Fill - Free fillable We are required by Ohio law (Ohio Revised (Youngstown State University) PDF form

PUBLIC SCHOOL DISTRICT OF RESIDENCE EMPLOYEE WITHHOLDING CERTIFICATE

We are required by Ohio law (Ohio Revised Code Section 5747.06b) to ask all employees for their

public school district of residence.

Please fill out, sign and date this form. Your exemptions are the same for school district withholding as

they are for state income tax withholding purposes.

Return the completed document to your Payroll Department.

NAME __________________________________________

SOCIAL SECURITY NUMBER _____________________

ADDRESS ______________________________________________________________

PUBLIC SCHOOL DISTRICT OF RESIDENCE ________________________________

PUBLIC SCHOOL DISTRICT NUMBER __________________

____________________________________________________ ________________

Signature of Employee Date

IT 4

Rev. 5/07

Employee’s Withholding Exemption Certificate

Print full name Social Security number

Home address and ZIP code

Public school district of residence School district no.

(See The Finder at tax.ohio.gov.)

1. Personal exemption for yourself, enter “1” if claimed ...............................................................................................................

2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) ............................................

3. Exemptions for dependents .......................................................................................................................................................

4. Add the exemptions that you have claimed above and enter total ...........................................................................................

5. Additional withholding per pay period under agreement with employer ..................................................................................

Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.

Signature Date

IT 4

Rev. 5/07

✁✁

✁ please detach here

Notice to Employee

1. For state purposes, an individual may claim only natural de-

pendency exemptions. This includes the taxpayer, spouse

and each dependent. Dependents are the same as defined

in the Internal Revenue Code and as claimed in the taxpayer’s

federal income tax return for the taxable year for which the

taxpayer would have been permitted to claim had the tax-

payer filed such a return.

2. You may file a new certificate at any time if the number of your

exemptions increases.

You must file a new certificate within 10 days if the number of

exemptions previously claimed by you decreases because:

(a) Your spouse for whom you have been claiming exemp-

tion is divorced or legally separated, or claims her (or his)

own exemption on a separate certificate.

(b) The support of a dependent for whom you claimed ex-

emption is taken over by someone else.

tion must be dropped for federal purposes.

The death of a spouse or a dependent does not affect your

withholding until the next year but requires the filing of a new

certificate. If possible, file a new certificate by Dec. 1st of the

year in which the death occurs.

For further information, consult the Ohio Department of Taxa-

tion, Personal and School District Income Tax Division, or

your employer.

3. If you expect to owe more Ohio income tax than will be

withheld, you may claim a smaller number of exemptions;

or under an agreement with your employer, you may have

an additional amount withheld each pay period.

4. A married couple with both spouses working and filing a

joint return will, in many cases, be required to file an indi-

vidual estimated income tax form IT 1040ES even though

Ohio income tax is being withheld from their wages. This

result may occur because the tax on their combined in-

come will be greater than the sum of the taxes withheld

from the husband’s wages and the wife’s wages. This

requirement to file an individual estimated income tax form

IT 1040ES may also apply to an individual who has two

jobs, both of which are subject to withholding. In lieu of

filing the individual estimated income tax form IT 1040ES,

the individual may provide for additional withholding with

his employer by using line 5.

hio

Department of

Taxation

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

Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

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 . . .............

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)

Page 2

income includes all of your wages and

other income, including income earned by

a spouse if you are filing a joint return.

Line G. Other credits. You may be able to

reduce the tax withheld from your

paycheck if you expect to claim other tax

credits, such as tax credits for education

(see Pub. 970). If you do so, your paycheck

will be larger, but the amount of any refund

that you receive when you file your tax

return will be smaller. Follow the

instructions for Worksheet 1-6 in Pub. 505

if you want to reduce your withholding to

take these credits into account. Enter “-0-”

on lines E and F if you use Worksheet 1-6.

Deductions, Adjustments, and

Additional Income Worksheet

Complete this worksheet to determine if

you’re able to reduce the tax withheld from

your paycheck to account for your itemized

deductions and other adjustments to

income, such as IRA contributions. If you

do so, your refund at the end of the year

will be smaller, but your paycheck will be

larger. You’re not required to complete this

worksheet or reduce your withholding if

you don’t wish to do so.

You can also use this worksheet to figure

out how much to increase the tax withheld

from your paycheck if you have a large

amount of nonwage income not subject to

withholding, such as interest or dividends.

Another option is to take these items into

account and make your withholding more

accurate by using the calculator at

www.irs.gov/W4App. If you use the

calculator, you don’t need to complete any

of the worksheets for Form W-4.

Two-Earners/Multiple Jobs

Worksheet

Complete this worksheet if you have more

than one job at a time or are married filing

jointly and have a working spouse. If you

don’t complete this worksheet, you might

have too little tax withheld. If so, you will

owe tax when you file your tax return and

might be subject to a penalty.

Figure the total number of allowances

you’re entitled to claim and any additional

amount of tax to withhold on all jobs using

worksheets from only one Form W-4. Claim

all allowances on the W-4 that you or your

spouse file for the highest paying job in

your family and claim zero allowances on

Forms W-4 filed for all other jobs. For

example, if you earn $60,000 per year and

your spouse earns $20,000, you should

complete the worksheets to determine

what to enter on lines 5 and 6 of your Form

W-4, and your spouse should enter zero

(“-0-”) on lines 5 and 6 of his or her Form

W-4. See Pub. 505 for details.

Another option is to use the calculator at

www.irs.gov/W4App to make your

withholding more accurate.

Tip: If you have a working spouse and your

incomes are similar, you can check the

“Married, but withhold at higher Single

rate” box instead of using this worksheet. If

you choose this option, then each spouse

should fill out the Personal Allowances

Worksheet and check the “Married, but

withhold at higher Single rate” box on Form

W-4, but only one spouse should claim any

allowances for credits or fill out the

Deductions, Adjustments, and Additional

Income Worksheet.

Instructions for Employer

Employees, do not complete box 8, 9, or

10. Your employer will complete these

boxes if necessary.

New hire reporting. Employers are

required by law to report new employees to

a designated State Directory of New Hires.

Employers may use Form W-4, boxes 8, 9,

and 10 to comply with the new hire

reporting requirement for a newly hired

employee. A newly hired employee is an

employee who hasn’t previously been

employed by the employer, or who was

previously employed by the employer but

has been separated from such prior

employment for at least 60 consecutive

days. Employers should contact the

appropriate State Directory of New Hires to

find out how to submit a copy of the

completed Form W-4. For information and

links to each designated State Directory of

New Hires (including for U.S. territories), go

to www.acf.hhs.gov/css/employers.

If an employer is sending a copy of Form

W-4 to a designated State Directory of

New Hires to comply with the new hire

reporting requirement for a newly hired

employee, complete boxes 8, 9, and 10 as

follows.

Box 8. Enter the employer’s name and

address. If the employer is sending a copy

of this form to a State Directory of New

Hires, enter the address where child

support agencies should send income

withholding orders.

Box 9. If the employer is sending a copy of

this form to a State Directory of New Hires,

enter the employee’s first date of

employment, which is the date services for

payment were first performed by the

employee. If the employer rehired the

employee after the employee had been

separated from the employer’s service for

at least 60 days, enter the rehire date.

Box 10. Enter the employer’s employer

identification number (EIN).

Form W-4 (2019)

Page 3

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself .............................. A

B Enter “1” if you will file as married filing jointly ....................... B

C Enter “1” if you will file as head of household . . . .................... C

D Enter “1” if:

{

• You’re single, or married filing separately, and have only one job; or

• You’re married filing jointly, have only one job, and your spouse doesn’t work; or

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

}

E Child tax credit. See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.

• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each

eligible child.

• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for

each eligible child.

• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” .......

F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.

• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every

two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have

four dependents).

• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” .......

G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet

here. If you use Worksheet 1-6, enter “-0-” on lines E and F ..................

H Add lines A through G and enter the total here . . ....................

For accuracy,

complete all

worksheets

that apply.

{

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you

have a large amount of nonwage income not subject to withholding and want to increase your withholding,

see the Deductions, Adjustments, and Additional Income Worksheet below.

• If you have more than one job at a time or are married filing jointly and you and your spouse both

work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the

Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form

W-4 above.

Deductions, Adjustments, and Additional Income Worksheet

Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage

income not subject to withholding.

Enter an estimate of your 2019 itemized deductions. These 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. See Pub. 505 for details ...................... 1

2 Enter:

{

$24,400 if you’re married filing jointly or qualifying widow(er)

$18,350 if you’re head of household

$12,200 if you’re single or married filing separately

}

........... 2

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . .............. 3

4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any

additional standard deduction for age or blindness (see Pub. 505 for information about these items) . .

5 Add lines 3 and 4 and enter the total ...................... 5

6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6

7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7

8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction ............................

9 Enter the number from the Personal Allowances Worksheet, line H, above . . ........ 9

Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/

Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here

and enter this total on Form W-4, line 5, page 1 ...................

