January 2016

Dear LHUP Student Employee:

lp}\1\\\11111/Uff?P ... LOCK HAVEN UNIVERSITY

As a new student employee, there are several steps that must be completed prior to beginning employment at Lock Haven

University. Please know that you will not be able to begin your employment, or be paid for time worked, until all of the

steps below are completed:

l. All information requested on the student employment forms is personal information. If you need assistance in determining the correct information needed to complete any of these documents, please contact your parent, legal guardian, accountant, or someone who is familiar with your personal situation. Department timekeepers do not have knowledge of your personal information to complete these forms.

2. Training on the use of E-time (the process by which you will be entering your hours worked for payroll) is available at the Office of Human Resources. If you require training on the process to enter time in E-time, please contact the Office of Human Resources at 570-484-2230. If you are unable to log on to E-Time, please call the Computing Center Hotline at 570-484-2286.

You will not have access to E-time until all your paperwork is completed and returned to the payroll office. Once this step is complete you will have access to enter your hours via E-time at https://po11al.passhe.edu/ irj/po1tal. Your login will be your full LHU email address and your password will be temp!xOO xOO (x=your middle initial & OO=the last two digits of your SSN).

3. Effective January I, 2015, in accordance with Act 153 of 2014 (HB 43 5), all student employees are required

to complete the following background clearances PRIOR to beginning employment: Act 34, Pennsylvania

Criminal Record Clearance; Act 151 , Child Abuse Clearance; and Act 114, Federal Bureau oflnvestigations

(FBI) Criminal Background Checks. Employment is contingent upon completion of a satisfactory

background investigation. Employment cannot begin until the student, supervisor, and timekeeper

receive an email from LHU Student Employment indicating a student is cleared for employment.

4. Student Employees should contact Judy Saxon - Student Payroll at 570-484-2230 or jsaxon@lhup.edu to apply for appropriate background clearances. You will receive an email with directions to complete each background clearance. Students who believe they already possess the required clearances should also contact Judy Saxon.

5. Appointment is provisional for a single 90 day period provided the enclosed "Arrest/Conviction Report and Certification Form" is returned accompanied by all other required employment documents.

Sincerely,

~M_~-t(,(~ Deana Hill

Associate Vice President of Human Resources

Lock Haven University • Lock Haven, PA 17745

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This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Pennsylvania’s State System of Higher Education Background Clearance Certification

for Provisional Employment or Volunteering (Under the Child Protective Services Law)

Please read this entire form carefully before completing it. This form is to be used by prospective volunteers who reside in another state or country and employees to meet the written certification requirement to be considered as a provisional hire or volunteer assignment. This form does not apply to volunteers who reside in Pennsylvania. In certain limited circumstances, current employees/volunteers may need to complete this form.

Section 1. Personal Information

Full Legal Name: __________________________________________________ Date of Birth: ____/____/_______

Any former names or aliases by which you have been identified: _____________________________________________

Section 2. Instructions

If you have any question about whether to report an offense, you should report it. Failure to report may result in disqualification for employment.

List of Reportable Offenses

A Reportable Offense enumerated under Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6344(c), consists of one or more of the following:

1. Provisions of Title 18 of the Pennsylvania Consolidated Statutes (relating to crimes and offenses) or an equivalentcrime under the laws or former laws of the United States or one of its territories or possessions, another state, theDistrict of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of theCommonwealth of Pennsylvania:

Chapter 25 relating to criminal homicide Section 2702 relating to aggravated assault Section 2709.1 relating to stalking Section 2901 relating to kidnapping Section 2902 relating to unlawful restraint Section 3121 relating to rape Section 3122.1 relating to statutory sexual assault Section 3123 relating to involuntary deviate sexual

intercourse Section 3124.1 relating to sexual assault Section 3125 relating to aggravated indecent assault Section 3126 relating to indecent assault

Section 3127 relating to indecent exposure Section 4302 relating to incest Section 4303 relating to concealing death of a child Section 4304 relating to endangering welfare of

children Section 4305 relating to dealing in infant children A felony offense under Section 5902(b) relating to

prostitution and related offenses Section 5903(c) or (d) relating to obscene and other

sexual materials and performances Section 6301 relating to corruption of minors Section 6312 relating to sexual abuse of children

2. An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The ControlledSubstance, Drug, Device and Cosmetic Act,” committed within the preceding five-year period.

3. A founded report of child abuse within the preceding five-year period in the statewide database maintained by theDepartment of Human Services.

