Student Payroll Packet Checklist
First
Time
Employment
at
UC
THIS
IS
MY
FIRST
JOB
ON CAMPUS. I
will
complete
the
following steps:
__
Complete Student Employment Contract
You
complete Section A
Your employer must complete Section B
__
Complete W-4 Form
Use
your
home address
International
Students-
use Ursinus College address
Sign
and date
the
form
__
Complete
1-9
form
Complete Section 1.
Sign
and date the form.
Bring
the
required forms
of
identification
to
Human Resources.
You
must
present your ORIGINAL forms
of
identification
to
Human Resources.
__
Complete Residency Certification Form
Complete Section 1
Sign and date
the
form
The Business Office has listings
to
help you complete
the
"Resident
PSD
Code" information in Section 1.
__
Complete
the
Direct Deposit Authorization
form
Complete this form and attach a voided check.
If
you are requesting direct deposit
to
your
savings account, attach a form
from
your bank showing account and transit
number
of
your bank.
All
of
the
above documentation must
be
turned
into
the
Human Resources Office
in
order
for
you
to
get paid
for
your
employment.
-----
URSINUS
COLLEGE
STUDENT EMPLOYMENT
CONTRACT
Your
first
responsibility
in
accepting
employment
ls
to
complete all
the
required documents. Please refer
to
the
appropriate
employment
check
list
included
with
the
student
employment
packet
to
assure all
documentation is completed.
Return
form
to
the
Human Resources office located
on
the
lower
level
of
Corson Hall.
SECTION
A:
STUDENT
INFORMATION (Print Clearly)
Name:
_____________________________
_
Campus Address:
_________________________
_
Phone Number:
__________________________
_
The
Higher Education
Act
of
1965, as amended (HEA),
in
Section 441(a) states
that
the purpose
of
the Federal Work
Study
(FWS)
Program is
to
promote
the
part-time
employment
of
students
who
are in need
of
earnings
to
pursue courses
of
study. As a
student
participating
in
part-time
work
at
Ursinus College,
whether
FWS
or
otherwise,
it
is
my
understanding
that
the college
will
not
permit
student
workers
to
work
during scheduled class times.
STUDENTSIGNATURE:
________________
Date:
_______
_
Expected Graduation Date:
________
_
SECTION
B:
POSITION INFORMATION (Completed
By
Employer)
Position Title:
________________
Hours
per
Week:
_______
_
Student is (check one):
___
New
to
position
___
Returning
to
position
Date
student
is
to
begin
work:
_____
(Contract
must
be received
by
Business Office/Payroll first)
Department Charged:
__________
Account Charged:
_________
_
Hourly Rate:
$
____
_
The Higher Education
Act
of
1965, as amended
(HEA),
in Section 441(a) states
that
the purpose
of
the
Federal Work
Study
(FWS)
Program
is
to
promote
the
part-time
employment
of
students
who
are in
need
of
earnings
to
pursue courses
of
study. As a
student
participating
in
part-time
work
at
Ursinus College,
whether
FWS
or
otherwise,
it
is
my
understanding
that
the college
will
not
permit
student
workers
to
work
during scheduled class times.
EMPLOYER
SIGNATURE:
_____________
Date:
_______
_
For Office Use Only:
Dept
Code:
PC
TS
File Number:
Rate Code:
click to sign
signature
click to edit
click to sign
signature
click to edit
Form W•4
Employee's Withholding Certificate
0MB
No.
1545-0074
Complete
Form
W-4
so
that
your
employer
can
withhold
the
correct
federal
income
tax
from
your
pay.
~@
20
Department
of
the
Treasury
Give
Form
W-4
to
your employer.
Your
withholding
is
subject
to
review by
the
IRS.
Internal
Revenue
Sesvice
Step 1:
(a) First name
and
middle
initial
I
Last
name
(bl
Social security number
Enter
Address
Does
your
name
match
the
Personal
name
on
your
social
security
Information
card?
If
not,
to
ensure you get
City
or
town, state, and ZIP code
credit
for
your earnings,
con
tact
SSA
at 800-772-1213
or
go
to
www.ssa.gov
.
(c)
0 Single
or
Married
filing
separately
0 Married filing jointly (or Qualifying widow(er))
D Head of
household
(Check
only
if
you're unmarried and pay more than half
the
costs
of
keeping
up
a home
for
yourself
and
a
qua
lifying individual.)
Complete
Steps
2-4
ONLY
if
they
apply
to
you; otherwise,
skip
to
Step
5.
See page 2 for more information on each step,
who
can
claim exemption from withholding, when
to
use
the
online estimator, and privacy.
Step 2:
Complete this step
if
you
(1)
hold more than one j
ob
at
a time,
or
(2)
are married filing jointly and your spouse
Multiple Jobs
also works. The correct amount
of
withholding depends
on
income earned from all
of
these jobs.
or
Spouse
Do
only
one
of
the
following.
