Suffix

State Zip

State ZipBirthdate

(MM/DD/YY)

Gender (M/F)

Parsons(LB)

KLETC,Yoder (RN)

KUMC,Kansas City

(WY)KUMC,

Wichita (SG)

Employee Name:

INTERNAL USE ONLY:

Social Security Number: KUHRPAY(12/14)

Temporary Alien

Former Names

Phone

County Mobile Phone

I am not a veteran

I am not a protected veteran

Self-Identification: Military Status and Recently Separated Veteran (optional)

City

City

Native US Citizen Naturalized US Citizen Permanent Resident

The State of Kansas uses a one-question format for reporting purposes. Please indicate your primary race:

Are you Hispanic or Latino? A person of Cuban, Mexican, Puerto Rican, South orCentral American, or other Spanish culture or origin regardless of race.

American Indian orAlaska Native (5)

Asian/PacificIslander (4)

Black or AfricanAmerican (2) Hispanic (3)

YES, Hispanicor Latino

No, Not Hispanicor Latino

Active Duty Wartime or Campaign Badge Veteran

Disabled Veteran

Recently Separated Veteran

In addition if applicable, choose one or more of the following racial categories to describe yourself:American Indian or Alaska Native: A person having origins in any of the original peoples of North and South American (including Central America), and who maintains tribal affiliation or community attachment.

Highest EducationLevel

(Select One)

Please type or print legibly. Information is keyed directly into the Human Resource/Payroll System from this form.

Enter name as it is printed on your social security card

Preferred Name (Directory Use)

Mailing Address(if different)

Primary CampusWork Location(Check One)

KU Lawrence (DG)

Edwards Campus, OP (JO)

Juniper Gardens, KC (WY)

3-YearsCollege

TechnicalSchool

Campus Work Phone

Birth City

Other (City/State) :

1-YearCollege

Home (W-2)Address County

Bachelor's Degree

Social Security Number

TalentSearch, KC

(WY)Capital Center,

Topeka (SN)KGS Well Library

Wichita (SG)

Street

Some Graduate School Master's Degree

Street

If non U.S. Citizen-Indicate Birth Country

Date:

White - not Hispanic (1)

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Employee Signature

Professional Education:

I identify as one or more of the classifications of protected veteran listed:

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

If you believe you belong to any of the classifications of protected veterans, please indicate by selecting the appropriate option below. (See Invitation to Self-Identify Disable and/or Veteran Status for descriptions). Disabled Veterans, please fill out the additional form Disclosure Form for Persons with Disabilities

Military Discharge Date:

I am a protected Veteran, but I choose not to self-identify the classification to which I belong

Armed Forces Service Medal Veteran

University of Kansas Employee Data Sheet

Citizenship Status

Post Doctorate

Email Address

Married KU Student ID

Less than HighSchool Graduate

High School Grador equivalent

Degree Date (MM/DD/YY) Major School Country/State

2-YearsCollege

Non-Tax Marital Status

Last/Family

Single

4-YearsCollege

Doctorate

First Middle

Employee’s Name

Employee ID Number

Direct Deposit Authorization of Employee Pay

I authorize the State of Kansas to initiate accounting transactions to deposit my employee pay directly to the account(s) indicated below and to correct any errors which may occur from these transactions. I also authorize the Financial Institution to post these transactions to these accounts. This authorization is to remain in force until the State of Kansas receives written notice from me to cancel or change this authorization. After 6 months from termination of employment, this authorization will expire.

PRIMARY ACCOUNT

SECONDARY ACCOUNT (If applicable)

________________________________________ ___________________ Employee Signature Date

Your Bank Information: Routing Number Bank Name

Distribution Instructions: Account Number Account Type Deposit Type Amount or Percent Deposit Order

Your Bank Information: Routing Number Bank Name

Distribution Instructions: Account Number Account Type Deposit Type Amount or Percent Deposit Order

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

8. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

6. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 11/14/2016 N

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form W-4 (2017)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20171 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

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

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

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

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, 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.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . 7

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.