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This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Section 3. No Conviction

By checking this box, I certify that I have not been convicted of any Reportable Offense or an offense similar in nature to a Reportable Offense under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of the Commonwealth of Pennsylvania. (See Section 2 for a list of Reportable Offenses.)

Section 4. Application for Background Checks

I certify that I have applied for the following required background clearance checks:

A report of criminal history record from the Pennsylvania State Police (PSP) or statement from the PSP that no criminal record exists.

Certification from the Pennsylvania Department of Human Services as to whether I am named in the statewide database as a perpetrator in a pending child abuse investigation or in a founded report or indicated report of child abuse.

A report of federal criminal history record information. I understand that I must submit a full set of fingerprints to the PSP to obtain this report.

I further certify that I have provided copies of the completed request forms for these background clearance checks to Pennsylvania’s State System of Higher Education. (Appropriate forms may be attached to this Certification Form.)

Section 5. Certification

By signing this form, I swear and affirm under penalty of law that the statements made in this form are true, accurate, correct, and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

I understand that after successful completion of the criminal background clearance process, I have a continuing obligation to notify the Human Resources Department within seventy-two (72) hours after an arrest or conviction for an offense defined in the “Reportable Offense” list. If I am unsure about the applicability of my arrest or conviction as a Reportable Offense, it is my responsibility to notify the Human Resources Department for further review. I understand that failure to disclose any arrest or conviction of a “Reportable Offense” shall be considered as non-compliance, subject to disciplinary action, up to and including termination, and/or criminal prosecution, as applicable.

_____________________________________________________ _____________________________________ Signature Date

LOCK HAVEN UNIVERSITY OF PA Student Application for New Employment or Fund Center Change

*Student may not begin work until employment paperwork is completeIt is the policy of the PASSHE that you cannot work until you have a social security number

If your address changes at any time, please notify Student Payroll

Name

PERNR# - Completed by Payroll

Social Security Number

Date of Birth Local or Cell Telephone Number

Beginning Date of Employment

PU.S. Citizen

lease mark the appropriate box.

Resident or Nonresident Alien (Every calendar year you must complete Statement of Citizenship in the International Office. You will not be put on the payroll until all paperwork is completed.)

Gender: Male Female

Check here if you are a veteran

Currently enrolled in classes at Lock Haven University

I declare that this statement, to the best of my knowledge, is true and correct. Falsifying hours worked will result in IMMEDIATE TERMINATION of Student Employment Student Signature Date

LHUP E-mail address

NOTE TO SUPERVISORS: Students may work no more than 20 hours per week during the semesters. Prior approval must be obtained, in writing, from Department of Student Affairs to work more than 20 hours. Students may work 37.5 hours per week, a maximum of 7.5 in a day, during summer and scheduled breaks provided there are sufficient monies in your department fund center.

Completed paperwork is to be forwarded to Student Payroll Office, EC J207. Delay in submitting paperwork will result in student not being paid in a timely manner.

1. ______________________________ _______________ Department Date

__ __ __ __ __ __ __ __ __ __.__ __ __ __ __ 10 digit Fund Center (Grant WBS)

2. _____________________________Supervisor - Printed Name Supervisor - Signature

_____________________________

Form W-4 (2017)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20171 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under 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.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

Form W-4 (2017) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,700 if married filing jointly or qualifying widow(er)$9,350 if head of household . . . . . . . . . . .$6,350 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 07,001 - 14,000 1

14,001 - 22,000 222,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 95,000 10

95,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $8,000 08,001 - 16,000 1

16,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 70,000 570,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

LOCAL EARNED INCOME TAXRESIDENCY CERTIFICATION FORM

DCED-CLGS-06 (1-11) COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT

GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES

EMPLOYEE INFORMATION - PERMANENT RESIDENCE LOCATION

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.

This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last, FIrst, Middle Initial)

FIRST LINE OF ADDRESS (If PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE

PHONE NUMBER EMAIL ADDRESS

MUNICIPALITY (City, Borough, Township) Write Municipality name and Circle Municipality type

COUNTY PSD CODE Payroll Use Only TOTAL RESIDENT EIT RATE

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN

FIRST LINE OF ADDRESS (IIf PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough, Township)

COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,

please refer to the Pennsylvania Department of Community & Economic Development website:

www.newPA.com

Select Get Local Gov Support, >Municipal Statistics

LOCK HAVEN UNIVERSITY OF PENNSYLVANIA 

ETHNICITY/RACE INFORMATION 

A racial identification code is an integral part of the personnel records of every employee at Lock Haven University.  All information is confidential. 

Please provide accurate information. 

