Form W-4 - Uw Employee Self-Identification And W-4 Withholding Forms
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4University 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)
National ID Type:
SSN or ITIN:
Date of Birth:
Sex:
Social Security Number
Individual Tax ID Number
mm/dd/yyyy
Routing Instructions: Submit to your local HR/Payroll Office. (If at UW-Madison, submit to 21 North Park Street, Suite
5101.)
Ethnicity and Heritage Code
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
No
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.
Signature:
Date:
mm/dd/yyyy
_____________________________________________________________________ _______________________
For Office Use Only | Empl ID: ___________________ Empl Rcd#: _______________
H322.20140324
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