Exempt New Hire Checklist
 UMBC Personnel Action Request Form (Hire, Rehire, Reinstatement,
and Transfer)
 Photocopy of Personnel Requisition form with appropriate signatures
 W-4 (and supporting documents if employee is non-resident alien)
 Completed I-9 and Copies of Supporting Documents
 Social Security Number Verification* (ex: pay stub, W-2, transcript,
social security card, etc.)
 Signed Substance Abuse Acknowledgement of Receipt form
 Retirement Plan Selection Form
NOTE: Employee will send to Courtney Allen, HR – Benefits
 Signed CHIP Acknowledgement Form
 Direct Deposit form (Not Required for New Hire)
Department is required to provide to the employee an email/copy of:
o Substance Abuse Policy
o Children’s Health Insurance Program (CHIP) Policy
*Required if the employee does not provide a copy of the social security card to satisfy the I-9
requirement.
Revised 1/30/13
UMBC
Personnel Action Request Form
Hire, Rehire, and Transfer
An Honors University in Maryland
University of Maryland Baltimore County
1000 Hilltop Circle
Baltimore, MD 21250
Instructions: Please complete this form and attach all supporting
Documents. Forward to Human Resources – Payroll. HELP TEXT A
APPEARS IN THE BOTTOM LEFT CORNER OF THE SCREEN
1 Action*
3 Supporting Documents
2 Reason*
W-4
I-9 & Supporting Documents
Retirement Selection Form
Social Security Verification
Non-resident Alien/
Required Docs On File
7 Prior Agency Code (USM Transfer)
Permanent Resident
Faculty Supplemental Data Form
Select 1 Option/NA
Substance Abuse
CHIPRA Acknowledgement Form
Select 1 Option
4 Effective Date*
5 Employee ID (If Known)
6 Prior USM/State Service Date
PERSONAL DATA (complete all fields; for one-time pay appointments complete only those fields with an asterisk (*)
8 First Name*
9 Middle Name/Initial
10 Last Name*
11 Suffix
Select 1 Option
12 Home Address*
13 County of Residence*
Select 1 Option
14 City*
15 Postal (Zip)*
16 State*
17 Preferred Email
18a Home Phone #
Other:
18b Campus Phone #
19 Gender*
20 Highest Education Level
21 Marital Status
22 Military Status
23 US Citizen*
Select 1 Option
Select 1 Option
Select 1 Option
Select 1 Option
Select 1 Option
24 Date of Birth*
25 Birth Country*
26 Social Security #*
27 Visa Type*
Academic Organization: FACULTY; class scheduling
UMBC
Select 1 Option
28a Ethnicity*
28b Race*
Select 1 Option
American Indian/Alaska Native
Black or African American
Asian
Native Hawaiian/Other Pacific Islander
White
JOB DATA (complete all fields; for one-time pay appointments complete only those fields with an asterisk (*)
29 Position Number*
30 Department ID*
31 Department Name*
32 Job Code/Title*
33 Standard HRS / FTE
34 End Date*/Term
29a
30a
31a
32a
33a
34a
29b
30b
31b
32b
35 Employee Class*
33b
36 Payment Method*
34b
37 Bi-weekly/Hourly Rate
38 Annual Salary
Select 1 Option
Select 1 Option
EMERGENCY CONTACT INFORMATION
39 Name
40 Relationship
41 Address
Same Address as Employee
42 Phone
Same Phone as Employee
Comments:
THE APPROVALS SECTION MUST BE COMPLETED
COMPLETED BY
Name (Please Type or Print)
Signature
Date
Phone Number
E-mail Address
SIGNATURE AUTHORITY
Name (Please type or Print)
Signature
Date
Phone Number
E-mail Address
HR APPROVAL/VERIFICATION (HR USE )
Pay Group
FICA Status
SAL
CNT
HRL
Subject
Retirement System
Eligible
Not Eligible
Transfers Only
ORP - TIAA
Pay Frequency
W9MTH
U26
UM22
HRL
Exempt
ORP - Fidelity
Empls Pension 7%
Comments
Teacher's Pension 7%
LEOPS
Empl’s Ret, 5%
Emp’s Retire 7%
Payroll Staff Initials
Date
Comments
Data Entry Staff Initials
Date
Employee ID /Rcd
Teacher’s Ret, 5%
Teacher’s Ret, 7%
Comments
Revised: 01/2015
Employee Withholding Allowance Certificate
FOR MARYLAND
MA
AND S
STATE
TE GOVERNM
G
RNMENT
T EMP
MPLOYEES
S ONLY
2015
2007
Form W-4
-4
Department
Depa
tment of the Treasu
easury
Internal Revenue
R venue Service
vice
Form
orm MW 507
Comptroller
Compt
oller of Maryland
Ma land
Please
lease complete
c mplete form in black
bla k ink.
ink Whether
hether you
ou are
a e entitled to claim
laim a ce
certain
tain number of all
allowances
wances or exemption
exempti n ffrom
om withholding is
subject to revi
view
w by the IRS.
