Fillable Uw Employee Self-Identification And W-4 Withholding Form (Page 2 of 3) in pdf

University of Wisconsin Service Center

Human Resource System

Employee Self-Identification Form

Last Name:

First Name:

Middle Initial:

Veterans Survey

If you are a veteran or a spouse of a disabled or deceased veteran, we invite you to indicate your status below. If none of the

categories apply to you, please check "None of the selections below apply to me". We are requesting this information to fulfill annual

federal and state statistical reporting and affirmative action monitoring requirements. Submission of this information is voluntary and

no adverse consequences will result from either providing this information or declining to provide it. Your responses will be kept

confidential.

Should you decide not to self-identify your veteran status at this time, you may do so at any time in the future. If you have any

questions, please contact your payroll office.

None of the selections below apply to me.

Veteran (If you are a veteran, please select all categories below that apply.)

A person who served on active duty in the U.S. armed forces. Discharge Date:

mm/dd/yyyy

Regional

Armed Forces Service Medal Veteran (federal)

A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States

military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Other Protected Veteran (federal)

A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or

expedition for which a campaign badge has been authorized. For a complete list of wars, campaigns and expeditions, please

see

Vietnam Era Veteran (federal)

A veteran who served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and

who was discharged or released there from with other than a dishonorable discharge, or was discharged or released from

active duty for a service-connected disability, if any part of such active duty was performed in the Republic of Vietnam

between February 28, 1961 and May 7, 1975 or between August 5, 1964 and May 7, 1975, in all other cases.

UW Personal

Wartime Veteran (state)

A veteran who served in one of the wartime periods or campaigns listed at

Non-Wartime Veteran (state)

A veteran who served on active duty for the full period of service obligation, but did not serve in any of the qualifying

wartime periods or campaigns listed at

Disabled Veteran (federal)

A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to

compensation) under laws administered by the Secretary of Veterans Affairs, or who was discharged or released from

active duty because of a service-connected disability.

Please indicate percent disability:

Special Disabled Veteran (federal)

A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who, but for the receipt of

military retired pay, would be entitled to compensation) under laws administered by the Department of Veterans Affairs

for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20 percent in the case of a veteran who has been

determined under 38 U.S.C. 3106 to have a serious employment handicap, or a person who was discharged or

released from active duty because of a service-connected disability.

UW Personal

Spouse of a 70% Disabled Veteran (state)

A spouse of a disabled veteran whose service-connected disability is 70% or higher.

UW Personal

Spouse of a Deceased Veteran (state)

An unremarried spouse of a veteran who was killed in action or a veteran who died of a service-connected disability.

Signature:

Date:

mm/dd/yyyy

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

For Office Use Only:

Empl ID:

Empl Rcd#:

H322.20121015

Page 2 of 3

Uw Employee Self-Identification And W-4 Withholding Form Page 2

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