1. WHAT IS YOUR ETHNICITY? (Select One Option)

Hispanic or Latino 

Persons of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. 

Not Hispanic or Latino 

2. WHAT IS YOUR RACE? (Select one or more)

American Indian or Alaska Native 

Persons having origins in any of the original peoples of North and South America (including Central America). 

Asian 

Persons 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. 

Black or African American 

Persons having origins in any of the black racial groups of Africa. 

Native Hawaiian or Pacific Islander 

Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands. 

White/Caucasian 

Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. 

Signature______________________________________ Date_______________ 

Student Employment Practices Lock Haven University of PA

In accordance with the Board of Governors Policy, 1983-10, Lock Haven University of PA [hereafter the University or LHUP] has established undergraduate student employment practices for Campus Employment and Federal Work Study [FWS] employment. Students receiving financial aid who are interested in Federal Work Study may be granted those funds through the Student Financial Services [SFS] Office located in 223 Ulmer Hall. Students may identify both Campus Employment and FWS employment opportunities through LHUP website.

General Guidelines

• Students earn minimum wage and are permitted to work up to 20 hours per week during theacademic year.

• Students may work up to 20 hours during the academic year and 37.5 hours per week during thesummer and scheduled breaks.

• It is recommended that first year students be limited to no more than 15 hours per week during theacademic year.

• Students cannot be assigned to work directly for any family members.• Students may not work for more than two fund centers, and the total combined hours worked

cannot exceed 20 hours during the academic year and 37.5 hours during the summer.• No student may work more than 7.5 hours in a single day.

• Students must be enrolled for at least six credits each semester as an undergraduate studentor three credits as a graduate student..• Students seeking employment for the summer must be enrolled either for a summer session or forthe next fall session.

• Students returning to work in the same office need not complete the employment applicationprocess again unless there is a change in fund center.

• Students may identify employment opportunities through the following website:http://www.lhup.edu/students/student_resources/career_services/

• Any student enrolled at the University may be employed through Campus Employment.• Campus Employment is funded through established fund centers and is subject to budget

restrictions. A fund center is assigned a specific amount of student employment funding at thebeginning of the fall semester which can be used to fund as many students as funding permits.

• Student employment forms for LHUP students are available on the LHUP web site.

• Students must complete the required employment forms, which should then be given to theirdepartment supervisor/timekeeper for review and signature. Supervisors/timekeepers mustreview all forms for completeness. The I-9 form instructions must be followed, and theappropriate documents must be copied and attached to the completed employment forms. Yoursupervisor/timekeeper will review/copy the I-9 doucments for you.

• No student may begin working until all forms are completed, signed, and reviewed and thesupervisor/timekeeper has submitted them to the Human Resources Office for processing.

I, ________________________________________ (print name), affirm that I have read and understand the above guidelines and agree to abide by them.

__________________________________________ __________________ Signature of LHUP Student Employee Date

State System of Higher Education The System Works for Pennsylvania

Tired of going to the bank or waiting in line to cash your check? Introduce yourself to Direct Deposit.

How Direct Deposit works: The State System of Higher Education notifies your Financial Institution electronically of the funds to be deposited on your behalf. Your Financial Institution records this transaction into an account of your choice, creating immediate access on the day of deposit. You receive an earnings statement documenting this payment.

It’s convenient - saves you a trip to the bank.It’s faster - most banks post the funds to your account at the beginning

of the day’s business on payday allowing immediate access. It’s safer - Direct Deposit eliminates the worry of a lost or stolen paycheck. It’s confidential - funds are automatically processed and you can instruct the

bank to apply them to your savings or checking account.

Sign up today by completing the form below and contacting your Human Resource Office. ---------------------------------------------------------------------------------------------------------------------

Direct Deposit Authorization

Name___________________________ SAP PERNR # Completed by Payroll ________________

I hereby authorize the State System of Higher Education to (check one) ___ Start ___ Change ___ Stop total bi-weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings and loan association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2) accepts electronic funds transfer. Payroll will notify you if the institution you choose does not qualify.

Financial Institution’s Name___________________________ Transit Routing Number______________________________ Account Number____________________________________ Type of Account____________________________________ (Checking or Savings)

Effective with pay date of_____________________________

I have an established account at the Financial Institution indicated above, and authorize the State System of Higher Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries in error to my (our) account(s) indicated above. I have provided a copy of a voided check (see attached) solely for the purpose of verifying my account number and the Financial Institution’s routing number. My authorization will remain in effect until revoked by me in writing or I terminate my employment with the State System of Higher Education.