Employee’s signature

(This form is not valid unless you sign it.) Date

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

Form W-4 (2017) Page 2

Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,700 if married filing jointly or qualifying widow(er)$9,350 if head of household . . . . . . . . . . .$6,350 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4

5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5

6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1

Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 07,001 - 14,000 1

14,001 - 22,000 222,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 95,000 10

95,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $8,000 08,001 - 16,000 1

16,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 70,000 570,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2

Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

K- 4 KANSASEMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE (Rev. 8-15)

Use the following instructions to accurately complete your K-4 form, then detach the lower portion and give it to your employer. For assistance, call the Kansas Department of Revenue at 785-368-8222. Purpose of the K-4 form: A completed withholding allowance certificate will let your employer know how much Kansas income tax should be withheld from your pay on income you earn from Kansas sources. Because your tax situation may change, you may want to refigure your withholding each year. Exemption from Kansas withholding: To qualify for exempt status you must verify with the Kansas Department or Revenue that: 1) last year you had the right to a refund

of all STATE income tax withheld because you had no tax liability; and 2) this year you will receive a full refund of all STATE income tax withheld because you will have no tax liability. Basic Instructions: If you are not exempt, complete the Personal Allowance Worksheet that follows. The total on line F should not exceed the total exemptions you claim under “Exemptions and Dependents” on your Kansas income tax return. NOTE: Your status of “Single” or “Joint” may differ from your status claimed on your federal Form W-4). Using the information from your Personal Allowance Worksheet, complete the K-4 form below, sign it and provide it to your

employer. If your employer does not receive a K-4 form from you, they must withhold Kansas income tax from your wages without exemption at the “Single” allowance rate. Head of household: Generally, you may claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the cost of keeping up a home for yourself and for your dependent(s). Nonwage income: If you have a large amount of nonwage Kansas source income, such as interest or dividends, consider making estimated tax payments on Form K-40ES. Without these payments, you may owe additional Kansas tax when you file your state income tax return.

Personal Allowance Worksheet (Keep for your records)

A Allowance Rate: If you are a single filer mark “Single” If you are married and your spouse has income mark “Single” If you are married and your spouse does not work mark “Joint”

A Single Joint

B Enter “0” or “1” if you are married or single and no one else can claim you as a dependent (entering “0” may help you avoid having too little tax withheld) . B _________ ..............................................................................................................

C Enter “0” or “1” if you are married and only have one job, and your spouse does not work (entering “0” may help you avoid having too little tax withheld) C _________ .......................................................................................................................

D Enter “2” if you will file head of household on your tax return (see conditions under Head of household above) D _________ .....

E Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or dependents that your spouse has already claimed on their form K-4 E _________ . .....................................................................

F Add lines B through E and enter the total here F _________ ..........................................................................................................

Cut here and give the lower portion to your employer. Keep the top portion for your records.

Kansas Employee’s Withholding Allowance Certificate K-4 Whether you are entitled to claim a certain number of allowances or exemptions from withholding is subject to review by theKansas Department of Revenue. Your employer may be required to send a copy of this form to the Kansas Department of Revenue. (Rev. 9-12)

1 Print your first name and middle initial Last Name 2 Social Security Number

Mailing Address

City or Town, State, and ZIP Code

3 Allowance Rate Mark the allowance rate selected in line A above.

Single Joint

4 Total number of allowances you are claiming (from line F above)

5 Enter any additional amount you want withheld from each paycheck (this is optional)

6 I claim exemption from withholding. You must meet the conditions explained in the “Exemption from withholding” instructions above. If you meet those conditions, write “Exempt” on this line. .................... Note: The Kansas Department of Revenue will receive your federal W-2 forms for all years claimed Exempt.

...........................................................

...............................

