Request for Taxpayer Identification Number and Certification

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1 GEORGIA REGENTS UNIVERSITY OFFICE OF STUDENT & MULTICULTURAL AFFAIRS MEDICAL COLLEGE of GEORIGA GB 3300 SUPPLEMENTAL INSTRUCTION PROGRAM SIP LEADERS SIGN-UP FORM Instructions: Please complete and have the Course Director/Module Director sign where indicated. Return to the Office of Educational Outreach & Partnerships. You will be notified via when a student has been assigned to you. You are responsible for setting up SIP sessions and taking accurate attendance. If you have not made contact with your assigned student(s) within 48 hours of our notification, please notify our office immediately. NOTE: If approved to work as an SIP Leader, you will be able to provide a maximum of 4 hours per week of academic assistance. If more hours are needed by your assigned student(s), you must receive approval from the SIP Director/Administrators PRIOR TO providing these additional SIP services. Name: Date: Home Address: Gender: Male Female Ethnicity: Home phone: Cell phone: Banner ID#: MCG Please indicate the Campus, School, Year, and Program that applies to you: Campus enrolled: Augusta Athens Other: ALLIED HEALTH 1 st year 2 nd year 3 rd year 4 th year Post Doc MEDICINE 1 st year 2 nd year 3 rd year 4 th year Post Doc GRADUATE STUDIES 1 st year 2 nd year 3 rd year 4 th year Post Doc NURSING 1 st year 2 nd year 3 rd year 4 th year Post Doc SIP Leader (Small Group Tutoring) Course Name & Number You Are Interested in Assisting With: Large Group Tutoring (Tutoring Tuesday/Test-Prep Thursday) Grade Received in Course Signature of Course Director: Previous Experience Providing Academic Assistance or Instruction: Number of hours available per week to work: OMITTING THIS SECTION COULD RESULT IN A DELAY IN YOUR PAYMENT Are you currently on MCG Payroll? Yes No If yes, Department Employed In Current Supervisor s Information: Name: Phone #: Applicant s Signature: ******************************************************************************************************************************* FOR OFFICE USE ONLY Received by: Date: Assigned Student(s): Suite GB 3300 Augusta, GA (706) Fax (706)

2 Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Name (as shown on your income tax return) Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code Exempt payee List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No X Form W-9 (Rev )

3 1. TO: Georgia Regents University AUTHORIZATION FOR EXTRA DUTY EMPLOYMENT Section 1 2. Printed Name of Extra Duty Employee & ID # 3. Signature 4. Date Permission is requested to work in an extra duty capacity in the department indicated below. This additional work will not interfere with, or adversely affect the performance of the duties of my regular job. If permission to perform extra duty is approved I understand and agree that this permission will be withdrawn if at any time the extra duty interferes with my regular job. I also understand and agree that any additional work (beyond the normal work commitment) of my regular job will take precedence over extra duty employment. 5. Extra Duty Department Name & Department ID 6. Name and Telephone Number of Extra Duty Supervisor 7. Beginning date of extra duty period 8. Ending date of extra duty period 9. Maximum extra duty hours per day (if non-exempt) 10. Maximum extra duty hours per week (if non-exempt) 11. Approved Disapproved (subject to limitations indicated in spaces 9 and 10 above). 12. Printed Name of Home Dept./Div Supervisor 13. Home Dept Supervisor Signature 14. Date Section II TO: Human Resources Division - The employee, whose name appears in box 2 above, is authorized to perform extra duty in this department during the period indicated in boxes 7 and 8 above. Dates and hours of work will be scheduled by the supervisor whose name appears in box 6 above. 15. Extra Duty Job Title 16. Extra Duty Payment Fund Source 17. Agreed Extra Duty Rate 18. Shift Differential Rates 19. Weekend Premium Rate Evening_ Night None 20. Overtime Rate None The rates of pay and conditions of employment stipulated above have been agreed upon by undersigned. 21. Printed Name of Extra Duty Supervisor 22. Signature 23. Date 24. Printed Name of Extra Duty Dept. Approving Official 25. Signature 26. Date 27. Printed Name of Extra Duty Employee 28. Signature 29. Date Section III (To be completed by Human Resources Division only) 30. HUMAN RESOURCES REPRESENTATIVE 31. Signature 32. Date Rev 2.13

4 Instructions Section 1 to be completed by employee requesting permission to perform extra duty and employee s current supervisor: Box 1 Box 2 Enter the name of employee s current supervisor and home department (or Division). Enter full name of Extra Duty Employee and their employee ID # (if known). Box 3 & 4 Extra Duty Employee completes box 3 and 4. Box 5 Box 6 Box 7 Box 8 Box 9 & 10 Enter name of extra duty department (or Division) and Department ID. Enter name and telephone number of the person who will supervise the extra duty work. Enter the earliest date on which extra duty work will be performed. Enter the latest date that extra duty work will be performed. (It is recommended that extra duty not be authorized for more than 6 months at a time). Enter the maximum number of extra duty hours that employee is authorized to work per day and per week. Box 11 Home department supervisor checks either approved or disapproved and completes boxes Box 12 Enter the name of employee s home department supervisor. Department Supervisor signs box 13. Section II to be completed by extra-duty department and employee requested to perform extra-duty: Box 15 Box 16 Enter the most appropriate title for the work being performed. For assistance, call the Compensation & Performance Management Section ( ) for determination of appropriate title. Enter the chart field combination indicating the fund source for the extra duty work being performed. For assistance with rates for Boxes 17-20, please call the Compensation & Performance Section ( ). Box 17 Enter the agreed extra duty rate. This rate must be within the limits established in MCG Administrative Policy Employment of Extra Duty Personnel. Please call the Compensation and Performance Management section for determination of appropriate assignment rate for exempt employees. Box 18 Box 19 Box 20 Enter the agreed (and authorized) evening and night shift differential rates. If shift differential is not authorized place an X in the none box. Enter the agreed (and authorized) weekend premium rate. If weekend premium is not authorized place an X in the none box. Enter the agreed (and authorized) overtime rate. For non-exempt employees the overtime rate will be 1 ½ times the regular extra duty rate (box 17). Exempt employees are not eligible for overtime. Box 21 Enter the name of Extra Duty Supervisor. Extra Duty Supervisor signs box 22 and enters date in block 23. Box 24 Box 27 Enter the name of the Extra Duty Departmental Approving Official (this will be the name of the person authorizing payment for the extra duty work being requested. Approving Official signs blocks 25 and enters date in block 26. Enter the name of Extra Duty Employee. Extra Duty Employee signs block 28 indicating that he/she agrees to the rates of pay and stipulations of employment indicated above. Human Resources will complete boxes 30, 31 and 32.

5 Authorization Agreement for Direct Deposit Expense Reimbursements INSTRUCTIONS PLEASE ATTACH A VOID CHECK HERE DEPOSIT SLIPS ARE NOT ACCEPTED 1. PLEASE PRINT ALL INFORMATION LEGIBLY 2. Attach a void check if you designate a checking account. DO NOT SUBMIT A DEPOSIT SLIP. 3. Please sign and date this form. Omission of Signature will delay processing. 4. Mail or fax completed form to the address or fax number indicated at the bottom of this page. 5. Notify Payroll AND Accounts Payable of any account changes or account closings. PARTICIPANT INFORMATION First Name Last Name Six-digit PeopleSoft Employee ID# or Last 4 of SS# Daytime Telephone Number (including Area Code) Day: ( ) PAY CYCLE Bi-Weekly Monthly BANK INFORMATION Check ONLY one: Set-up Direct Deposit for: Checking (attach void check above) Change Account Information Cancel Direct Deposit effective (please enter date) Priority # 1 This is your main account. If you have multiple accounts, the balance of your net pay will be deposited into Priority # 1. Financial Institution Name City and State account was opened: Routing Number (9-digit number on the lower left of check) Account Number: Type of Account (Please check one) Checking Priority # 2 (Specify a flat amount for your second account) Financial Institution Name Routing Number (9-digit number on the lower left of check) Flat Amount($) City and State account was opened: Account Number: Type of Account (Please check one) Checking AUTHORIZATION I hereby authorize MEDICAL COLLEGE OF GEORGIA, to initiate my direct deposit. I understand that if there is an error in my reimbursement that the MEDICAL COLLEGE OF GEORGIA may retract my direct deposit from my bank account and issue me a corrected check. It is my responsibility to notify the Accounts Payable Department immediately if I have changed or closed my account. Employee Signature: Date: Mail to: Medical College of Georgia Controller s Division HSB th Street Augusta, GA Or Fax to: (706) Attn Donna Rayner

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