10/19/70 - Laserfiche WebLink

Home

Form Unit No. I he,reby certify that according to the records be.came an employee of this , (Office, Dept. or Institution) PERA-OASI COORDINATED FUND; LAWS 1967, CHAPTER 687 PUBLIC EMPLOYEES RETIRE~MENT ASSOCIATION TO BE COMPLETED BY EMPLOYING DEPARTMENT ~: I DO NOT USE THIS SPACE Membership No. (Governmental Unit) on (Month, Day and Year) and salary is $ Date __ and that the title of his ~ her position is per hour - per day - Per re°nth, By ~ (Authorized slgnatute) (Title) MEMBER'S PERSONAL INFORMATION ~TO BE cOMPLETi~EO ~¥ MEMBER Note to employee - accurate and complete information is essential to insure that salary, deductions taken from your compen- sation for the Public Employees Retirement Fund will be c0£iecti¥ credited to your individual account. Your name: f~flce, Dept. or Institution) PRINT (First Name) (Middle, Maiden{ and former Married Name, i[ any) Your date of birth: ~ ~-;/~ 7- , ~-~-~ (Re~ionship, if any) (Go, etnm~ Unit) (Last Name) MALE FEMALE , whose address is ~ . , who is my as my beneficiary - beneficiaries, to (Share and share alike o~ to ~he Survivor or survivors), hereby revoking any and all (Cross out any or all of this:phrase Which does not apply) former designations of beneficiaries which may appear on the records of the Public Employees Retirement Association. Names and birth dates of minor dependent children: IMPORTANT - Complete record of public service, including present employment and prior public service, if any: ~ From To : From To ' From To · ~ From To Are you a member of any other Minnesota public retirement System? If so, name system: Your Social Security No. ~/~'--- (/~,- ~-5/ i~;-'~_' . (Signature of Employe~~'- In Ink) (Address) (Zin Code] EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE Type or print full ~ame ...:..~_~(~_~ ...... ~.~ ................ ~ ....................... Social Secdri~ Number ........... ~..'.2..:L...~......~A~7._L..~.a: / Home addre...~..._~_~~~.....~ ....... Ci~ ...~~ ................... Stat, .~.Z..~./. ............. ZIP code.xS.:.~..=:2.C2 '~ EMPLOYEE: File this form with your employ- er. Otherwise, he must withhold U.S. income tax from .your wages with- out exemption. EMPLOYER: Keep this cer- tificate' with your records. If the employee is be- lieved to have claimed too many exemptions, the District Director should be so advised, HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS I. If SINGLE (or if married and wish withholding as single person), write "1." If you claim no exemptions, write "0". ............. 2. If MARRIED, one exemption each is allowable for husband and wife if not claimed on another certificate. (a) If you claim both of these exemptions, write 2; (b) If you claim one of these exemptions, write 1 ; (c) claim neither of these exemptions, write "0" . . .- ....................... 3. -Exemptions for age and blindness (applicable only to you and your wife but not to dependents): (a) If you or your wife will be 65 years of age or older at the end of the year, and you claim this exemption, write 'T'; if both will be 65 or older, and you claim both of these exemptions, write "2" . ....................... (b) If you or your wife are blind, and you claim this exemption, write "1"; if both are blind, and you claim both of these exemptions, write "2" . ........................................ 4. If you claim exemptions for one or more dependents, write the number of such exemptions. (Do not claim exemption for a dependent unless you are qualified under Instruction 4 on other side.) ........................... 5. If ~tou claim additional withholding allowances for itemized deductig.r~ fill out and attach Schedule A (Form W-4), and enter the number of allowances claimed (if claimed file new Form W-4 e~h year) ........................... 6. Add the exemptions and allowances (if any) which you have claimed above and write total .......... 7. Additional withholding per pay period under agreement with employer. (See Instruction 1.)~-.' ....... I CERTIFY tjlat the number of withholding exemptions claimed on this certificate does not exc. eed'l~p nupl~er to .which l_.,m entiJIcqT-') ' .~ c48--10--?0051-1 ....... ..... ¢,g,ed .... ...... ....................................