4

5

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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. SIGN HERE DATE 7 Employer’s name and address 8 EIN (Employer Identification Number)

State of Kansas SUBSTANCE ABUSE POLICY

AFFIRMATION FORM

Statement of Policy

Employees are the State of Kansas' most valuable resource and, therefore, their health and safety is a serious concern. The State of Kansas will not tolerate substance abuse or use which imperils the health and well-being of its employees or threatens its service to the public. Furthermore, employees have a right to work in an environment free of substance abuse and with persons free from the effects of drug or alcohol abuse. It shall therefore be the policy of the State of Kansas to maintain a workforce free of substance abuse.

A. Reporting to work or performing work for the state while impaired by or under the influence of controlled

substances or alcohol is prohibited.

B. The unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in

the workplace, or while the employee is on duty, official state business or stand-by-duty.

C. Violation of such prohibitions by an employee is considered conduct detrimental to state service and may result

in a referral to the Employee Assistance Program or discipline in accordance with K.S.A. 75-2949d, or other

appropriate administrative regulations.

D. Employees are required by federal law to notify the employing state agency head in writing of his or her

conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days

after such conviction.

(1) An employee who is convicted of violating any criminal drug statute in such workplace situations asstated above will be subject to discipline in accordance with K.S.A. 75-2949d, or other appropriateadministrative regulations.

(2) A conviction means a finding of guilt (including a plea of nolo contendre) or the imposition of a

sentence by a judge or jury, or both, in any federal or state court.

E. Agencies that receive federal grants or contracts must, in turn, notify federal granting agencies in writing,

within ten calendar days of receiving notice from an employee or otherwise receiving actual notice of such

conviction. Employers of convicted employees must provide notice, including position title to every grant

officer or other designee on whose grant activity the convicted employee was working, unless the Federal

agency has designated a central point for the receipt of such notices. Notice shall include the identification

number(s) of each affected grant.

F. Employees will be given a copy of the Substance Abuse Policy. Employees will be informed that they mustabide by the terms of the policy as a condition of employment and of the consequences of any violation of suchpolicy.

AFFIRMATION OF POLICY

As an employee for the State of Kansas, I affirm that I have read and understand the meaning of the above Substance Abuse Policy. I am aware of the provisions of this policy which is mandated by the Federal Drug-Free Workplace Act, and that a violation of this policy will result in disciplinary action as stated above.

Name of Employee: _____________________________________ Soc. Sec. No.___________________________

Agency Number and Name:_________________________________ Employee ID No. _______________________