I
Your
our employer
empl er may be requi
equired
ed to send a copy of this form to the IRS.
I
Section 1 - Employee
Empl yee Information
Info mation
Payroll
oll System
stem (check one)
RG
CT
Name
ame of Empl
Employing
ing Agen
Agency
UM ✔
UMBC
ocial Secu
ecurityy Number
umber
Social
Agencyy Number
Agen
umber
360231
Add
ddress
ess Continued (apartment
(apa tment numbe
number, if any)
Home Add
ddress
ess (number and street
st eet or rural
ural route)
oute)
City
State
Employee
Empl
yee Name
ame
Zip Code
(Nonresidents enter Maryland County or
Baltimore City where you are employed)
County of Residence (required)
Section 2 - Federal
ederal Withholding
ithholding Form W-4
-4
The federal wo
worksheet
ksheet is available online at http://ww
http://www.irs.g
.irs.gov/pub/irs-pdf/fw4.pdf
v/pub/irs-pdf/fw4.pdf
4
If
your
our
last
name
differs
from
f
om
that
shown
on
your
our
social
security
secu y card
ard,
ingle
Mar
Married
ied
Married
Mar ied, but withhold at higher Single
ingle Rate
3 Single
checkk here.
che
here You
ou must
ust call
all 1-800-772-1213 for a replacement card.
ard.
Note
ote. If married
mar ied, but legally
legal y separated,
separated or spouse is a nonresident
non esident alien
alien, che
checkk the “Singl
ingle” b
box.
5 Total
otal number of all
allowances
wances you
ou aaree claiming
laiming (f
(from
om page 1 or page 2 of the federal wo
worksheet)
ksheet)
6 Additional
dditional amount,
amount if any,
an you
ou want withheld ffrom
om each payche
pa heckk .....................................................................................
5
6 $
7 I claim
laim exemption ffrom
om withholding for 2015,
2015 and I ce
certify
tify that I meet both of the following
foll wing 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
ou meet both conditions
conditi ns, write
ite “Exemp
Exempt” he
here.........................................................................
e.........................................................................
7
Section
ection 3 - Maryland
Ma land Withholding
ithholding Form
m MW 507
The Maryland
Ma land worksheet
wo ksheet is available online at http://forms.ma
http://forms.marylandtaxes.com/cur
landtaxes.com/current_forms/MW507.pdf
ent_forms/MW507.pdf
Withhold at Single Rate
Married (surviving spouse or unmarried Head of Household) Rate
Married, but withhold at Single Rate
1. Total
otal number of exemptions you
ou are
a e claiming
laiming not to exceed line f in Personal Exemption Worksheet on page 2. . .
1.________________
2. Additional
dditional withholding per pay pe
period
iod under agreement
ag eement with employer.
empl yer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.________________
3. I claim
laim exemption fro
from
m withholding be
because
ause I do not expect to owe
we Maryland
Ma land tax.
tax See instructions and check boxes that apply.
a. Last
ast year I did not owe
we any Maryland
Ma land income tax and had a right
ight to a full refund
efund of all income tax withheld and
b
b. This year I do not expect to owe
we any Maryland
Ma land income tax and expect to have the right
ight to a full refund
efund of all income tax withheld.
withheld
(This
(This in
includes
ludes seasonal and student empl
employees
ees whose annual income will
wi l be below
bel w the minimum
mini um filing requi
equirements)
ements).
If both a and b apply,
app enter year applicable
appli able _______ (year effective) Enter “EXEMPT
PT” he
here.
e. . . . . . . . . . . . . .
3.________________
4. I claim
laim exemption fro
from
m withholding be
because
ause I am domiciled in the foll
following
wing state.
state
Virginia
irginia
I further
fu ther certify
ce tify that I do not maintain a place of abode in Ma
Maryland
land as described
desc ibed in the instructi
inst uctions.
ns.
Enter “EXEMPT” he
heree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.________________
5. I claim exemption from Maryland state withholding because I am domiciled in the Commonwealth of Pennsylvania
and I do not maintain a place of abode in Maryland as described in the instructions on Form MW507.
