PAYROLL INFORMATION AND W-4 FORM by gaa11000

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									         PAYROLL INFORMATION AND W-4 FORM
Name _____________________________________ ID No. ___________
Address _____________________________________________________
City/State ____________________________________ZIP_____________ County_________________
Social Security Number ___________________________ Date of Birth _________________________
Marital Status: Single _______               Married ________ Telephone Number ____________________

Federal Tax Withholding (Will Replace IRS W-4)

Tax Withholding Status (check one): Single or Head of Household                   _______        Married        ________

Federal Allowances: _________          Additional Dollar Amount: $ __________ Per Month (Optional)
(You may designate a number of allowances or one of the following percentages: 10%, 15%, 25%, 27% or 28%)

State Tax Withholding – SAU reports income to Michigan or Ohio. You are only required to pay
tax to one state provided there is a Reciprocity Agreement. If you are eligible for Reciprocity for your
state of residence, please complete the appropriate Withholding Certificate on the back of this form).

Michigan State Tax (Will Replace MI-W4) - Complete if a Michigan Resident or Working in Michigan

State Allowances:      _________       Additional Dollar Amount: $ __________ Per Month (Optional)
(May not exceed the number of personal exemptions you are entitled to claim when filing your Federal return.)

   I am a resident of Illinois, Indiana, Kentucky, Minnesota, Ohio or Wisconsin (circle one) and elect not to have
Michigan taxes deducted. I have completed the Statement of Residency on the back of this form.

Ohio State Tax (Will Replace an IT-4 or IT 4NR) – Complete if an Ohio Resident

State Allowances: __________           Additional Dollar Amount $___________ Per Month (Optional)
(May not exceed the number of personal exemptions you are entitled to claim when filing your Federal return.)

County ___________________ Public School District/Tax Number _____________________________________

City Tax Withholding - If you reside in any of these cities, as an SAU employee, you will be responsible to
have your allocated income reported and/or may be responsible to pay city tax. Please note your residence status
for each of these cities.

Michigan Info: Battle Creek: Resident ____ Grand Rapids: Resident ____
               Jackson:      Resident ____ Lansing:      Resident ____

Ohio Info:       Maumee:              Resident ____



Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on
this certificate or, if claiming exemption from withholding, that I am entitled to claim the exempt status.

Employee’s Signature ___________________________________________ Date ____________________

C:\Documents and Settings\rnegron\Local Settings\Temporary Internet Files\OLK17F\Student Payroll
Info and W-4 Form.doc            Revised 7/31/2007
Complete only one if you are working in a state that has reciprocity with your resident state. Please contact
the Human Resource Office with any questions…(517) 750-6431


I Work in Michigan but a Resident of Another State With Reciprocity:

                    Michigan Employee’s Statement of Residency In a Reciprocity State

Print full name _______________________________________________Social Security Number ______________________

Home address and ZIP Code ______________________________________________________________________________

Michigan Employers: Employers located in Michigan must withhold Michigan income tax from all compensation paid to
nonresident employees for work done in Michigan, unless covered by a reciprocal agreement. Michigan has entered into
reciprocal agreements with the states of Illinois, Indiana, Kentucky, Minnesota, Ohio and Wisconsin. This means that a
Michigan employer will not withhold Michigan income tax from residents of these states who work in Michigan.
Employees residing outside Michigan and in a state with whom Michigan reciprocity: If you are a resident of a state with
whom Michigan has reciprocity, you may claim exemption from withholding of Michigan income tax by completing this form
and filing it with your employer under reciprocal withholding agreements between Michigan and these states.

Note: If you change your residence from the state specified herein to any other state, you must notify your employer with 10
days.

I hereby declare, under penalties of perjury, that I am a resident of the state of _____________________ and that, pursuant to
an agreement existing between that state and the state of Michigan. I claim exemption from withholding of Michigan income
tax on compensation paid to me in the state of Michigan.

Signature ____________________________________________________________ Date ____________________________




C:\Documents and Settings\rnegron\Local Settings\Temporary Internet Files\OLK17F\Student Payroll
Info and W-4 Form.doc            Revised 7/31/2007

								
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