__________________________________________ ________________________________ (Signature of Employee) Date

__________________________________________ ________________________________ (Signature of Agency Representative) Date

DPS 417 Original to Agency. Copy to Employee Rev. 5/2/07

FOR REVIEW ONLY

Employee’s Name

Employee ID Number

State of Kansas Tax Clearance Information Form for New Hires

Purpose: All citizens of the State of Kansas are expected to fulfill their responsibility to pay their share of state taxes. Through education, enforcement of tax laws, and identification of non-compliance, equal treatment of all taxpayers is ensured. Public trust in state government is strengthened when public servants understand and fulfill their responsibility to pay their share of state taxes. The State of Kansas Tax Clearance Program for New Hires is authorized by gubernatorial Executive Order #2004-03, effective June 6, 2004. Coverage: Pursuant to Executive Order #2004-03, all new employees hired by participating state agencies shall be subject to a tax clearance check. Employees of the legislative and judicial branches of state government, employees of elected officials, and students employed by Board of Regents institutions shall not be subject to the tax clearance check for hiring purposes. A tax clearance check shall not delay or prevent the hiring of any candidate for employment. Tax Clearance Check: A tax clearance check consists of a review of the records maintained by the Kansas Department of Revenue for purposes of determining whether an employee is current in the filing of tax returns, payment of tax liabilities and otherwise in compliance with Kansas tax statutes. All information provided by the Department of Revenue shall be confidential. The Kansas Department of Administration will electronically submit the hiring information on the new employees to the Department of Revenue. Resolution of Tax Liability: If the review of a new employee’s tax account(s) indicates that an outstanding tax liability exists or that the new employee is otherwise not in compliance with Kansas law, the employee shall be notified that the tax clearance has been denied. Upon receiving notification of the denial, the employee shall be required to resolve any outstanding tax liability and correct any form of non-compliance. An outstanding tax liability may be resolved either by payment in full of the balance due or establishment of an installment payment agreement with the Department of Revenue. For Tax Assistance, please contact the Kansas Department of Revenue at 785-296-3199. Setoff Program: Employees who fail to cooperate with the Department of Revenue in resolving outstanding tax liabilities, including the failure to remain current in making installment payments, shall be referred to the Kansas Department of Administration debtor setoff program, under which 25% of an employee’s net pay may be offset to satisfy outstanding Kansas tax liabilities. In addition, a collection fee of 17% will be added to the balance. Former Residents of Other States: Newly hired faculty and staff who have not been Kansas residents prior to KU employment are likely to receive a "denial" tax clearance letter from the Kansas Department of Revenue. If that letter is received, you may be asked to provide or to complete information verifying that you were not previously a Kansas tax payer. That information may be an affidavit stating your prior residence or a tax return from the state of your last residence. If you receive a denial letter and need assistance with determining the appropriate verification of prior residence and/or tax payer status, please contact the Department of Revenue, Compliance Enforcement Analytical Research Team at 785-296-6121 for assistance. Non-Resident Aliens: If you are a newly hired faculty or staff who is a non-resident alien from a country that has a tax treaty with the U.S.A., your records will be exempt from the tax clearance program. Please sign this form nonetheless. Employee Acknowledgement I acknowledge that I have been informed of the Tax Clearance Program for the State of Kansas and am aware of the requirements for payment, if applicable. ________________________________________ ___________________ Employee Signature Date

{L0012623.43 } 1

Employee Invention Assignment Agreement

This Employee Invention Assignment Agreement (“Agreement”) is made by and between the University of Kansas (“University”) and ____________________ (“Employee”) and is effective on the date of Employee hire or participation in projects administered by University, whichever is earlier, and is binding on Employee, and Employee’s estate, heirs and assigns.

Whereas, University has offered Employee employment with University, and Employee has accepted University’s offer of employment; and

Whereas, University, consistent with applicable laws and regulations, and in accordance with Kansas Board of Regents policy (“Board Policy”), has an official policy that governs Intellectual Property (“IP Policy”), and Employee agrees to abide by the terms and conditions of the IP Policy, as it may be amended from time to time.

Now therefore, pursuant to Board Policy and the IP Policy in force at this date and as may from time to time be amended, and in consideration of the mutual promises made and exchanged by Employee and University concerning employment, including Employee’s receipt of remuneration from University, participation in projects administered by University, access to or use of facilities or resources provided by University and for other good and valuable consideration, which is acknowledged by both, the University and Employee agree to the following terms and conditions:

1. Employee acknowledges and agrees that if he/she shall invent, discover, author ordevelop any new process, products, art, machine, method of manufacture, or compositionof matter, tangible research property, or any new hardware, firmware, or softwaretechnology (except software developed in self-initiated mediated courseware as providedin the IP Policy) or improvement thereof or know-how, trade secret, copyrightable work(except self-initiated mediated courseware, scholarly and artistic works, and manuscriptsfor academic journals as provided in the IP Policy), or trademark, service mark, or tradename, and other rights in and to such intellectual property as may be recognized byforeign jurisdictions where applicable, in connection with Employee’s work at University(“Invention”), he/she shall promptly and fully disclose such Invention to the Universityby submitting an invention disclosure form that is complete and accurate to the best ofEmployee’s knowledge to the University’s technology transfer office (or any individual,corporation, or governmental agency which the University may specify) after theInvention is conceived, discovered, or created by Employee and in advance of makingany public disclosure, in the case of a patentable or trade secret Invention, in order that adetermination of the rights and equities in such Invention may be made in accordancewith the IP Policy. In the event that University determines that no exceptions toUniversity ownership under the IP Policy or Board Policy apply and the disclosedInvention is property of the University under this Agreement and the IP Policy, Employeewill, at University’s request and expense and through an agent or agents selected byUniversity, apply every endeavor to obtain letters patent, copyright, or trademark

