TAX CLEARANCE

PURDUE UNIVERSITY Interoffice Memorandum To: From: Date: Subject: Tamara Carpenter / Tax Group Disbursements Tax Clearance Request Please provide the current year’s earnings information on Form W-2 and/or Form 1042S in order for the following individual to obtain a Tax Clearance from the Internal Revenue Service. NAME: SOCIAL SECURITY NUMBER: FINAL PAY AMOUNT: DATE LEAVING COUNTRY: ARRANGEMENTS FOR DELIVERY / PICKUP: Mail the forms to department Will pick up the forms in Freehafer Hall DEPARTMENT NAME: FINAL PAY DATE: DATE FORM NEEDED: The Form W-2 and/or Form 1042S will be available for pick up in Freehafer Hall at 1:00 p.m. on the date indicated above. Therefore, if the individual plans to go to the IRS on a Monday morning to obtain their tax clearance, you should indicate the forms are needed no later than the prior Friday. OTHER INFORMATION (IF NECESSARY): THIS SECTION TO BE COMPLETED BY PAYROLL Marital Status Federal Exemptions State Exemptions Year-To-Date Gross Pre-Tax Items Adjusted Gross Federal Tax State Tax County Tax SS/OASDI SS/HI Final Pay Tax Clearance Tax Clearance Adjusted Gross Form W-2 Form 1042S taxclearancerequest.xls (Rev 10-2002)