Form W-4 (2019)

Page 4

Two-Earners/Multiple Jobs Worksheet

Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the

Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that

worksheet) .............................. 1

Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re

married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for

you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . .....

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”)

and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . ..........

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to

figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet ........... 4

5 Enter the number from line 1 of this worksheet ........... 5

6 Subtract line 5 from line 4 .......................... 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here ..... 7

8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8

Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every

2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in

2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld

from each paycheck ...........................

Table 1

Married Filing Jointly

If wages from LOWEST

paying job are—

Enter on

line 2 above

$0 - $5,000 0

5,001 - 9,500 1

9,501 - 19,500 2

19,501 - 35,000 3

35,001 - 40,000 4

40,001 - 46,000 5

46,001 - 55,000 6

55,001 - 60,000 7

60,001 - 70,000 8

70,001 - 75,000 9

75,001 - 85,000 10

85,001 - 95,000 11

95,001 - 125,000 12

125,001 - 155,000 13

155,001 - 165,000 14

165,001 - 175,000 15

175,001 - 180,000 16

180,001 - 195,000 17

195,001 - 205,000 18

205,001

and over

All Others

If wages from LOWEST

paying job are—

Enter on

line 2 above

$0 - $7,000 0

7,001 - 13,000 1

13,001 - 27,500 2

27,501 - 32,000 3

32,001 - 40,000 4

40,001 - 60,000 5

60,001 - 75,000 6

75,001 - 85,000 7

85,001 - 95,000 8

95,001 - 100,000 9

100,001 - 110,000 10

110,001 - 115,000 11

115,001 - 125,000 12

125,001 - 135,000 13

135,001 - 145,000 14

145,001 - 160,000 15

160,001 - 180,000 16

180,001 and over 17

Table 2

Married Filing Jointly

If wages from HIGHEST

paying job are—

Enter on

line 7 above

$0 - $24,900 $420

24,901 - 84,450 500

84,451 - 173,900 910

173,901 - 326,950 1,000

326,951 - 413,700 1,330

413,701 - 617,850 1,450

617,851

and over

1,540

All Others

If wages from HIGHEST

paying job are—

Enter on

line 7 above

$0 - $7,200 $420

7,201 - 36,975 500

36,976 - 81,700 910

81,701 - 158,225 1,000

158,226 - 201,600 1,330

201,601 - 507,800 1,450

507,801 and over 1,540

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(f)(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 who claims no

withholding allowances; 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

Services 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 aren’t required to provide the

information requested on a form that’s

subject to the Paperwork Reduction Act

unless the form displays a valid OMB

control number. Books or records relating

to a form or its instructions must be

retained as long as their contents may

become material in the administration of

any Internal Revenue law. Generally, tax

returns and return information 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

income tax return.

Authorization for Direct Deposit of Pay

This form must be submitted at the time of initial hire or anytime banking information changes. Allow two weeks for

processing this request. Your pay stub may be viewed through the YSU Portal.

auhorize Youngstown State University (YSU) to initiate direct deposit of my net pay to the

financial institution(s) and account number(s) specified below. In the event YSU deposits funds erroneously into my account(s), I authorize YSU to debit my

account(s) for an amount not to exceed the original amount of credit. I agree to indemnify YSU against any loss sustained by me by reason of such action. I

understand that YSU maintains the right to terminate, suspend, or amend the direct deposit program in whole or in part at any time.

Employee Name

Employee

Information

Action

Requested

Banner ID# or SSN

Campus Department

Phone

Select One

Enroll Cancel Change

Payroll Office Use Only Entered into system on________ __ by __________

ATTACH YOUR VOIDED CHECK HERE

RETURN C

OMPLETED FORM TO THE PAYROLL OFFICE

Payroll – November, 2014

Bank

Information

Note: You may choose up to three financial institutions or accounts for deposit of your pay. If you choose two or more, you

must specify a dollar amount to be deposited into the first account(s); the remainder of your net pay will go into the account

with no dollar amount specified.

Select One

Checking

Savings

Checking

Savings

Checking

Savings

Bank Name

Bank Routing Number

Bank Account Number

Amount To Be Deposited

Signature (Required)

Date

Reset Form

StudentEmployeesOhioPublicEmployeeRetirementSystem(OPERS)Membership

As a newly hired student employee of Youngstown State University (YSU), you will automatically  be enrolled in Ohio Public

EmployeesRetirementSystem(OPERS).Yourcontributionsare10%ofyourearningseachpay,whichisdeductedonapre‐taxbasis.