Enter “EXEMPT” here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. I claim exemption from Maryland local tax because I live in a local Pennysylvania jurisdiction within York or
Adams counties. Enter “EXEMPT” here and on line 4 of Form MW507. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. I claim exemption from Maryland local tax because I live in a local Pennsylvania jurisdiction that does not impose
an earnings or income tax on Maryland residents. Enter “EXEMPT” here and on line 4 of Form MW507. . . . . .
8. I certify that I am a legal resident of the state of ____________ and am not subject to Maryland withholding because
l meet the requirements set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses
Residency Relief Act. Enter “EXEMPT” here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.________________
6.________________
7.________________
8.________________
Section
ection 4 - Employee Signature
nature
Under penalties of perjury,
perju I decla
de laree that I have examined this certifi
ce tificate
ate and to the best of my knowledge
kn wledge and belie
belief, it is true,
t
correct
cor
ect, and complete
complete. I
further
fu
ther ce
certify
tify that I am entitled to the number of withholding all
allowances
wances claimed
laimed on line 1 ab
above, or if claiming
laiming exemption from
fr om withholdin
withholding, that I am
entitled to claim
laim the exempt status on which ever
ver line(s) I completed.
Employe
Empl
yee’ss signature
si nature
(Form
orm is not valid unless you
ou sign it.) __________________________________________________________________
Employer’s name and address (including zip code) (For employer use only)
Central Payroll Bureau
P.O. Box 2396
Annapolis, MD 21404
Date_________________________
Federal Employer identification number
52-6002033
(For State of Maryland - CPB use only)
Impo tant: The informa
Important
info mation
ion you
ou supply
supp y must
ust be complete.
complete This form
fo m will
wi l replace in total any
a y ce
certifi
ificate
ate you
ou pr
previous
viouslyy submitted.
submit ted.
Web
eb Site
ite - http://compnet.comp.state.md.us/cpb
http://compnet.c
.state.md.us/cpb
STATE OF MARYLAND
SUBSTANCE ABUSE POLICY
ACKNOWLEDGEMENT OF RECEIPT
As an employee of the University of Maryland Baltimore County, I,
_____________________________, hereby certify that I have received a copy of
the State of Maryland Substance Abuse Policy as well as the UMBC Abuse Policy
and Campus Plan which concern the maintenance of a drug-free work place and
campus. I realize that the unlawful manufacture, distribution, dispensation,
possession of use of a controlled dangerous substance is prohibited on the State’s
owned or utilized premises and violation of either of these policies can subject me
to discipline up to and including termination. As a condition of employment, I
must abide by the terms of this policy and will notify my supervisor of any
criminal drug conviction no later than five (5) days after such conviction. I further
realize that if I am directly supported by a Federal grant or contract, Federal law
mandates that the employer communicate the conviction to that Federal agency,
and I hereby waive any and all claims that may arise for conveying that
information to that Federal agency.
__________________________________
Employee’s Signature
_______________________
Date
__________________________________
Supervisor’s/Witness Signature
_______________________
Date
STATE OF MARYLAND
MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
ACKNOWLEDGEMENT OF RECEIPT
As an employee of the University of Maryland, Baltimore County, I,
_____________________________ (printed name), hereby certify that I have
received a copy of the Medicaid and the Children’s Health Insurance Program
(CHIP) Notice, which provides details and contact information for states that
offer premium assistance for health coverage. I further understand that while
Maryland is not a state that currently provides premium assistance under
Medicaid and CHIP, if interested, it is my responsibility to contact the appropriate
state to inquire about eligibility for health premium assistance under these
programs for me or my dependents.
_______________________________
Employee’s Signature
________________
Date
STATE OF MARYLAND
STATE OF MARYLAND
PAYROLL DIRECT DEPOSIT AUTHORIZATION
PAYROLRegular
L DIRECT DEContract
POSIT AUTH
ORIZATION
Payroll System (Check one)
University of Maryland
Regular
Payroll System (Check one)
Social Security Number
Social Security Number
Agency Code
Agency Code
--
Contract
University of Maryland
Employee’s Name (please print)
Employee’s Name (please print)
--
Agency Name (please print)
Agency Name (please print)
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
(Check One)
CPB Use Only
(Check One)
CPB Use Only
1. Initiate Deposit directly to my checking/savings account
1.(Will
Initiate
my checking/savings
account
takeDeposit
at least directly
two paytoperiods
to allow for pre-note
process.)
(Will take at least two pay periods to allow for pre-note process.)
2. Change account type(checking/savings account), and/or bank routing number to which my net salary
2.isChange
account
type(checking/savings
account),
and/or
bank
which
net salary
deposited
(cancel
of old account will occur
within
21 days
forrouting
receiptnumber
of CPB;toyou
willmy
receive
deposited
(cancel
of old
occur within 21 days for receipt of CPB; you will receive
aispayroll
check
until the
newaccount
accountwill
is established)
a payroll
check
until the
newpayroll
account
is established)
Do
not close
account
until
check
is issued.
Do not close account until payroll check is issued.
3. Discontinue direct deposit into my checking/savings and issue a payroll check instead.
3.Do
Discontinue
direct deposit
my checking/savings
not close account
until into
payroll
check is issued. and issue a payroll check instead.
Do not close account until payroll check is issued.
Bank Name:
(Omit
if action
3 is checked)
Bank
Name:
Processed by:
Processed by:
(Omit if action 3 is checked)
Account Type: (Must Check One)
Type
(Must
One)
IfAccount
not marked this
form: will
be Check
returned
If not marked this form will be returned
Effective PPE:
Effective PPE:
Checking
Checking
Savings
Savings
Bank Number
Bank Number
Checking/Savings Account Number
Checking/Savings Account Number
IAT requirement
IAT requirement
Verify carefully. For checking copy directly from your personal check. Do not
Verify carefully.
Fornumber.
checkingDo
copy
yourslip
personal
check. Do not
include
your check
not directly
use yourfrom
deposit
number.
include your check number. Do not use your deposit slip number.
Check box if your full net pay is subsequently transferred to a foreign bank.
Check box if your full net pay is subsequently transferred to a foreign bank.
I authorize the State of Maryland to deposit my net salary to the bank and account named above. This authorization is to remain in force until the State of
Maryland
receives
written
notification
from me
itssalary
termination
in time
manner
that allows
State
and the bank
opportunity
act upon
I authorize
the State
of Maryland
to deposit
myofnet
to the bank
andand
account
named
above.the
This
authorization
is toa reasonable
remain in force
until thetoState
of it.
InMaryland
the eventreceives
that the written
State ofnotification
Maryland notifies
theofbank
that funds to
I am
not entitled
have the
beenState
deposited
my account
in error,
I authorize
directit.
from me
its termination
in which
time and
manner
that allows
and thetobank
a reasonable
opportunity
to and
act upon
the
to return
saidState
funds
the Statenotifies
as soonthe
as possible.
the funds
erroneously
to my
account
havetobeen
that account
so that
In bank
the event
that the
oftoMaryland
bank thatIffunds
to which
I am not deposited
entitled have
been
deposited
my drawn
accountfrom
in error,
I authorize
and direct
return
of those
funds
by funds
the bank
to the
State
is notaspossible,
authorize
theerroneously
State to recover
thosetofunds
by setting
offbeen
the amount
erroneously
paid me
from
the bank
to return
said
to the
State
as soon
possible.I If
the funds
deposited
my account
have
drawn from
that account
so that
any
future
payments
thebank
Statetountil
amount
of the erroneous
deposit
has been
recovered,
full. by setting off the amount erroneously paid me from
return
of those
fundsfrom
by the
the the
State
is not possible,
I authorize
the State
to recover
thoseinfunds
any future payments from the State until the amount
of the erroneous deposit has been recovered, in full.
_________________________
__________________________________
_________________________
_________________________
Date
Date
Instructions:
__________________________________
Employee signature
Employee signature
_________________________
Daytime phone number
Daytime phone number
• Instructions:
Only one account is permitted for direct deposit. You can choose either checking or savings not both.
• •Type
print
only (except
signature).
Onlyorone
account
is permitted
for direct deposit. You can choose either checking or savings not both.
• •Use
black
ink only.
Type
or print
only (except signature).
• •Complete
blocked
Use blackallink
only. areas in the top part of form except for the section “CPB use only.”
• •Read
authorization
andareas
sign the
completed
Unsigned
or the
Incomplete
formsuse
willonly.”
be returned.
Complete
all blocked
in the
top part form.
of form
except for
section “CPB
• •Deposit
amount will and
be full
of pay
intoUnsigned
either your
Read authorization
signnet
theamount
completed
form.
orchecking/savings
Incomplete formsaccount..
will be returned.
• •IfDeposit
changing
your account
type,
and or
youchecking/savings
will receive a payroll
check until new direct deposit becomes effective.
amount
will be full
netbank
amount
of account
pay into number,
either your
account..
• •Do
not send ayour
voided
blanktype,
check.
If changing
account
bank and or account number, you will receive a payroll check until new direct deposit becomes effective.
• •Send
completed
form toblank
Central
Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
Do not
send a voided
check.
• Send completed form to Central Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
CPB/c/dd/0059/2-2010