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

{L0012623.43 } 2

registration or other protection of the United States and/or of any state or foreign countries covering the Invention (“Invention Protection”).

2. Pursuant to the IP Policy and Board Policy, this Agreement applies to Inventions andInvention Protection that Employee develops using University equipment, supplies,facilities, time, personnel or trade secrets; or result from work he/she performs forUniversity; or relate to University’s actual or demonstrably anticipated research ordevelopment. Employee agrees to assign, and hereby does assign, to University all right,title and interest and, where applicable, waives moral rights in and to said Inventions andto any Invention Protection that is filed, issued or maintained thereon to which theUniversity has rights pursuant to the IP Policy and Board Policy. To the extent the IPPolicy and Board Policy waive or limit University ownership of Inventions, Employeewill retain such rights. Employee will promptly execute all documents and do all thingsrequested by University to further secure such Invention Protection and to enable theUniversity to comply with the terms of any grant, contract, or award relating to suchInventions. Employee will, if necessary, testify in any interference, litigation orproceeding related thereto. The legal expenses associated with each one of these actions,if such action is requested by the University, are to be at the expense of University. Theforegoing obligations extend to any and all Inventions that may be disclosed subsequentto Employee’s term of employment if the Inventions pertain to work performed byEmployee in the course of his/her employment with University.

3. If the University receives revenue from an Invention assigned by Employee pursuantto this Agreement, Employee understands that, in accordance with the IP Policy andBoard Policy,* inventors shall collectively receive revenues from royalties, license fees,and other charges generated by Inventions after the University recovers its costs inaccordance with the provisions of the University’s Technology Transfer RevenueDistribution Policy in effect on the date that the Invention is disclosed to University.Employee may prospectively assign rights to revenue (for a certain period or inperpetuity) to a trust, legal entity or another person by a written instrument so indicatingand properly acknowledged before a notary. Such assignment will only be treated aseffective upon approval by the paying agent and the general counsel for the University ofKansas or counsel for the University of Kansas Center for Research, Inc. or counsel forthe University of Kansas Medical Center Research Institute, Inc., as appropriate. The taxidentification number of the substituted payee must also be provided before any paymentto anyone other than the Employee.

4. It is understood that this Agreement shall not include rights of Employee to anyInvention reduced to practice, owned, or controlled by the Employee before the EffectiveDate of this Agreement. If Employee has made any Inventions before his/heremployment with the University, which belong to him/her and which are not assigned orassignable to the University under this Agreement (“Employee Prior Inventions”),Employee shall list and describe all of them on the attached page (Exhibit A) and includeany pertinent documentation. Such Employee Prior Inventions shall be made a part of this

* In accordance with Kansas Board of Regents and University of Kansas policies on intellectual property,ownership of scholarly and artistic works and royalties derived therefrom shall reside with the creators.

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

{L0012623.43 } 3

Agreement. University makes no claim to any Employee Prior Inventions. If no such list is attached, Employee agrees that it is because no such Employee Prior Inventions exist or because Employee has assigned such inventions to a prior employer or other entity. Employee acknowledges and agrees that if he/she uses any Employee Prior Inventions in the scope of his/her employment with the University, or includes them in a product or service of the University, Employee hereby grants to the University a perpetual, irrevocable, nonexclusive, world-wide, royalty-free license to use, disclose, make, sell, copy, distribute, modify, and/or create works based on such Employee Prior Inventions and to sublicense them to third parties with the same rights.

