Systems and Procedures
A Division of The Corporate Controller's Office


Form Instructions

  1. I-9 Stamp - This box is for Human Resources use only.
  2. PSU-ID # - Enter your PSU-ID number
  3. Social Security Number - Enter your Social Security Number
  4. Last Name - Enter your Last Name as it appears on your Social Security Card.
  5. First Name - Enter your First Name
  6. Middle Name - Enter you Middle Name or Initial
  7. Suffix - Enter any Suffix (Jr., Sr., II, III, etc.) as applicable
  8. Home Street Address - Enter your home street address
  9. Home City or Town - Enter your home city or town
  10. State - Enter the two (2) letter abbreviation of your state
  11. Zip Code - Enter your zip code
  12. Taxing Authority (City, Borough, or Township) - If a Pennsylvania resident, enter your city, borough, or township taxing authority. If not a Pennsylvania resident, skip this box
  13. School District - If a Pennsylvania resident, entry the school district associated with your taxing authority. If not a Pennsylvania resident, skip this box.
  14. Home Phone - Enter your home phone number including the area code
  15. Work or Campus Location - Enter your PSU work or campus location
  16. County of above Address - If a Pennsylvania resident, enter the County of resident. Please note that this is COUNTY not COUNTRY.
  17. Date of Birth - Enter your date of birth. The format must be mm/dd/yyyy
  18. Office Address - Enter your office address
  19. Building Name - Enter your building name
  20. Do you work for PSU in Pennsylvania? If Yes check box 1 or check box 2 if No
  21. If NO - What state or country do you work in for PSU? If you do not work for PSU in Pennsylvania, enter the state or country in which you work
  22. Are you a citizen of the U.S.? If yes, check box 1. If no, check box 2
  23. Type of Visa - If not a citizen of the U.S. enter the type of Visa used to enter USA (F, J, H, etc.) or enter your residency status (i.e. Perm Res, EAD, etc.).
  24. Are you a non-resident alien for US tax purposes? If yes, check box 1. If no, check box 2
  25. Sex - If male, check box 1. If female, check box 2
  26. Department Employed By - Enter the name of the department you are employed by
  27. Marital Status - Select Box 1 to withhold at the Single rate. Select Box 2 to withhold at the Married rate. Select Box 3 to indicate Married, but withhold at higher Single rate. Note: If married, but legally separated, or spouse is a non-resident alien, check "Single" box
  28. Different last name - If your last name differs from that shown on y our social security card, check this box and call 1-800-772-1213 to request a new card.
  29. Withholding Allowances - Enter the total number of allowance you are claiming (use IRS Publication 505 with related worksheets, as necessary). You may also elect to have additional withholding. If so, indicate the additional dollar amount you want deducted from each pay. This amount must be in whole dollars.
  30. Email Address - Enter your email address (this may be either your PSU email or a personal email address)
  31. Signature (Required) - You are required to sign this form
  32. Date (Required) - You are also required to date this form
Image of W-4 Employee Withholding Allowance Certificate Form