i-94 w form

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Tax Summary ReportSummary of Information Entered Into GLACIER:

Name:SSN / ITIN:

Email Address:

Country of Tax Residence:Country of Citizenship:

Current Immigration Status:

Date of Entry to U.S.: Changed Immigration Status?

Immigration Status Expiration: Immigration Status Change Date:

Original Immigration Status:

Estimated Date of Departure:

Tax Determinations and Results Based on the data entered, GLACIER has made the following determinations:Tax Residency Status:

Residency Status Change Date:

Residency Status Start Date:

Residency Status Change Date 2 (if applicable):

Residency Status Start Date 2 (if applicable):

Applicable Tax Withholding Rate:(If Tax Treaty Does Not Apply or Form Is Not Submitted)

Tax Treaty Exemption Status:

Tax Treaty Time Limit:

Tax Treaty Exemption Period:

Tax Treaty Dollar Limit:

OPTION

ADRIEN MATTHIEU HUSSON

ApplyForSSN

France

France

J1 Student

January 02, 2009

December 11, 2009

UID: 403754072 December 11, 2009

No

2009 - 92 Days

Nonresident Alien for U.S. Tax Purposes

July 03, 2014 to Resident Alien

January 01, 2014 to Resident Alien

Single, 1(Bi-Weekly)

TAXTaxable

Not Applicable

Not Applicable

Not Applicable

[email protected]

Employee Compensation: Wages/Salary/Bonus

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Tax Summary Report InstructionsCongratulations You Have Completed Your Individual Record!

To finish this process, please follow the directions below:

1) Review, sign and date each of the Required Forms (listed on previous page and from GLACIER);2) Photocopy each of the Required Documents (as indicated on previous page of the Tax Summary Report);3) Submit the Required Forms and Required Documents to the address below; and4) Properly exit GLACIER and save your Individual Record.If any information in your Individual Record changes, you must log in to GLACIER and update yourIndividual Record as soon as possible.

Please submit all Required Forms and Required Documents within days.If all Required Forms and Required Documents are not submitted you may have more tax than requiredwithheld from payments made to you.

Please submit all Required Forms and Required Documents to the address below:

7

Cicili Mislang, Administrative SpecialistUniversity of California, Los Angeles

10920 Wilshire Blvd, Suite 620

Mail Code 141648

Los Angeles, CA 90024

Telephone : 310-794-8718

Facsimile : 310-794-8751

[email protected]

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U.S. Tax Information For Non-United States Citizens/Non-U.S. Permanent Resident Aliens

Why Am I Required to Provide Information inGLACIER? The Internal Revenue Service (IRS), the U.S.government tax authority, has issued strict regulations regarding the taxation and reporting of payments made tonon-United States citizens. As a result, payments made to you may be subject to U.S. income tax and reportingto the IRS. GLACIER Online Tax Compliance System is an efficient and effective way to manage tax liability.

Why Is My Tax Status Important? In order to comply with the U.S. tax laws, your U.S. Tax Residency Statusmust be determined. The Substantial Presence Test is used to determine whether an individual is a

Nonresident Alienor Resident Alienfor purposes of U.S. tax withholding. GLACIER Online Tax ComplianceSystem will calculate your U.S. Residency Status for Tax Purposesbased on the information provided by you.

What is the Difference between a Nonresident Alien and Resident Alien? If you are a Nonresident Alien forTax Purposes, you are subject to special tax withholding and reporting regulations; if you are a Resident Alienfor Tax Purposes, you are taxed in the same manner as a U.S. Citizen.

How Long Will I Be a Nonresident Alien? Your Residency Status Change Dateis the day on which your U.S.Residency Status for Tax Purposeswill change, generally from Nonresident Alien for Tax Purposesto Resident

Alien for Tax Purposes. The U.S. tax system is based on a calendar year period (January 1 December 31).In most cases, when your U.S. Residency Status for Tax Purposeschanges, you will become a Resident Alienfor Tax Purposesretroactive to the first day of the calendar year during which your status changed; this day iscalled the Residency Status Start Date.

How Will I Be Taxed on Payments From U.S. Sources? As a Nonresident Alien for Tax Purposes, U.S. taxlaw requires that you be taxed in the following manner:

If you receive Dependent Compensation (salary or wages), you are generally required to complete Form

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OMB No. 1545-0074Employees Withholding Allowance Certificate

W-4

FormDepartment of the TreasuryInternal Revenue Service

Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.

1

Last name

2

Your social security number

Home address (number and street or rural route)

Married

Single

3

Married, but withhold at higher Single rate.

City or town, state, and ZIP code

Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box.

5

5

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

$6

6

Additional amount, if any, you want withheld from each paycheck

7

I claim exemption from withholding for 2009, and I certify that I meet both of the following 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.

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If you meet both conditions, write Exempt here

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Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employees signature

(Form is not valid unless you sign it.)

Date 9

Employer identification number (EIN)

Employers name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

Office code (optional)

10

4

If your last name differs from that shown on your social security card,

check here. You must c all 1-800-772-1213 for a replacement card.

Cat. No. 10220Q

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Form W-4 (2009)

2009ADRIEN M

B

HUSSON

558 Glenrock Avenue Apt#6


Nonresident Alien

1

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EMPLOYEES WITHHOLDING ALLOWANCE CERTIFICATE

1. Number of allowances for Regular Withholding Allowances, Worksheet A

Number of allowances from the Estimated Deductions, Worksheet BTotal Number of Allowances (A + B) when using the CaliforniaWithholding Schedules for 2009

OR

2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C

Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does notexceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt

status.

Signature Date

Employers Name and Address California Employer Account Number

City, State, and ZIP Code

Home Address (Number and Street or Rural Route)

Type or Print Your Full Name Your Social Security Number

Filing Status Withholding Allowances

SINGLE or MARRIED (with two or more incomes)

MARRIED (one income)

HEAD OF HOUSEHOLD

This form can be used to manually

compute your withholding allowances, oryou can electronically compute them at

www.taxes.ca.gov/de4.xls(Microsoft Excel required).

ADRIEN HUSSON

0

558 Glenrock Avenue Apt#6


0

$


University of California, Los Angeles

10920 Wilshire Blvd., Suite 620

s