5. University, in compliance with Kansas state law, hereby notifies Employee of theprovisions of K.S.A. 44-130. Specifically, and subject to section 6 below, Employeeacknowledges and understands that because this Agreement contains a provisionassigning Employee's rights in any invention to the University, the University isrequired to provide, at the time this Agreement is made, a written notification toEmployee that this Agreement does not apply to an Invention for which no equipment,supplies, facility or trade secret information of the University was used and which wasdeveloped on Employee's own time, unless:

(a) The Invention relates directly to the business of the University or to theUniversity's actual or demonstrably anticipated research or development; or

(b) The Invention results from any work performed by Employee for theUniversity.

Also, even though Employee may meet the burden of proving the conditions specified in K.S.A. 44-130, Employee shall disclose, at the time of employment or thereafter, all Inventions being developed by Employee, for the purpose of determining University and Employee rights in an invention. See Exhibit A.

6. Employee acknowledges that he/she may enter into a consulting agreement thatassigns rights to an Invention developed under a private consulting arrangement whensuch an Invention to be assigned:

a) is developed on Employee's own time,

b) makes no use of University equipment, supplies, facility or trade secretinformation,

c) is made in compliance with University polices on intellectual property andconsulting,

d) is not based on, does not improve upon or, to be practiced, does not require theuse of an Invention owned by the University,

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

{L0012623.43 } 4

e) arises out of a specific scope of work defined in a written agreement betweenthe Employee and the organization,

and

f) if such Inventions are within the specific subject area of Employee’s current andongoing University research activities, such Employee has received the priorwritten approval from his/her department chair, school dean, unit director orsimilar administrative officer to engage in such external research activity andwritten notice of such approval has been provided to University’s technologytransfer office.

Employee agrees and understands that Employee is prohibited from assigning, licensing, or otherwise transferring Inventions subject to the IP Policy to organizations engaging Employee’s services under this exception. Employee agrees to make his/her obligations to the University clear to those with whom he/she contracts and will provide or will arrange to have provided to the organization a current statement of the University’s IP Policy. Before assigning an Invention under this exception, the Employee has the responsibility to disclose the Invention to the University and provide to the University additional information sufficient for the University’s technology transfer office to demonstrate that such Invention qualifies as defined herein.

7. Employee hereby certifies that no assignment, sale, agreement or encumbrance hasbeen or will be made or entered into by Employee that would conflict with thisAgreement.

8. The University’s IP Policy and such other policies covering Inventions as may beestablished by the University from time to time and as may be in effect during the term ofthis Agreement are hereby incorporated and made a part of this Agreement, and, asapplicable, said policies shall govern the interpretation of this Agreement.

9. Employee understands that this Agreement is part of the terms of Employee’semployment with the University and that any contract of employment heretofore orhereafter entered into between Employee and the University shall be deemed to includethis Agreement except to the extent than an express provision of such contract ofemployment is inconsistent therewith.

10. This Agreement shall be governed by and construed under the laws of the State ofKansas.

11. This Agreement fully and completely states the understanding of Employee andUniversity. All prior understandings and agreements between Employee and Universityare merged with this Agreement.

12. This Agreement shall remain effective and enforceable throughout Employee’semployment with the University, and as to any Inventions made during employment with

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

{L0012623.43 } 5

the University, it shall survive Employee’s termination of employment with the University.

In Witness Whereof, the Employee and University have caused this Agreement to be executed as of the date below.

By Employee: Accepted and Agreed to by University of Kansas:

___________________________ ____________________________ Signature James W. Tracy

Vice Chancellor for Research ___________________________ Printed name

____________________________ Date of Execution

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

{L0012623.43 } 6

EXHIBIT A

List of Employee Prior Inventions

Note: This list may be amended from time to time to reflect Prior Intellectual Property or Inventions inadvertently omitted at the time of completion of this Exhibit A.