Date_______________________ Signature________________________________________

Co-Signature (If Joint Account)________________________________________

I:\Payroll\BEH\Direct Deposit Authorization

LOCAL SERVICES TAX – EXEMPTION CERTIFICATE 2017

Tax Year

APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX

A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax for the municipality or school district in which you are primarily employed. This application for exemption from the Local Services Tax must be signed and dated. No exemption will be approved until proper documentation has been received.

Name: Address: City/State:

Soc Sec #: Phone #: Zip:

REASON FOR EXEMPTION

1._______ MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal employer that shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld. List all employers on the reverse side of this form. You must notify your other employers of a change in principal place of employment within two weeks of the change.

2. ______ EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCESWITHIN City of Lock Haven (municipality or school district) WILL BE LESS THAN $ 12,000.00 : Attach copies of your last pay statements or your W-2 for the year prior.

If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior year.

3._______ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to active duty status. Annual training is not eligible for exemption. You are required to advise the tax office when you are discharged from active duty status.

4._______ MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a statement from the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this exemption.

EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by the tax collector to withhold the tax.

Tax Office: City of Lock Haven Address: 20 E. Church St. City/State: Lock Haven, PA

Phone #: 570-893-5621 Zip: 17745

IMPORTANT NOTE TO EMPLOYERS 1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers

and self-employment) in their municipality is less than $12,000 when the combined rate exceeds $10.00. 2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the

income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999. 3. Contact the tax office where your business worksites are located to obtain this information.

LST Exemption 10-07

Employment Information: List all places of employment for the applicable tax year. Please list your PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self employed, write SELF under Employer Name column.

1. PRIMARY EMPLOYER 2. 3. Employer Name Lock Haven University Address 301 W. Church St. Address 2 City, State Zip Lock Haven, PA Municipality Lock Haven Phone 570-484-2230 Start Date 1/1/17 End Date 12/31/17 Status (FT or PT) PT Gross Earnings

4. 5. 6. Employer Name Address Address 2 City, State Zip Municipality Phone Start Date End Date Status (FT or PT) Gross Earnings

PLEASE NOTE:

All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX.

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND ATTACHED TO THIS FORM IS TRUE AND CORRECT:

SIGNATURE: DATE:

LST Exemption 10-07

1.

2.

3.

4.

5.

6.

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LISTA LISTB LISTC

Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization

Employment Authorization DR AND

U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number

Permanent Resident Card or Alien State or outlying possession of the card, unless the card includes one of

Registration Receipt Card (Form 1-551) United States provided it contains a the following restrictions: photograph or information such as (1) NOT VALID FOR EMPLOYMENT

Foreign passport that contains a name, date of birth, gender, height, eye

(2) VALID FOR WORK ONLY WITH color, and address temporary 1-551 stamp or temporary INS AUTHORIZATION 1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION

provided it contains a photograph or Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545)

3. School ID card with a photograph 3. Certification of Report of Birth For a nonimmigrant alien authorized

to work for a specific employer 4. Voter's registration card issued by the Department of State

because of his or her status: (Form DS-1350) 5. U.S. Military card or draft record

a. Foreign passport; and 4. Original or certified copy of birth

b. Form 1-94 or Form 1-94A that has 6. Military dependent's ID card certificate issued by a State,

the following: 7. U.S. Coast Guard Merchant Mariner county, municipal authority, or territory of the United States

(1) The same name as the passport; Card bearing an official seal and

8. Native American tribal document (2) An endorsement of the alien's 5. Native American tribal document

nonimmigrant status as long as 9. Driver's license issued by a Canadian 6. U.S. Citizen ID Card (Form 1-197) that period of endorsement has government authority not yet expired and the 7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or unable to present a document States (Form 1-179) limitations identified on the form. listed above:

8. Employment authorization Passport from the Federated States of 10. School record or report card document issued by the Micronesia (FSM) or the Republic of Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form 1-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Form 1-9 03/08/13 N Page 9of9

STATEMENT OF CITIZENSHIP STATUS and TAXATION Pennsylvania State System of Higher Education

March 25, 2008 1 of 3

__________________________________ University Tax Year 20_______

In order to comply with the applicable provisions of the U.S. Internal Revenue Code, the information requested on this form is necessary for the University to determine the correct rate of Federal tax withholding.

DIRECTIONS: 1. Permanent U.S. resident immigrant, complete sections A,B,C, D and F, and attach a photo copy of your alien

registration card (green card). 2. All others, complete entire form, and attach a copy of your I-94 (Arrival and Departure Record) and your work

authorization paper work (DS-2019/IAP-66, I-20, Notice of Action, Employment Authorization Card).