Works
(a)
Use
the
estimator
at
www.irs.gov/W4App
for
most
accurate withholding for this step (and Steps 3-4);
or
(b) Use the Multiple Jobs Worksheet
on
page 3
and
enter
the
result
in
Step
4(c)
below for roughly accurate withholding;
or
(c)
If
there are only two jobs total, you may check this box. Do the same
on
Form W-4
for
the other job. This option
is accurate
for
jobs with similar pay; otherwise, more
tax
than necessary may be withheld .
D
TIP:
To
be
accurate, submit a 2020 Form W-4 for all other jobs.
If
you (or your spouse) have self-employment
income, including
as
an independent contractor,
use
the
estimator.
Complete
Steps
3-4(b)
on
Form
W-4
for
only
ONE
of
these jobs. Leave those steps blank
for
the
other jobs. (Your withholding will
be
most
accurate
if
you compl
ete
Steps
3-4(b
} on
the
Form
W-4
for
the
highest paying job.)
Step
3:
Claim
Dependents
Step4
(optional):
Other
Adjustments
If your income will be $200,000
or
less ($400,000
or
less
if
married filing jointly):
Multiply the number
of
qualifying children under age
17
by
$2,000
$
-'-
------
Multiply
the
number
of
other dependents
by
$500
Add
the
amounts above and enter the total here
..,.
$
____
_
(a) Other income (not from jobs).
If
you want tax withheld for other income you expect
this year that won't have withholding, enter the amount
of
other income here. This may
3 $
include interest, dividends, and retirement income 4(a) $
f--'-'!..:.'-<..f-"-------
(b) Deductions.
If
you expect
to
claim deductions other than the standard deduction
and want
to
reduce your withholding, use the Deductions Worksheet
on
page 3 and
enter
the
result here 4(b) $
!--''--'-~------
(c) Extra withholding. Enter any additional
tax
you
want
withheld each
pay
period 4(c) $
Step
5:
Sign
Here
Under
penalties
of
perjury, l
declare
that
this
certificate,
to
the
best
of
my
knowledge
and
belief,
is
true, correct,
and
comp
lete.
Employee's signature
(Th
is form is not valid unless you sign it.)
Date
Employers
Only
Employer's name
and
address
First
date
of
employment
Employer identification
number
(E
IN)
For
Privacy
Act
and Paperwork Reduction
Act
Notice,
see
page
3.
Cat.
No
.
10
22
00
Form
W-4
(2020)
Foon
W-4
(2020)
Page2
General Instructions
Future Developments
For
the
latest information
about
developments related
to
Form W-4, such
as
legislation
enacted
after
it
was
published,
go
to
www.irs.gov/ForrnW4.
Purpose
of
Form
Complete Form
W-4
so
that
your employer can withhold the
correct federal income
tax
from your pay.
If
too
little
is
withheld, you will generally
owe
tax
when you file
your
tax
return and may
owe
a penalty.
If
too
much
is
withheld, you will
generally
be
due
a refund. Complete a
new
Form
W-4
when
changes
to
your personal or financial situation would change
the entries
on
the
form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption
from
withholding. You may claim exemption from
withholding for 2020
if
you meet both
of
the following
conditions: you had no federal income
tax liability in 2019 and
you expect
to
have no federal income tax liabili
ty
in 2020. You
had
no
federal income tax liability
in
2019
if
(1)
your total tax on
line 16 on your 2019 Form 1040
or
1040-SR is zero (or less
than the sum
of
lines 18a, 18b, and 18c),
or
{2)
you were
not
required
to
file a return because your income
was
below the
filing threshold for your correct filing status.
If
you claim
exemption, you will have
no
income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both
of
the conditions above
by
writing "Exempt"
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1
a,
1 b, and
5.
Do
not
complete any other steps. You will
need
to
submit a new Form W-4
by
February 16, 2021.
Your
privacy.
If
you prefer
to
limit
information provided
in
Steps 2 through 4, use
the
online estimator,
which
will also
increase accuracy.
As
an
alternative
to
the
estimator.
if
you have concerns
with
Step
2(c), you
may
choose
Step
2(b);
if
you have
concerns with
Step
4(a), you
may
enter an additional
amount
you want withheld
per
pay
period
in
Step
4(c).
If
this
is
the
only
job
in
your
household, you
may
instead
check
the
box
in
Step
2(c), which will increase
your
withholding
and
significantly reduce
your
paycheck (often
by
thousands
of
dollars
over
the
year).
When
to
use
the
estimator.
Consider using
the
estimator
at
www.irs.gov/W4App
if
you:
1 . Expect
to
work
only
part
of
the
year;
2.
Have dividend
or
capital gain income,
or
are subject
to
additional taxes,
such
as
the
additional Medicare
tax
;
3.
Have self-employment
income
(see below);
or
4. Prefer
the
most
accurate withholding
for
multiple
job
situations.
Sett-employment. Generally, you will
owe
both
income
and
self
-employment taxes
on
any
self-employment
income
you
receive separate
from
the
wages you receive
as
an
employee.
If
you
want
to
pay
these
taxes through
withholding from your wages,
use
the
estimator
at
www.irs.
gov/W4App
to
figure the amount
to
have withheld.
Nonresident alien.
If
you're
a nonresident alien,
see
Notice
1392, Supplemental
Fonn
W-4 Instructions
for
Nonresident
Aliens, before completing
this
form.
Specific Instructions
Step 1(c).
Check
your
anticipated filing status. This will
detennine
the
standard deduction and
tax
rates used
to
compute
your
withholding.
Step
2.
Use
this
step
if
you (1) have
more
than
one
job
at
the
same time,
or
(2) are married filing jointly and you and your
spouse
both
work.
Option
{a}
most
accurately calculates
the
additional
tax
you
need
to
have withheld, while
option
(b) does
so
with a
little
less
accuracy.
If
you (and your spouse) have a total
of
only
two
jobs, you
may instead check
the
box
in option (c). The
box
must also be
checked
on
the
Form
W-4
for the other
job
.
If
the box is
checked
, the
standard
deduction
and
tax
brackets
will
be
cut
in half for each
job
to
calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may
be
withheld, and this extra amount will be
larger
the
greater
the
difference in
pay
is between the
two
jobs.
W.. Multiple jobs. Complete Steps 3 through 4(b)
on
only
m!imi
one Form W-4. Withholding
will
be
most
accurate
if
·
you
do
this
on
the Form W-4
for
the highest paying
job
.
Step
3.
Step
3
of
Form
W-4
provides instructions for
determining
the
amount
of
the
child
tax
credit and the credit
for
other
dependents
that
you
may
be able
to
claim when
you file
your
tax
return.
To
qualify
for
the
child tax credit, the
child
must
be
under
age
17
as
of
December 31,
must
be
your
dependent
who
generally lives
with
you
for
more than
half
the
year, and
must
have
the
required social security
number
. You
may
be
able
to
claim a credit
for
other
dependents
for
whom
a
ch
i
ld
tax credit
can't
be claimed,
such
as an
older
child
or
a qualifying relative. For additional
eligibility requirements
for
these credits, see Pub. 972, Child
Tax Credit and Credit
for
Other Dependents. You can also
include
other
tax
credits
in
this
step
,
such
as
education
tax
credits and
the
foreign
tax
credit.
To
do
so, add
an
estimate
of
the
amount
for
the
year
to
your
credits
for
dependents
and
enter
the
total amount
in
Step
3. Including these credits
will increase
your
paycheck and reduce
the
amount
of
any
refund you
may
receive when you file
your
tax return.
Step
4 {optional).
Step
4(a). Enter
in
this step
the
total
of
your
other
estimated income
for
the
year,
if
any. You
shouldn't
include
income
from
any
jobs
or
self-employment.
If
you complete ,
Step
4(a), you likely
won't
have
to
make estimated tax
payments
for
that
income
.
If
you prefer
to
pay
estimated tax
rather
than
having
tax
on
other
income withheld from
your
paycheck,
see
Form 1040-ES, Estimated Tax
for
Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5,
if
you expect
to
claim deductions other than
the basic standard deduction
on
your 2020 tax return and
want
to
reduce your withholding
to
account
for
these
deductions. This includes both itemized deductions and other
deductions such as
for
student loan interest and IRAs.
Step 4(c). Enter in this step any additional
tax
you want
withheld from your
pay
each
pay
period, including any
amounts from
the
Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund
or
reduce any amount
of
tax that you owe.
Page3
Form
W-4
(2020)
Step
2(b)-Multiple
Jobs Worksheet (Keep
for
your
records.)
If
you choose the option
in
Step 2{b) on Form W-4, complete this worksheet {which calculates the total extra tax for
all
jobs)
on
only
ONE
Form W-4. Withholding will be most accurate
if
you complete the worksheet and enter the result
on
the Form W-4 for the highest paying job.
Note:
If
more than one job has annual wages
of
more than $120,000
or
there are more than three jobs, see Pub. 505
for
additional
tables; or, you can use the online withholding estimator at
www.irs.gov/W4App.
1
Two jobs.
If
you have
two
jobs
or
you're married filing jointly and you and your spouse each have one
job, find the amount from
the
appropriate table on page 4. Using the "Higher Paying
Job"
row and the
"Lower Paying
Job"
column, find the value at the intersection
of
the
two
household salaries and enter
1 $
that value on line
1.
Then,
skip
to
line 3 .
--'-------
2 Three jobs.
If
you and/or your spouse have three
jobs
at the same time, complete lines 2a, 2b, and
2c
below. Otherwise, skip
to
line 3.
a Find the amount from
the
appropriate table on page 4 using the annual wages from
the
highest
paying
job
in
the
"Higher Paying
Job"
row and the annual wages for your next highest paying
job
in
the "Lower Paying
Job"
column. Find the value at
the
intersection
of
the
two
household salaries
and enter
that
value
on
line
2a
.
2a
.,_
$
_____
_
b Add the annual wages
of
the
two
highest paying jobs from line 2a together and use
the
total as the
wages in the "Higher Paying
Job"
row and use the annual wages for your third
job
in the
"lower
Paying
Job"
column
to
find
the
amount from the appropriate table on page 4 and enter this amount
on line
2b
2b
-=$
_____
_
c
Add
the
amounts from lines
2a
and
2b
and enter
the
result on line
2c
2c $
-'-----
--
3 Enter
the
number
of
pay periods
per
year for the highest paying
job
. For example,
if
that
job
pays
weekly, enter 52;
if it
pays every other week, enter 26;
if it
pays monthly, enter 12, etc. 3
4
Divide
the
annual amount on line 1
or
line
2c
by
the number of
pay
periods on line
3.
Enter this
amount here and in
Step 4(c)
of
Form W-4
for
the
highest paying job (along with any other additional
amount you want withheld) .
4 $
Step
4(b)-Deductions
Worksheet (Keep
for
your
records.)
1
2
Enter
an
estimate
of
your
2020 itemized deductions {from Schedule A {Form 1040
or
1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up
to
$10,000), and medical expenses in excess
of
10%
of
your income
$24,800
if
you're married filing jointly
or
qualifying widow(er) l
Enter: $18,650
if
you're head
of
household
(
$12,400
if
you're single
or
married filing separately
1
2
$
-'--------
.;::$
____
_
3
If
line 1 is greater than line 2, subtract line 2 from line 1.
If
line 2 is greater than line 1, enter
"-0-"
.
3
..;:.$
____
_
4 Enter
an
estimate
of
your student loan interest, deductible IRA contributions, and certain other
adjustments (from Schedule 1 {Form 1040
or
1040-SR)). See Pub. 505 for more information
4
..;::.$
____
_
5
Add
lines 3 and
4.
Enter the result here and in Step 4(b)
of
Form
W-4
.
5 $
Privacy
Act
and Paperwork
Reduction
Act
Notice.
We
ask
for
the
information
on
this
form
to
carry
out
the
Internal Revenue
laws
of
the
United States. Internal
Revenue
Code
sections
3402(1)(2)
and
6109
and
their
regulations require
you
to
provide
this
information;
your
employer
uses
it
to
determine
your
federal
income
tax
withholding. Failure
to
provide a properly
completed
form
will
result
in
your
being
treated as a single person
with
no
other
entries
on
the
form;
providing
fraudulent information
may
subject
you
to
penalties. Routine
uses
of
this
information
include
giving
it
to
the
Department
of
Justice
for
civil
and
criminal
litigation;
to
cities, states,
the
District
of
Columbia,
and
U.S.
commonwealths
and
possessions
for
use
in administering their
tax
laws;
and
to
the
Department
of
Health
and
Human
5eNices
for
use
in
the
National Directory
of
New
Hires.
We
may
also
disclose
this
information
to
other
countries
under
a
tax
treaty,
to
federal
and
state
agencies
to
enforce federal
nontax
criminal
laws,
or
to
federal
law
enforcement
and
intelligence agencies
to
combat
terrorism.
You
are
not
required
to
provide
the
information requested
on
a form
that
is
subject
to
the
PapeJWOrk Reduction
Act
unless the
form
displays a valid
0MB
control
number.
Books
or
records relating
to
a
form
or
its
instruct
i
ons
must
be
retained
as
long
as
their
contents
may
become
material in
the
administration
of
any
Internal Revenue law. Generally,
tax
returns
and
return
informat
i
on
are
confidential,
as
required
by
Code
section
6103
.
The average
time
and
expenses
required
to
complete
and
file
this
form
will
vary
depending
on
individual circumstances.
For
estimated averages,
see
the
instructions
for
your
income
tax
return.
If
you
have
suggestions
for
making
this
form
simpler,
we
would
be
happy
to
hear
from
you.
See
the instructions
for
your
i
ncome
tax
return.
Form W
-
4
(2020)
Page4
Married
Filina Jointly
or
Qualifving Widow(er)
Higher
Paying
Job
Lower Paying
Job
Annual Taxable Wage & Salary
Annual
Taxable
$0-
$10,000-
$20,000-
$30,000-
$40,000- $50,000-
$60,000- $70,000-
$80,000-
$90,000-
$100,000-
$110,000
Wage & Salary 9,999 19,999
29,999
39,999 49,999 59,999 69,999
79,999 89,999
99,999 109,999 120,000
$0-
9,999
$0
$220
$850
$900
$1,020
$1,020
$1,020
$1,
020
$1,020 $1,210 $1,870 $1,870
$10,000-
19,999
220
1,220 1,900 2,100
2,220 2,220 2,220 2,220
2,410 3,410 4,070
4,070
$20,000-
29,999
850
1,900
2,730 2,930
3,050 3,050
3,050
3,240
4,240 5,240 5,900 5,900
$30,000
39,999
900
2,100
2,930 3,130 3,250 3,250
3,440
4,440 5,440 6,440
7,100 7,100
$40,000
49,999
1,020 2,220 3,050 3,250
3,370 3,570 4,570
5,570 6,570 7,570 8,220 8,220
$50,000-
59,999
1,020
2,220 3,050 3,250
3,570 4,570 5,570
6,570 7,570 8,570 9,220 9,220
$60,000-
69,999 1,020
2,220 3,050
3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220
10,220
$70,000-
79,999
1,020 2,220
3,240 4,440 5,570 6,570 7,570 8,570 9,570
10,570 11,220 11,240
$80,000-
99,999 1,060
3,260
5,090 6,290 7,420 8,420 9,420 10,420
11,420
12,420
13,260 13,460
$100,000- 149,999
1,870
4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920
14,120 14,980 15,180
$150,000 - 239,999 2,040 4,440
6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250
$240,000- 259,999
2,040
4,440 6,470 7,870 9,190 10,390 11,590
12
,790
13,990
15,520 17,170 18,170
$260,000- 279,999
2,040
4,440
6,470
7,870 9,190 10,390 11,590
13
,
120
15,120 17,120 18,770 19,770
$280,000 - 299,999
2,040
4,440
6,470 7,870 9,190 10,720 12,720 14,720 16,720
18,720 20,370 21,370
$300,000 - 319,999
2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320
20,320 21,970 22,970
$320,000 364,999 2,720
5,920 8,750
10,950
13,070
15,070 17,070 19,070 21,290 23,590 25,540 26,840
$365,000- 524,999
2,970 6,470 9,600 12,100
14,530 16,830 19,130 21,430 23,730 26,030 27,980
29,280
$525,000
and
over
3,140
6,840
10,170
12,870
15,500
18,000 20,500 23,000 25,500 28,000 30,150 31,650
ing e
or
M
arrie
"dFT
11na
Se
parate
y
Higher
Paying
Job
Lower Paying Job Annual Taxable Wage
& Salary
Annual
Taxable
$0-
$10,000- $20,000- $30,000-
$40,000-
$50,000
$60,000 -
$70,000-
$80,000-
$90,000-
$100,000- $110,000
Wage & Salary
9,999 19,999 29,999
39,999
49,999
59,999
69,999 79,999 89,999 99,999
109,999 120,000
$0
-
9,999
$460 $940 $1,020 $1,020 $1,470
$1,870 $1,870
$1,870 $1,870 $2,040
$2,040
$2,040
$10,000-
19,999 940 1,530 1,610 2,060
3,060
3,460 3,460
.
3,460
3,640
3,830
3,830 3,830
$20,000 · 29,999 1,020
1,610
2,130
3,130
4,130
4,540
4,540 4,720
4,920 5,110
5,110
5,110
$30,000-
39,999 1,020
2,060 3,130
4,130
5,130
5,540
5,720
5,920 6,120 6,310
6,310
6,310
$40,000-
59,999 1,870 3,460 4,540
5,540
6,690 7,290 7,490
7,690 7,890 8,080
8,080
8,080
$60,000-
79,999 1,870 3,460 4,690 5,890
7,090
7,690 7,890
8,090
8,290
8,480 9,260
10,060
$80,000 99,999 2,020 3,810
5,090 6,290
7,490
8,090 8,290
8,490
9,470 10,460
11,260
12,060
$100,000 124,999 2,040 3,830 5,110
6,310 7,510
8,430 9,430
10,430
11,430 12,420
13,520
14,620
$125,000 - 149,999 2,040 3,830
5,110 7,030
9,030
10
,
430
11,430 12,580
13,880
15,170 16,270
17,370
$150,000-174,999
2,360 4,950
7,030
9,030 11,030 12,730
14,030 15,330
16,630
17,920
19,020 20,120
$175,000-199,999
2,720
5,310
7,540
9,840 12,140
13,840
15,140 16,440 17,740
19,030 20,130
21,230
$200,000 - 249,999 2,970 5,860
8,240
10,540 12,840 14,540
15,840 17,140
18,440
19,730 20,830
21,930
$250,000- 399,999 2,970
5,860 8,240
10,540 12,840
14,540
15,840 17,140
18,440 19,730
20,830
21,930
$400,000 - 449,999 2,970
5,860
8,240
10,540 12,840
14,540
15,840 17,140
18,450 19,940
21,240
22,540
$450,000
and
over
3,140 6,230
8,810
11,310 13,810
15,710
17,210 18,710
20,210
21,700
23,000
24,300
Head
of
Household
Higher
Paying
Job
Lower Paying
Job
Annual Taxable Wage & Salary
Annual
Taxable
$0-
$10,000-
$20,
000-
$30,000 ·
$40,000-
$50,000-
$60,000
$70,000-
$80,000-
$90,000 - $100,000-
$110,000 -
Wage &Salary
9,999 19,999 29,999
39,999
49,999
59,999
69,999
79,999
89
,
999
99,999
109,999
120,000
$0-
9,999
$0
$830
$930
$1,020
$1,020 $1,020
$1,480
$1,870 $1,870
$1,930
$2,040
$2,040
$10,000-
19,999
830 1,920
2,130 2,220
2,220
2,680 3,680
4,070
4,130
4,330
4,440 4,440
$20,000-
29,999
930
2,130
2,350
2,430
2,900
3,900
4,900
5,340 5,540
5,740
5,850 5,850
$30,000-
39,999 1,020
2,220
2,430 2,980
3,980
4,980 6,040
6,630
6,830 7,030
7,140
7,140
$40,000 -
59,999 1,020 2,530
3,750
4,830
5,860
7,060
8,260
8,850
9,050 9,250
9,360
9,360
$60,000-
79,999 1,870
4,070
5,310
6,600
7,800
9,000 10,200
10,780
10,980 11,180 11,580
12,380
$80,000-
99,999
1,900
4,300
5,710
7,000 8,200
9,400
10,600 11,180
11,670
12,670
13,580
14,380
$100,000 124,999
2,040 4,440
5,850
7,140
8,340
9,540
11,360 12,750
13,750
14,750
15,770
16,870
$125,000
-149,999
2,040 4,440
5,850 7,360
9,360
11,360
13,360 14,750
16,010
17,310 18,520
19,620
$150,000 - 174,999
2,040 5,060
7,280
9,360
11,360
13,480 15,780
17.460 18,760
20
,060 21,270
22,370
$175,000 - 199,999 2,720
5,920 8,130
10,480 12,780
15,080 17,380 19,070
20,370 21,670
22,880 23,980
$200,000 - 249,999
2,970
6,470
8,990
11,370 13,670
15,970 18,270
19,960
21
,
260
22,560 23,770 24,870
$250,000 - 349,999
2,970
6,470
8,990 11,370
13,670
15,970 18,270
19,960
21,260 22,560 23,770
24,870
$350,000 449,999
2,970
6,470
8,990 11,370
13,670
15,970 18,270
19,960
21,260 22.560 23,900
25.200
$450,000 and
over
3,140
6,840
9,560
12,140 14,640
17,140
19,640 21,530
23,030 24,530 25,940
27,240
-------
USCIS
Employment Eligibility Verification
Form
1-9
Department
of
Homeland Security
OM0No
. 1615-0047
U.S. Citizenship and Immigration Services
E'(p1
rcs
IOi3 l!202:?
START HERE: Read instructions carefully before completing this form. The instructions must be available, either
in
paper
or
electromcally,
during completion
of
this form. Employers are liable for errors in the completion
of
this form.
ANTI-DISCRIMINATION NOTICE: It
is
illegal to discnminate against work-authorized
ind
jvlduals. Employers
CANNOT
specify which document(s) an
employee
may
present
to
establi
sh
emp
loyment authonzation and idenbty.
The
refusal to hire
or
contu
nue
to
employ an indivcdual because the
documentation presented
has
a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees
must
complete
and
sign Section 1
of
Form
1-9
no
later
than the first
day
of
employment.
but
not
before accepting a
job
offer.)
Last
Name (Family Name)
First
Name
(Given Name,
Middle Initi
al
Other Last Names Used (
if
any)
Address (Street Number
and
Name)
Apt.
Number
City
or
Town
State
ZIP Code
Date
of
Birth (mmlddlyyyy)
U.S. Social
Secunty
Number
Employee's E-mail Address
Employee's Telephone Number
[[D-m-11111
I
am
aware that federal law provides
for
imprisonment and/or fines for false statements
or
use
of
false documents
in
connection with the completion
of
this form.
I attest, under penalty
of
perjury, that I
am
(check
one
of
the
following boxes):
D 1. A citizen
of
the United States
2. A noncitizen national
of
the United States (See instructions)
,__...
----
------
~--~
D 3. A lawful permanent resident (Alien Registration Number/USCIS Number
>:
D 4.
An
alien authorized
to
work
until (expiration date. if applicable, mm/dd/yyyy):
Some aliens
may
write
"N
I
A"
In
the
expiration date field. (See instructions)
Aliens authorized
to
work
must
provide
only
one
of
the following document numbers to complete Form
1-9
:
An
A
li
en Registration Number/USCIS Number
OR
Form
1-94
Admission Number
OR
Foreign Passport Number
1. Alien Reg
i,
st
f
al
ion NumberJUSCIS Number:
OR
2.
Form
1-94
Admission Number:
OR
3.
Foreign Passport
Number
:
Country
of
Issuance:
QR
Code -
Sec110n
1
Do No1 Wti
1e
In This
Spa
ee
s·Ignature
of
Employee Today's
Date
(mmlddlyyyy)
Preparer and/or Translator Certification (check one):
D I did
not
use a preparer
or
translator. 0 A preparer(s) and/or translator{s) assisted
the
employee
in
completing Section 1.
(Fields
below
must
be
completed
and
signed when preparers and/or translators assist an employee
in
completlng Section 1.)
I attest, under penalty
of
perjury, that I have assisted
in
the
completion
of
Section 1
of
this form and that to the best of my
knowledge
the
information is true
and
correct.
Signature
of
Preparer
or
Translator
IToday's Date (mmlddlyyyy)
Last Name (Family Name) First
Name
(Given Name)
Address (Street Number
and
Name)
City
or
Town
State
ZIP Code
Employer Completes
Next
Page
Fonn
1-9
I0
l
'.?
l r.!
Ol':.l
USCIS
Employment Eligibility Verification
Form I-9
Department
of
Homeland Security
OMBNo
. 1615-00-t7
U.S. Citizenship and Immigration Services Expires IOl.l I
.'
2022
Section-2. Employer
or
Authorizet:1
1Re~re~e~tative~Revievi
1
and~Verificatipn· . . _ . -
(Employers
or
their authorlzeil.representatlve mustcompfete anil sign Section 2 wfthln 3 business
~ays
of
the
emptoy_ef!S-ff1t
i:J~y
of
~mployment
.•
You
must
physl~a(ly
examine.
one
document
from
LJstA-OR a
.:
comblnatlon·
of
one
document.fr-om
List B and one document
from
IJst C as listed,on
the
l.lsts
of
Acceptable·Documents.") _ _
.-
~
_
Last Name (Family Name) IFirst Name (Given Name)
IMJ.
1Citizensh1p/lmmigration Status
Employee
Info
from
Section
1
I
List
A OR
list
B AND
List
C
Document Title
Document Title
Document Title
Issuing Authority
Issuing Authority
Issuing Authority
Document Number
Document Number
Document Number
Expiration Date
(if
any) (mmlddlyyyy)
Expiration Date
(if
any) (mmlddlyyyy)
Expiration Date
(if
any) (mmlddlyyyy)
Document Title
QR
Code
SetlKl<l$ 2 & 3
Issuing Authority
Additional
Information
Do
Not
Write n
ThlS
Spa~
Document Number
Expiration Date
(
if
any) (
mmlddlyyyy
)
Document
Tit
re
Issuing Authority
,,
"
Document Number
,;
Expiration Date /if any) (mmldd/yyyy)
Identity
and
Employment Authorization Identity Employment Authorization
Certification:
I attest,
under
penalty
of
perjury, that (1) I have examined the document(s) presented
by
the above-named employee,
(2) the above-listed document(s) appear
to
be genuine and to relate to
the
employee named, and (3)
to
the best
of
my knowledge the
employee is authorized
to
work
in
the United States.
The
employee's first day
of
employment (mmldd/yyyy):
_______
(See instructions for exemptions)
Signature
of
Employer
or
Authorized Representative
roday's
Date (mmldd/yyyy) I Title
of
Employer
or
Authorized Representative
Last
Name
of
Employer
or
Authorized
Representative
IFirst
Name
of
Employer
or
Authorized
Representative
IEmployer's Business or Organization Name
Employer's Business
or
Organization Address (Street
Number
and
Name) ICity or Town
IState
IZIP
Code
Section
~.
"
Reverification
and
Retiir,es,
n;-o
:
be
~mpleted and-signea'by employer
or
:authorized.
rep_resentative.)
I
B. Date
of
Rehire
(If
applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
A.
New
Name
(if
applicable)
Date (mmlddlyyyy}
1
C.
If
the employee's previous grant
of
employment authorization has
expired,
provide the information
for
the document
or
receipt that establishes
continuing employment authorization in the space provided below.
Document Title I Document Number
IExpiration Date (if any) (mmlddlyyyy)
I
attest,
under
penalty
of
perjury,
that
to
the
best
of
my
knowledge,
this
employee
is
authorized
to
work
in
the
United
States,
and
if
the
employee
presented
document(s),
the
document(s)
I
have
examined
appear
to
be
genuine
and
to
relate
to
the
Individual.
Signature
of
Employer or Authorized Representative Today's Date (mmlddlyyyy) Name
of
Employer
or
Authorized Representative
Page 2
of3
Fonn
1-9
10/21/2019
click to sign
signature
click to edit
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
Band
one selection from List C.
LIST A
Documents that Establish
Both Identity and
Employment Authorization
OR
1.
U.S. Passport
or
U.S. Passport Card
2.
Permanent Resident Card
or
Alien
Registration Receipt Card (Form 1-551)
3.
Foreign passport that contains a
temporary
1-551
stamp
or
temporary
1-
551
printed notation on a machine-
readable
imm
igrant visa
4.
Employment Authorization Document
that contains a photograph (Form
1-766)
5.
For a nonimmigrant alien authorized
to work for a specific employer
because
of
his
or
her
status:
a.
