have questions about any item on this form, consult your personnel/payroll office.
SECTION B
Type of Transaction - Check all appropriate boxes and complete listed sections.
SECTION C
Social Security Number - Enter your number as it appears on your social security card.
If you do not have a social security card, you must apply for your card through the Social
Security Administration using the application for a social security number, SS-5. In the
box for social security number on STD. 457 you should write "SS-5 SENT". A copy of the
SS-5 form should be attached to the STD. 457. When you receive your social security
number, please notify your personnel/payroll office.
Name - Enter your name as it appears on your social security card. Enter last name first.
This same name must be used on all future employment documents unless formally
changed by you.
Name Change - Complete a new STD. 457 in your personnel/payroll office. You must
also submit a name change form (SS-5) to the Social Security Administration.
A copy of
the name change form (SS-5) or the receipt issued by the Social Security Administration
(SSA-5028-374) must be attached to the STD. 457.
SECTION D
Address - Enter your mailing address. This address will be used for W-2 statements and
mailing of final warrants, if any. Notify your employer immediately if your address
changes. Complete a new STD. 457 in your personnel/payroll office.
SECTION E
Birthdate - Enter numerically the month, day, and year of your birth. (March 20, 1949
enter 03/20/49.)
SECTION F
Sex - Enter "M" for Male or "F" for Female.
SECTION G
Ethnic Code - Enter the code of the ethnic group with which you most closely identify
yourself from the chart below. This request is consistent with U.S. Department of Labor
Regulations mandated by Federal Executive Orders 11246 and 11375. This confidential
information does not become part of an employee's personnel file. The employer is
required to make a visual identification of those individuals who do not complete this
item.
RACE / ETHNICITY ETHNIC CODE
Mexican, Mexican-American, Chicano .............. A
Puerto Rican ................................................. B
Cuban ............................................................... C
Any Other Spanish/Hispanic.............................. D
White ................................................................. E
Black .................................................................. F
Filipino ............................................................... G
Hawaiian ............................................................ P
Samoan ........................................................... Q
Guamanian/Chamorro ...................................... R
Other Pacific Islander ....................................... T
RACE / ETHNICITY
ETHNIC CODE
Japanese ............................................................. I
Chinese ............................................................... J
Korean ................................................................. K
Vietnamese .......................................................... L
Asian Indian ......................................................... M
Cambodian .......................................................... U
Laotian ................................................................ V
Other Asian ......................................................... S
American Indian .................................................. H
Eskimo ................................................................ N
Aleut ................................................................... O
Other, Not Listed ................................................ X
SECTION H
Part I - Federal and State Allowances
Part II - Special Treatment of State Allowance
Part III - Exemption from Withholding
Part IV - Nontaxable Wages
SECTION I
}
Use worksheets on Internal Revenue Service
Form W-4 or W-4A and California to complete
your withholding allowances.
}
See General Information above.
Employee Certification - You must sign your name, certifying to the accuracy of
information entered on the form.
SECTION K
Designee for State Payroll Warrants (G.C. 12479) - This item must be completed by all
employees. Notwithstanding any other provision of law, the person you designate, if 18
years or older, shall be entitled upon your death to receive all State warrants due you,
excluding retirement benefits. Your designee must fil
e written request for such warrants
with your personnel office within 60 days after the date of your death. NOTE: If you make
an error in designee name, you must complete a new STD. 457.
Designee Name - Enter the full name (Mary Jane Smith not Mrs. Robert L.
Smith) in K01
and K02. Specify the relationship of the person designated in K03 (e.g., wife, husband,
domestic partner, daughter, son, mother, father, parent, or friend). Enter address in K05
to K07. If
you have no designee, enter "NONE" in KO1.
Designee Address - Enter the permanent mailing address. File a new STD. 457 any-
time your designee's address changes.
Designee Change - You may change or revoke your designee at any time by completing
a new STD. 457.
SECTION L
Oath of Allegiance or Declaration of Permission to Work - Complete Part 1 or Part 2.
Every State employee, except legally employed noncitizens, must sign the Oath (Part 1).
The Declaration of Permission to Work (Part 2), is required of noncitizens. If you are a
nonresident, noncitizen employee and become a naturalized citizen, an oath must be
signed and filed.
The Oath/Declaration must be signed before entering into employment. Payment may not
be made to any CSU employee unless the employee has taken and subscribed to the
Oath/Declaration.
Penalties (G.C. 3108) - "Every person who, while taking and subscribing to the Oath or
affirmation required by this chapter, states as true any material matter which he/she
knows to be false, is guilty of perjury, and is punishable by imprisonment in the state
prison not less than one nor more than 14 years."
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

Spar-2014 CSU Student Payroll Action Request

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 17 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document