Employee's Name: _____________________________________________________________

Employee ID Number: _______________________________

Employee’s Name

Employee ID Number

State of Kansas Oath, University Policy and Mandated Notice Acknowledgment As a State of Kansas employee for the University of Kansas, I agree to abide by the State of Kansas Oath (K.S.A 75-4308 et. Seq. and K.S.A. 54-106) as well as follow all University policies, including but not limited to those identified below, and agree to the requirements, expectations and stipulations outlined therein. I understand that I may request a hard copy of any of the below identified notices and policies from Human Resources Management (HRM). I also understand that I may seek clarification or an explanation regarding my obligations under these policies from HRM. I also acknowledge the provision of information related to the “New Health Insurance Marketplace Coverage Options and Your Health Coverage” Provided below with the link to the Affordable Care Act.

State of Kansas Employee Oath I do solemnly swear (or affirm) that I will support the constitution of the United States and the constitution of the State of Kansas, and faithfully discharge the duties of my office or employment.

University Policies and Mandated Notices Affordable Care Act Notice http://www.humanresources.ku.edu/files/documents/benefits/ACA_Marketplace_Notice_for_Active_Employees.pdf

Alcohol and Drug Policies, the University of Kansas http://policy.ku.edu/human-resources/alcohol-and-drug http://policy.ku.edu/student-affairs/alcohol-drug-policies-brochure

Campus/Workplace Violence Policy https://documents.ku.edu/policies/provost/WorkplaceViolence.htm

Consenting Relationships, University of Kansas Policy on https://documents.ku.edu/policies/provost/ConsentingRelationships.htm

Criminal Background Check Policy https://documents.ku.edu/policies/Human_Resources/BackgroundCheck.htm

Institutional Conflict of Interest Policy https://documents.ku.edu/policies/research/institutionalconflictofinterest.htm

• Kansas Board of Regents Commitment of Time/Conflict of Interest Policy• Individual Financial Conflict of Interest Policy

Intellectual Property Policy for the Lawrence Campus https://documents.ku.edu/policies/provost/IntellectualPropertyPolicy.htm

Nondiscrimination, Equal Opportunity, and Affirmative Action Policies https://documents.ku.edu/policies/IOA/Nondiscrimination.htm

Overtime/Compensatory Time Policy Agreement http://www.humanresources.ku.edu/files/documents/overtime_compform.pdf

Policy Against Racial and Ethnic Harassment, the University of Kansas https://documents.ku.edu/policies/IOA/RacialEthnicHarassment.htm

Sexual Harassment Policy https://documents.ku.edu/policies/IOA/Sexual_Harassment.htm

Substance Abuse, Policy and Procedures on https://documents.ku.edu/policies/provost/SubstanceAbuse.htm

My signature below affirms my agreement to abide by the State of KS Oath and all University policies and receipt of the mandated notice. I hereby certify that I have reviewed and comprehend the policies identified above, and I acknowledge and agree to abide by the obligations and guidelines set forth therein.

Employee’s Signature Date

State of Kansas Agency

Employment Form

State of Kansas Agency Employment is defined as paid employment at a state agency or other Kansas

Board of Regents institution; examples include, Kansas State University, KU Medical Center, KS Board of

Regents, State of Kansas Department of Transportation etc.

Please check the appropriate box below

NO, I have never been employed at the University of Kansas or other State of Kansas Agency. (Proceed to the bottom of this form for signature and printed name)

YES, I am or was an employee at the University of Kansas or other State of Kansas Agency. (Please answer the questions below)

11 characters State of Kansas Employee ID (if known):

Other Names you may have been employed under:

Please fill out information below:

Agency/Division Name Approximate Dates

Employee Signature: _ Date:

Printed Name: __________________________________________________________________________________________________ For Office Use Only: Direct a copy of this form to Benefits (ACA Specialist) for any work conducted at a State of Kansas agency within the last 12 months.

Humanresources.ku.edu hrdept@ku.edu 785/864-4946 08/22/14