Foreign passport; and
b.
Form
1-94
or Form l-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.
6.
Passport from the Federated States
of
Micronesia (FSM)
or
the Republic
of
the Marshall Islands (RMI) with
Form 1-
94
or
Form 1~
94A
indicating
nonimmigrant admission under the
Compact
of
Free Association Between
the United States and the
FSM
or
RMI
LIST B
LISTC
Documents that Establish
Identity
AND
Documents that Establish
Employment Authorization
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,
he
ight, eye
color, and address
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 co,
or
, and address
3. School ID card with a photograph
4.
Voter's registration card
5.
U.S. Military card
or
draft record
6. Military dependent's ID card
7.
U.S. Coast Guard Merchant Mariner
Card
8.
Native American tribal document
9.
Driver's license issued
by
a Canadian
government authority
For persons under age 18 who are
unable to present a document
listed above:
10. School record
or
report card
11.
Clinic, doctor,
or
hospital record
12. Day-care
or
nursery school record
1.
A Social Security Account Number
card, unless the card includes one of
the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
{3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATI
ON
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
Amer
ican tnbal document
5.
U.S.
Cit
izen ID Card (Form
1-197
)
6.
Identification Card for Use
of
Resident
C1t
Izen
In
the United
States (Form 1-179)
7.
Employment authorization
document issued by the
Department
of
Homeland
Sec
unty
Examples
of
many
of
these documents appear in
the
Handbook for Employers (M-274).
Refer
to
the instructions for more information about acceptable receipts.
fo
nn 1-9 I
0!21120
19
Page 1
of1
CLGS-32-6 (8-111
RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding
TO
EMPLOYERS/TAXPAYERS:
This
fonn
is
to
be
used
by
employers and/or taxpayers
to
report essential information
for
the collection
and
distribution
of
Local Eamed Income Taxes.
This fonn
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.
STREET ADDRESS
(No
PO Box,
RD
or
RR)
SECOND LINE
OF
ADDRESS
CITY
MUNICIPALITY (City, Borough
or
Township)
COUNTY
STATE
ZIP CODE
RESIDENT
PSD
CODE
I I I I I I I
DAYTIME PHONE NUMB
ER
TOTAL RESIDENT E
IT
RATE
EMPLOYER BUSINESS NAME
(Use
Federal 10
Name)
Ursinus College
STREET ADDRESS
WHERE
ABOVE EMPLOYEE REPORTS
TO
WORK
(No
PO
Box
, RO or RR)
601
E. Main Street
SECOND LINE OF ADDRESS
ZIP
COD
E
CITY
STATE
Collegeville
PA
19426
PHONE NUMBER
610 409-3000
MUNICIPALITY (City, Borough
or
Township)
Collegeville
COUNTY
WORK
LOCATION
PSD
CODE
Montgomery
461201
WORK
LOCATION NON-RESIDENT
EIT
RATE
1.00%
CERTIFICATION
Under
penalties
of
pe~ury, I (we) declare
that
I (we) have examined this information, including
a'l
accompanying
schedules
and
statements and
to
the best
of
my
(our)
be
~ef, they
are
true, correct and complete.
SIGNATURE
OF
EMPLOYEE
IDATE (
MM/DDNYYY
)
IPHONE
NUMBER
EMAIL
ADDRESS
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
Urs
inus College
STUDENT
PAYROLL
DIRECT
DEPOSIT
AUTHORIZATION
FORM
Name:
_____________
Social Security
Number
:
________
(no
dashes)
Direct Deposit requires
full
net
pay
to
be
distributed
to
the
checking
or
savings account listed
below
.
IMPORTANT
NOTE
: You must
attach
a voided check
or
form
from
your
bank showing
your
account
number
and
transit/routing
number
for
the
bank.
Return all
information
to
the
Human Resources Office located on
the
lower
level
of
Corson Hall.
BANK
ACCOUNT
INFORMATION
Financial
Institution
Name, Address and Phone
Number
:
Net
Payroll
will
be
deposited
to
this
account:
Savings
Checking
Bank
Transit/Rout
ing
Number
(9 digits):
Action
to
be taken:
Start
Stop Change
Account Number:
Authorization:
I hereby
authorize
Ursinus College
(the
"College")
to
initiate
direct
deposit
into
the
account and financial
institution
listed above. Payroll
direct
deposits
will
be
made
to
the
account listed above
until
I choose
to
terminate
this
agreement
by
submission
of
a
new
Direct Deposit
Authorization
form
,
allowing
a
reasonable
amount
of
time
for
the
College
to
process such a change. Furthermore, I understand
that
termination
of
employment
with
the
College shall
constitute
sufficient
authorization
to
terminate
this
agreement.
Should funds be erroneously deposited
into
my
account, I authorize
the
College
to
debi
t
my
account
for
an
amount
not
to
exceed
the
amount
of
the
deposit.
EMPLOY
EE
SIGNATURE
:
______________
DATE
:
_________
_
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