by user

Category: Documents





Welcome to the Pickerington Local School District. You will find the following forms enclosed. Please
complete each form as indicated below. Your forms are due back to the district office by
The appointment will only take a few minutes, but the information is required to process your payroll.
The following forms are needed at the time of your appointment:
City Tax Form
Employment Eligibility Verification-Form I-9 (please bring proper ID or copy and attach)
Proper ID – driver’s license and social security card
Federal Tax Form W-4
State Tax Form IT-4 (Please include school district of residence)
Retirement System Application –School Employees
Social Security Form
Ohio New Hire Reporting Form
Health Insurance Marketplace
Direct Deposit (Mandatory)
Important Contacts
Treasurer’s Office
Judy Entinger – Payroll (Classified and Supplemental Staff)
[email protected] / 614.834.2138
Lora Hunt – Payroll (Certified Staff and Substitute Teachers)
[email protected] / 614.834.2144
Rick Knapp – Payroll and Benefits Coordinator
[email protected] / 614.834.2148
Human Resources
Vicki Baptist – Administrative Secretary Human Resources Department
[email protected] / 614.834.2162
Nichole Walters – Administrative Secretary Human Resources Department
[email protected] / 614.834.2159
IT 4
Rev. 5/07
Notice to Employee
1. For state purposes, an individual may claim only natural dependency exemptions. This includes the taxpayer, spouse
and each dependent. Dependents are the same as defined
in the Internal Revenue Code and as claimed in the taxpayer’s
federal income tax return for the taxable year for which the
taxpayer would have been permitted to claim had the taxpayer filed such a return.
2. You may file a new certificate at any time if the number of your
exemptions increases.
You must file a new certificate within 10 days if the number of
exemptions previously claimed by you decreases because:
(a) Your spouse for whom you have been claiming exemption is divorced or legally separated, or claims her (or his)
own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption is taken over by someone else.
(c) You find that a dependent for whom you claimed exemption must be dropped for federal purposes.
The death of a spouse or a dependent does not affect your
withholding until the next year but requires the filing of a new
certificate. If possible, file a new certificate by Dec. 1st of the
year in which the death occurs.
For further information, consult the Ohio Department of Taxation, Personal and School District Income Tax Division, or
your employer.
3. If you expect to owe more Ohio income tax than will be
withheld, you may claim a smaller number of exemptions;
or under an agreement with your employer, you may have
an additional amount withheld each pay period.
4. A married couple with both spouses working and filing a
joint return will, in many cases, be required to file an individual estimated income tax form IT 1040ES even though
Ohio income tax is being withheld from their wages. This
result may occur because the tax on their combined income will be greater than the sum of the taxes withheld
from the husband’s wages and the wife’s wages. This
requirement to file an individual estimated income tax form
IT 1040ES may also apply to an individual who has two
jobs, both of which are subject to withholding. In lieu of
filing the individual estimated income tax form IT 1040ES,
the individual may provide for additional withholding with
his employer by using line 5.
✁ please detach here
Department of
Print full name
IT 4
Rev. 5/07
Employee’s Withholding Exemption Certificate
Social Security number
Home address and ZIP code
Public school district of residence
(See The Finder at tax.ohio.gov.)
School district no.
1. Personal exemption for yourself, enter “1” if claimed ...............................................................................................................
2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) ............................................
3. Exemptions for dependents .......................................................................................................................................................
4. Add the exemptions that you have claimed above and enter total ...........................................................................................
5. Additional withholding per pay period under agreement with employer ..................................................................................
Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name
Employee ID#
Employer Name
Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you
may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social
Security based on either your own work or the work of your husband or wife, or former husband or wife, your
pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will
not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government
Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee
Form SSA-1945 (12-2004)
Information about Social Security Form SSA-1945
Statement Concerning Your Employment in a Job Not Covered by Social Security
New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State
and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not
covered under Social Security. The statement explains how a pension from that job could affect future Social
Security benefits to which they may become entitled.
Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the
document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential
effects of two provisions in the Social Security law for workers who also receive a pension based on their work in
a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s
Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social
Security benefit received as a spouse or an ex-spouse.
Employers must:
• Give the statement to the employee prior to the start of employment;
• Get the employee’s signature on the form; and
• Submit a copy of the signed form to the pension paying agency.
Social Security will not be setting any additional guidelines for the use of this form.
Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945.
Paper copies can be requested by email at [email protected] or by fax at 410-965-2037. The
request must include the name, complete address and telephone number of the employer. Forms will not be sent to
a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The
forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (12-2004)
Direct Deposit Authorization Form
I hereby authorize the Pickerington Local Schools to initiate direct deposit (credit entries) of 100% of
my individual earnings to the following account:
Employee Name:
Employee Social Security #:
Name of Financial Institution:
Transit Number of Financial Institution:
Employee's Account Number:
You must attach a voided check or printout from your bank (or online banking) verifying
the above account information.
 I would like my paystub notification mailed to my home address.
 I would like to receive my paystub electronically. (Please notify us of email address changes)
Email Address: ________________________________________________________________
**NOTE: If your account information changes, you must notify us immediately to stop your direct
deposit. Otherwise it could take several weeks to receive your pay back from the bank.
To change your account information, you will need to submit a new form.
Employee Signature
This authorization is contingent on the employee's financial institution's participation in the Automatic Clearing House (ACH} System.
Fly UP