YSU also contributes to the retirement plan based on 14% of

 your earnings.You must also complete the “StatementConcerning

YourEmploymentinaJobNotCoveredbySocialSecurity”form(SSA‐1945).



Requestfor Optional ExemptionfromOPERS ‐ As a studentemployee, youmay choose to request optional exemption from

membershipin OPERSwithin30daysofemployment.Yourexempt statuswillremain validthroughoutyourstudentemployment

withYSU.Ifyouareinterested,OPERSwillsendyouanemailandtextmessagewithinstructionsfordownloadingtheirmobileapp.

The app will have step‐by‐step directions for submitting a

 request for optional exemption.Once the request for exemption is

approvedbyOPERS,youwillreceiveanemailortextconfirmationfromOPERS.



PleaseNote‐Ifyouareemployedduringthesummerbutnotenrolledinoneormorecredithoursofclass,youwillberequiredto

contribute10%ofyourearningstoOPERS.Exemptstatusisnotavailableifyouarenotenrolledinatleastonecredithourofclass.

Ifyoureturntoenrollmentofoneormorecredithourofclassinthefall,youroriginalexemptionwillresumeandcontributionsto

OPERSwill

stop.Youmayrequesta refundofyourcontributionsfromOPERSafteryougraduateandterminateyouremployment

withYSU.Shouldyourequestarefund,OPERSwillonlyrefundyour10%contribution.Thiswilleliminateanyretirementservicein

OPERSthatyouhaveearnedduringyouremploymentwithYSU.



Additional Information‐For additional information, contact OPERS Member Services Center at 1‐800‐222‐7377 or visit their

websiteatwww.opers.org.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Basedontheinformationpresentedabove,pleaseselectoneoftheoptionsbelowbyplacingacheckmarkintheappropriatebox.



YES I would like to enroll in OPERS and understand an employee contribution of 10% will be deducted from my

paycheck.Thisdecisionisirrevocableduringmystudent

employmentatYSU.

UNDECIDEDIamormaybeinterestedinrequestingoptionalexemptionfromOPERSmembership.Iunderstandthat Iwillbe

contacted via email and/or text message from OPERS with instructions to download their mobile app that will

includeinstructionsoncompletingmyexemptionrequest.Mycontactinformationis

below.



FirstName  MiddleInitial

                                    

LastName  

                                      

SSN EmploymentDate CellPhoneNumber

  

‐

 

‐

     

‐



‐

 

‐

 

‐



EmailAddress

  



 

                              



Bysigningbelow,IagreethatIhavemadeaninformedselection,theretirementelectionoptionslistedabovehavebeenexplained

tome,andIunderstandtheoptionsastheyhavebeenpresented.



_________________________________________ _________________________________________ _____________

Signature PrintedName Date



ForOfficeuseonly: _________________________________ ___________________________________ OPERSDetermination(circleone)‐EnrolledExempt

 FormReceivedby‐Initials/Date EnteredinOPERS‐Initials/Date

Social Security Administration

Statement Concerning Your Employment in a Job

Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled,

you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit

from Social Security based on either your own work or the work of your husband or wife, or former husband or

wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits,

however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit

amount may be affected.

Windfall Elimination Provision

Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a

modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax.

As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this

job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as

a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not

totally eliminate, your Social Security benefit. For additional information, please refer to Social Security

Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision

Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you

become entitled will be offset if you also receive a Federal, State or local government pension based on work

where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or

widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social

Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If

you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 -

$400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security

benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security

Publication, “Government Pension Offset.”

For More Information

Social Security publications and additional information, including information about exceptions to each

provision, are available at www.socialsecurity.gov

. You may also call toll free 1-800-772-1213, or for the deaf

or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the

Windfall Elimination Provision and the Government Pension Offset Provision on my potential future

Social Security Benefits.

Signature of Employee

Date

Form SSA-1945 (01-2013)

Destroy Prior Editions

Information about Social Security Form SSA-1945 Statement Concerning Your

Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires

State and local government employers to provide a statement to employees hired January 1, 2005 or later in a

job not covered under Social Security. The statement explains how a pension from that job could affect future

Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is

the document that employers should use to meet the requirements of the law. The SSA-1945 explains the

potential effects of two provisions in the Social Security law for workers who also receive a pension based on

their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a

worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a

Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

•

Give the statement to the employee prior to the start of employment;

•

Get the employee’s signature on the form; and

•

Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website,

www.socialsecurity.gov/online/ssa-1945.pdf

. Paper copies can be requested by email at

ofsm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The request must include the name, complete

address and telephone number of the employer. Forms will not be sent to a post office box. Also, if

appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in

packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (01-2013)

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