A. PERSONAL INFORMATION:

Name (last, first, middle) Date of Birth Local Phone # Candidate for a degree? YES NO

Street address while in U.S. Street address in country of residence

City City Province

State Zip Code Country Postal Code

B. EMPLOYMENT INFORMATION:

Faculty / Staff Employee Student Worker (limited to 20 hours per week during the academic year)

C. SOCIAL SECURITY INFORMATION:

Have you applied for a Social Security Number (SSN)?

Yes - My number is _______ - ______ - _______

No have not applied. (In order work and be paid you are required to have a SSN. (Your university payroll office can direct you to the university representative who can assist you with this requirement. Please notify the Payroll office in writing when you receive your number.)

PRIVACY NOTIFICATIONS:

Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security Number is mandatory. Disclosure of the Social Security Number is required pursuant to sections 6011 and 6051 of Subtitle F of the Internal Revenue Code and with Regulation 4, Section 404.1256, Code of Federal Regulations under Section 218, Title II of the Social Security Act, as amended. The Social Security Number is used to verify your identity. The principal uses of the number shall be to report (1) state and federal income taxes withheld, (2) Social Security contributions, (3) state unemployment and Workers' Compensation earnings, and (4) earnings and contributions to participating retirement systems.

STATEMENT OF CITIZENSHIP STATUS and TAXATION Pennsylvania State System of Higher Education

March 25, 2008 2 of 3

D. CITIZENSHIP AND VISA INFORMATION:

Citizen of (Country) Resident of (Country)

What country issued you a passport? Passport Number What is the primary purpose of your visit to the US?

Is this your first visit to the U.S.? Yes No If no, please list all entries into the U.S. and the previous non-visitor visa types (F1, J1, H1-B):

Date of Entry into U.S. Date of Exit from U.S. Visa Type

Most recent U.S. entry date:

Visa type on I-94: Expiration date of I-94: Intended length of stay in U.S. (if known):

E. DETERMINATION OF FEDERAL TAX WITHHOLDING STATUS. (To be completed by alien.)

Follow directions for each test.

Test 1: “Exempt Individual” Days for Substantial Presence Check any applicable statement:

I have a Type A visa or Diplomatic or Consular status.

I have a J-1 visa and I was in the U.S. as a teacher, trainee, researcher, or student on a J-1 or F-1 visa for less than 2 calendar years of the preceding six years.

I am a student on an F-1 or J-1 visa and have been in the U.S. for five or fewer calendar years.

I am a student on an F-1 or J-1 visa and have been in the U.S. for more than five calendar years, and I have established with the IRS that I do not plan to reside in the U.S. when my education is completed. (Attach IRS notification letter)

If you marked any box, you are a nonresident alien for tax purposes. Please complete “Test 2” completely but instead of performing the calculation enter ZERO in the far right column, otherwise calculate the days.

STATEMENT OF CITIZENSHIP STATUS and TAXATION Pennsylvania State System of Higher Education

March 25, 2008 3 of 3

� Option: I elect to be treated as a U.S. citizen for income tax purposes. This election can be made as soon as I arrive in the United States. This will allow me to complete a W-4 like any U.S. citizen for federal withholding, and will make me subject to social security/Medicare taxes immediately. (Students may be exempt from FICA through the 218 Agreement.)

F. SIGNATURE:

I declare under the penalties of perjury that this statement, to the best of my knowledge and belief, is true and correct.

___________________________________________ Signature

______________________ Date

Department Contact:_________________________________________ Contact’s Phone #: ____________________

ATTACH ALL OF THE FOLLOWING DOCUMENTS:

All Nonresident Aliens in the U.S. under a visa � Completed Earned Income Questionnaire � Completed Form I-9 (1st time hired & thereafter upon

expiration of documents)� Completed Form W-4 � I-94� DS-2019/IAP-66 or I-20 � Copy of Social Security card � Copy of Passport & Visa Stamp

Green Card Holders � Completed Earned Income Questionnaire � Completed Form I-9 (1st time hired & thereafter upon

expiration of documents)� Completed Form W-4 (when hired, then optional

changes by employee)� Green Card (I1797/I1797Ad � Copy of Social Security card

Please forward this form and the requested documents to the Payroll Office.

Test 2: Substantial Presence Test (SPT)

I have been present in the US during the current and the previous two years as follows:

Enter year Visa Type

Date Entered US

Date Departed US

Number of Days in US

Computation of SPT

Current Year x 1 =

1st Preceding Year x 1/3 =

2nd Preceding Year x 1/6 =

Total Days: