Form W-4 - Uw Employee Self-Identification And W-4 Withholding Forms Page 4
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Human Resource System
Form W-4 | Employee’s Withholding Allowance Certificate
See Reverse Side for Instructions
Please Type Data Below. This is a tax form. Do not use this form for an Address Change only. On every W-4 form you
submit you must indicate your marital status and exemption status or it will be assigned to Single with zero exemptions.
Personal Information
Last Name
First Name
MI
Date of Birth
(mm/dd/yyyy)
Gender
U.S. Social Security Number
Empl ID (if known)
Home Phone Number
Male
Female
Other
Email Address
Citizenship – Check the box that best describes you
Born in USA
Naturalized Citizen
Neither
If ‘Neither’, complete International Visitors section at bottom.
Marital Status – For Tax Withholding (check only one)
Single (or married but legally separated)
Married
Married but withhold at higher Single rate
Note: All Nonresident Aliens are required to check either ‘Single’ or ‘Married but withhold at higher Single rate’
(see additional instructions on reverse side)
Street
Apt. No.
City
State
Zip
U.S.
Address
Street
Apt. No.
City
Foreign
Province
Country
Postal Code
Address
Home Information Release – My home address, telephone number, or email address may be made available for the staff directory and
released to the public upon request.
Yes
No
Withholding Information
Exempt (Exempt status expires annually on February 15). International Nonresident Alien employees cannot claim exempt.
(This is not international tax treaty. See Glacier instructions on back.)
I claim exemption from withholding this year. I certify that I meet BOTH of the following:
Last year I had a right to a refund of ALL income tax withheld because I had no tax liability; AND
This year I expect a refund of ALL income tax withheld because I expect to have no tax liability
AND that I do not meet the conditions listed on the reverse side.
EXEMPT for Federal Tax:
Yes
No
EXEMPT for Wisconsin State Tax:
Yes
No
If you have checked yes in one of these boxes, do NOT enter any amounts in the Federal and/or Wisconsin State Tax blocks.
FEDERAL TAX
WISCONSIN STATE TAX
Additional State Tax to be
Number of Allowances for
Additional Federal Tax to be
Number of Allowances for
Federal Tax (leave blank
Withheld:
State Tax (leave blank
Withheld:
if claiming exempt):
_______
$____________________
if claiming exempt):
_______
$____________________
Wisconsin Nonresident Reciprocity Declaration
I declare that while working in Wisconsin, I am a legal resident of the state indicated below, and that I am not subject to Wisconsin income
tax withholding in accordance with a reciprocal tax agreement. Check appropriate box:
Indiana
Illinois
Michigan
Kentucky
If you have checked one of these boxes, do NOT enter any amounts in the Wisconsin State Tax blocks.
If your UW work is performed outside of Wisconsin, you reside outside of Wisconsin, and you are not a Wisconsin resident, complete
the following:
USA State or foreign country of Residence: _______________________________________________________________________
USA State or foreign country where work is performed: ______________________________________________________________
U.S. Citizens working outside of the U.S. may qualify for exemption from state and federal income tax by filing
IRS Form
673.
Under the 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. (This form is not valid unless you sign it.)
Employee Signature
Date
(mm/dd/yyyy)
All International Visitors Complete the Following – See reverse side for instructions
Are you a permanent U.S. resident (green card holder)?
Original Date of Entry to the
Country of Citizenship:
U.S. on current immigration
status:
Yes
No - if ‘No’, specify Visa Type
Country of Tax Residence (not U.S.):
(current immigration status):__________
(mm/dd/yyyy)
P102.20150203
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