Fillable Std686 Form 06860905 (California State University, Fresno)

Fill Online, Printable, Fillable, Blank Std686 Form 06860905 (California State University, Fresno) Form

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

Std686 Form 06860905 (California State University, Fresno)

On average this form takes 11 minutes to complete

The Std686 Form 06860905 (California State University, Fresno) form is 1 page long and contains:

  • 0 signatures
  • 13 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fresno

BROWSE CALIFORNIA STATE UNIVERSITY, FRESNO 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
 
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. 9/2005) (FRONT)
CHECK ONE OR MORE BOX(ES) AND COMPLETE LISTED SECTIONS.
RETURN COMPLETED FORM TO YOUR PERSONNEL OFFICE.
USE BALLPOINT 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
FORMER NAME (Last, First and Middle)
C 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.)
E
Employers may be required to notify IRS of the
number of allowances claimed.
I. FEDERAL AND STATE ALLOWANCE
– For Tax Purposes Only. If no tax should be withheld, complete Part IV or V only.
MARITAL STATUS FOR TAX PURPOSES ONLY
(Check One)
02
TOTAL -
MARRIED
SINGLE
NOTE:
Number of allowances
you are claiming
01
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.
06
FEDERAL ADDITIONAL
DEDUCTION
07
STATE ADDITIONAL
DEDUCTION
$ $
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.
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.
MARITAL STATUS FOR TAX PURPOSES ONLY
(Check One)
04
REGULAR ALLOWANCE(S)
Total you are claiming
SINGLE
HEAD OF
HOUSEHOLD
05
ADDITIONAL ALLOWANCE(S)
Total you are claiming
MARRIED
NOTE: Employers may be required to notify EDD if more
than 10 allowances are claimed.
II.
03
IV.
NOTE:
08
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 may be required to notify IRS if you earn more than $200 per week.
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.):
09
V. NONTAXABLE WAGES – Check box 09 if wages you will receive are not subject to income tax withholding.
ADDRESS CHANGE OR NEW EMPLOYEE
*See Back of Third Page
F
01 EMPLOYEE ADDRESS (Street, Rural Route or P.O. Box) 02 CITY STATE 03 ZIP CODE
WORK PHONE HOME PHONE
04 EMPLOYMENT LIST
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
LAST EMPLOYED BY CALIFORNIA STATE AGENCY OR
CAMPUS OF:
01 LAST NAME (if different)
MO YR
03 SEPARATED
01
LAST EMPLOYED BY CALIFORNIA PUBLIC AGENCY OF:
(City, County, Public School or Utility, etc.)
04
LAST NAME (if different)05
MO YR
SEPARATED
06
H
MO DAY YR
BIRTHDATE
NEW EMPLOYEE OR BIRTHDATE CORRECTION
EMPLOYEE SIGNATURE PERSONNEL OFFICE USE
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.
I
EMPLOYEE SIGNATURE DATE
White – Personnel/Payroll Services Div. Yellow – Personnel Pink – Employee
REVIEWER'S SIGNATURE
#
J
DATE PHONE NO.
Clear
Print
STATE OF CALIFORNIA – STATE CONTROLLER’S OFFICE
EMPLOYEE ACTION REQUEST
STD. 686 (REV. 9/2005) (BACK, 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
IF YOU ARE EXEMPT FROM EITHER FEDERAL OR STATE WITHHOLDING, but not exempt from both, contact your
personnel office for special instructions.
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 the church in the exercise of his / her ministry” – employed by the State of California as a Chaplain.
b.
“Nonimmigrant Alien per Tax Treaty” (indicate on claim: “Exempt per Article ________ of treaty between 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” – agency 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.
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, the University of California or Legislative employees.
IF YOUR NORMAL LOCATION OF EMPLOYMENT IS NOT IN CALIFORNIA and you are a California State employee,
you may be eligible to have income tax for another state withheld from your wages under the reciprocity provisions required by
G.C. 1170.5. Contact your personnel office for additional information.
EARNED INCOME CREDIT (EIC)
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 advance payments of the earned
income credit each month or claiming the credit on Form 1040 or 1040A, your annual tax return, and receiving the credit when you
file. To find out more information about the credit, contact your personnel/payroll office or IRS at 1-800-829-1040. To request
advance EIC payments, you must complete a Form W-5, Earned Income Advance Payment Certificate. The W-5 is available at your
local IRS office or can be ordered by calling 1-800-829-3676.
ADDRESS CHANGE
IF YOU HAVE A U.S. SAVINGS BOND DEDUCTION and the address of the registered owner is changing, you must complete a
new United States Savings Bonds Purchase/Payroll Deduction Authorization, STD. 242.
IF YOU HAVE OTHER DEDUCTIONS, you must change your address with the deduction company. This form does not affect an
address change with deduction companies.
IF YOUR NAME APPEARS ON ANY DEPARTMENTAL EMPLOYMENT LIST (Open, Promotional, Reemployment, etc.),
and your address is changing, check Box 04 and enter your phone number(s) in Section F. Your department will update the appropriate
list(s) with this 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
Government Code Sections 12470 through 12479 and 16391 through 16395; California Unemployment Insurance Code Section 13020; delegated authority
notice to be provided when collecting personal information from individuals.
from the State Personnel Board; and delegated authority from the Trustees of the California State University.
The information you are asked to provide on this form is requested by the Office of the State Controller, Personnel/Payroll Services Division. The Certain items of information furnished on this form may be transferred to the following governmental or private agencies where authorized by law; State
information will be used by the State Controller’s Office for personnel, payroll, retirement and health benefits processing.
Personnel Board, Department of Personnel Administration, Trustees of the California State University, Employment Development Department, Department
Furnishing the information requested on this form is mandatory except for Prior Public Employment (Section G). Furnishing prior public employment
of Social Services, Department of Finance, Public Employees’ Retirement System, employing State agencies and campuses, Social Security Administration,
information is voluntary. Noncompliance in providing your social security number and name will result in refusal of employment. Failure to furnish
Federal Internal Revenue Service, California State Franchise Tax Board, other state income tax bureaus and other governmental entities when required by
other requested information may result in inaccurate determination of credit for State service, payroll calculations, retirement and/or health benefits.
state or federal law, organizations for which deductions are authorized by law, and collective bargaining organizations.
Legal references authorizing the maintenance of this information by the State Controller’s Office include: Federal Internal Revenue Code (26 USC Employees have the right to review their own personal information maintained by the State Controller’s Office unless access is exempted by law.
Sections 3402(a), 6011, 6051, and 6109) and the regulations thereto; Federal Public Health and Welfare Code (42 USC Section 403); and California Contact: Personnel/Payroll Services Division, State Controller’s Office, P.O. Box 942850, Sacramento, CA 94250-5878.
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

Std686 Form 06860905 (California State University, Fresno)

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 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document