Form W-4 - Employee'S Withholding Allowance Certificate
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2University of Wisconsin Service Center
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
Home Phone Number
(if known)
Male
Female
Other
Email Address
Citizenship – Check the box that best describes you
Born in USA
Naturalized Citizen
Neither
If Neither, complete the rest of this form AND the
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
Address
Province
Country
Postal Code
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
Number of Allowances for
Additional Federal Tax to be
Number of Allowances for WI
Additional WI State Tax to
Federal Tax (leave blank
Withheld:
State Tax (leave blank
be Withheld:
if claiming exempt):
if claiming exempt):
$
$
Leave above fields blank for all other states outside of Wisconsin.
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 primarily performed outside of Wisconsin (WI), you reside outside of WI and it is not a reciprocal state as defined
above, but a portion of your work is performed in WI during any calendar year; refer to instructions on the back for Non-WI residents.
U.S. state or foreign country of
U.S. state or foreign country
If CA residence, please indicate # of
Additional CA State Tax to
tax residence:
where work is performed:
allowances for CA state tax (leave
be Withheld:
blank if claiming exempt):
$
U.S. Citizens working outside of the U.S. may qualify for exemption from state and federal income tax by filing
IRS Form
673.
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 U.S.
Country of Citizenship
on current immigration status:
Yes
No - if No, specify Visa Type
Country of Tax Residence (not U.S.)
(current immigration status): _______
(mm/dd/yyyy)
Signature
Under the penalties of perjury, I declare that I have examined this entire 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)
For Office Use Only
Empl ID:
UDDS/Department ID:
P102.20150825
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