Fillable Uw Employee Self-Identification And W-4 Withholding Form printable pdf download

University of Wisconsin Service Center

Human Resource System

UW Employee Self-Identification and W-4 Withholding Forms

The University is required to collect data on race and ethnicity from its employees to comply with federal record keeping and reporting

requirements. The information obtained will be kept confidential and will be used for summary federal reporting purposes and to

support institutional affirmative action efforts. Providing this information is voluntary.

The University also needs your W-4 Withholding Form so you have the appropriate taxes taken.

Last Name:

First Name:

Middle Initial:

Empl ID:

(if known)

SSN or ITIN:

Date of Birth:

mm/dd/yyyy

Sex:

National ID Type:

Social Security Number

Individual Tax ID Number

Routing Instructions: Forward to your local HR/Payroll Office. (If at UW-Madison, send to 21 North Park Street, Suite 5101.)

Ethnicity and Heritage Code

Regional

Ethnicity is considered Hispanic/Latino if a person is of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish

culture or origin, regardless of race.

Is your ethnicity Hispanic/Latino?

Yes

Please identify yourself as one or more of the following races:

Black or African American

A person having origins in any of the black racial groups of Africa.

Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including,

for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native

A person having origins in any of the original peoples of North and South America (including Central America) who maintains

cultural identification through tribal affiliation or community attachment.

White

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Native Hawaiian or other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Disability Self-Identification

UW Personal

All new university employees are invited to indicate their status below. It will be used to review progress being made in providing

employment opportunities to persons with disabilities.

I am not a person with a disability.

I am a person with a disability.

The Americans with Disabilities Act of 1990 (ADA) defines a person with a disability as a person who has a physical or

mental impairment that substantially limits one or more major life activities. Examples of major life activities are: hearing,

seeing, speaking, breathing, performing manual tasks, walking, caring for oneself, learning or working. [29 C.F.R.

S1630.2(i)]

I am a person with a severe disability.

Severely disabled person means a person with a chronic disability if the chronic disability meets all of the following

conditions:

-It is attributable to a mental or physical impairment or combination of mental and physical impairments.

-It is likely to continue indefinitely.

-It results in substantial functional limitations in one or more of the following areas of major life activity: self-care,

receptive and expressive language, learning, mobility, capacity for independent living, and economic self sufficiency.

(s.230.04 (9r)(a) 2., Stats.)

H322.20121015

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Uw Employee Self-Identification And W-4 Withholding Form

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