State of Georgia
PeopleSoft HCM
Request for Payroll Action Form
|Employee ID: |Company: |Record #: |Employee Name: |Social Security #: |
| | | | | |
(Federal Tax Data 1) W-4 Attached (
| Effective Date: |Special Tax Withholding Status: |
| |( None |
| |( Maintain Taxable Gross: FWT will be zero unless specified in “Additional Withholding” below |
| |( Non-Resident Alien; taxation specified on Federal Tax Data 3 |
|Tax Marital Status: |Withholding Allowances: |Additional Withholding: |
|Single | | |
|Married | |Amount:_______________Percentage:_____________ |
(Federal Tax Data 2) W-5 Attached (
|Earned Income Credit: |
|( Not Applicable ( Single, or Married without spouse filling ( Married with both spouses filling |
(Federal Tax Data 3)
|Country: |Treaty ID: |Treaty Exp Date: |
|Form 8233 Recd? |8233 submit date:_____________ |Taxpayer ID #: |
|Form 1001 Recd? |1001 submit date:_____________ | |
(State Tax Data 1) G-4 Attached (
|State: |Resident? ( YES |Non-Residency Statement Filed? |UI Jurisdiction? ( YES |
| |( NO |( YES ( NO |( NO |
|Special Tax Withholding Status : |
|None |
|Do Not Maintain Taxable Gross and Do Not Withhold Tax |
|Maintain Taxable Gross: SWT will be zero unless specified in “Additional Withholding below |
|SWT Marital/Tax Status: |Withholding Allowances: |Additional Withholding: |
|Single | | |
|Married/ One Spouse Working | |Amount:________________ |
|Married /Both Spouses Working / filing Joint or Separate | | |
|Head of Household | |Percentage:_____________ |
(State Tax Data 2)
|Additional Allowances (G-4 lines 4 + 5): |( Exempt from SUT (Note: Check only if employee is exempt from Unemployment|
| |Insurance) |
(Additional Pay 1)
|Earning Code: |Effective Date: |End Date: |Reason: |
|Addl Seq #: |Separate Check #: |Hours: |Hourly Rate: |Earnings: |
|( Disable Direct Deposit ( Prorate Additional Pay ( OK to Pay ( Pension Eligibility |
|Applies to Pay Periods: ( First ( Second ( Third ( Fourth ( Fifth |
(Additional Pay 2 and 3)
|Before using Additional Pay Panels 2 or 3: contact Payroll Central Support Office for Assistance. |
*Note: Bold print indicates required fields
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