EMPLOYEE ASSIGNMENT FORM

January 2017

SALARY Annual Salary Amount: $ Hourly: $ /Hr. Period Salary Amount: $ /Bi-weekly

Total Salary: $ Approved: X Reason for Retro: Retro Required? No Yes: If yes, Pay Period From Date: Last Day of Pay Period Retro: (Office Use Only) Input by: Date:

SPECIAL INFORMATION MUST BE COMPLETED FOR NEW HIRES Education Level: Degree Expected: Date Degree Expected: If SUNY Student Fulltime (12-Credits or more)

Part-time (11-Credits or less) Licensure/Certification:

ADDRESS US Address (Primary Address in United States): City: State: Zip Code: County: Country: Primary: Y (Must be a US address) Telephone: ( ) E-Mail Address:

ASSIGNMENT Organization: 160 Group: Undergraduate Graduate Regular Summer Effort Reporting Status: E = Exempt N = Non-Exempt N/A = Not Applicable RF Job Title: Grade:

FTE (Full Time Equivalent): (Ex. 5 for 20-hours a week based on 40-hour week Location: Assignment Category: Exempt Regular Hourly Nonexempt Regular Supervisor: Status: Active Assignment SUNY Extra Service Work Week Basis: 37 ½ hours 40 hours Timecard Required: Yes No Payroll: Biweekly Salary Basis: Salaried Annual Salaried Period Hourly 37.5 Hourly 40 Hours Per Pay Period:

(For Hourly Employee)

Employee# (For Office Use Only) HOURLY (Paid for hours Worked) OR SALARIED (Set Salary for Set Hours)

Hire Date: (dd/mmm/yy) ie.22/jan/10

Rehire?

Yes

No

Prior Retirement Service Credit: Yes NO If Yes: (College/Univ. or Research Org.)

Prior SUNY Concurrent SUNY Prior Non SUNY State University for New York (SUNY), or any accredited college or university in the United States, or a private, nonprofit research organization incorporated in the United States under Section 501(c)(3) of the Internal Revenue Code. The primary function of this organization must be research.

PEOPLE DATA Last Name: First Name: Middle Name: Title: Dr. Miss Mr. Mrs. Ms. Gender: Male Female Type: Internal Social Security #: Birth Date: (dd/mmm/yy) (i.e 23/jan/45)

Nationality: US Citizen Non-Citizen in US on VISA Non-Citizen Not in US Perm. Resident Ethnic Origin: (select all that apply) American Indian or Alaska Native Asian Black or African American

Hispanic or Latino Native Hawaiian or other Pacific White I-9 Status: Complete Visa Type: I-9 Expiration Date: E-Verify Status: Date Authorized: Case Verification #: Vets 100 Status: Vets 100A Status: New Hire: Include in New Hire Report Mail Stop: Correspondence Language:

EMPLOYEE ASSIGNMENT FORM

hafrm003 January 2017 2

NAME: Employee #: SSN:

LABOR DISTRIBUTION Schedule Hierarchy ___Assignment ___Element

Schedule Line Changes

Project Task Award Organization Expenditure Type LD

Start Date

LD

End Date %

Input by: Date:

DECLARATION AND AUTHORIZATION

I accept the position offered as an employee of The Research Foundation of State University of New York. I understand this position is subject to final

approval by the Research Foundation and is terminable at will. I also agree to abide by all policies and regulations of the Research Foundation.

Intellectual Property Waiver and Release Agreement I have read State University of New York’s Patents and Inventions Policy (“Policy”). I agree to abide by the Policy and by any

additional terms and conditions imposed by any sponsor from which I accept support through RFSUNY, including but not limited to the

Patent and Trademark Amendments Act (i.e. Bayh-Dole Act) and its implementing regulations found in 37 CFR 401. I will promptly

disclose to RFSUNY or its designee any Intellectual Property subject to the Policy or sponsor requirements, and will cooperate with

RFSUNY, the sponsor, and the State University of New York, and execute any such documents as may be necessary to protect the

subject Intellectual Property. I understand that the prompt disclosure of Intellectual Property developed within the scope of my

employment is required to enable its protection prior to U.S. or foreign statutory bars and to establish the government’s rights, where

applicable. I hereby assign to RFSUNY all rights in Intellectual Property subject to the Policy, and will execute any documents required

to effectuate such assignment to or as directed by RFSUNY.

AS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER, THE RESEARCH FOUNDATION FOR SUNY

WILL NOT DISCRIMINATE IN ITS EMPLOYMENT PRACTICES DUE TO AN APPLICANT’S RACE, COLOR,

RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN, AND VETERAN OR

DISABILITY STATUS.

Employee Signature:___________________________________________________________ Date:___________________________________

APPROVALS This assignment is consistent with sponsored program terms and conditions and with Research Foundation policies.

Project Director/Co-Project Director:

(Signature) (Date)

Funds are in the account for this assignment.

Operations Manager:

(Signature) (Date)

Additional Campus Signatures as Required:

(Signature) (Date)

(Signature) (Date)

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)

First name and middle initial Last name Your social security number

Permanent home address (number and street or rural route) Apartment number

City,village,orpostoffice State ZIPcode

Are you a resident of New York City? ........... Yes NoAre you a resident of Yonkers? ..................... Yes NoComplete the worksheet on page 3 before making any entries.1 TotalnumberofallowancesyouareclaimingforNewYorkStateandYonkers,ifapplicable(from line 17) ........... 12 Total number of allowances for New York City (from line 28) .................................................................................. 2

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 NewYorkStateamount ........................................................................................................................................ 34 New York City amount ........................................................................................................................................... 45 Yonkers amount .................................................................................................................................................... 5

Department of Taxation and Finance

Employee’s Withholding Allowance CertificateNew York State • New York City • Yonkers

SingleorHeadofhousehold Married

Married, but withhold at higher single rate

Note:Ifmarriedbutlegallyseparated,markanX in the Single or Head of household box.

IcertifythatIamentitledtothenumberofwithholdingallowancesclaimedonthiscertificate.Employee’s signature Date

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.) Employeridentificationnumber

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Changes effective for 2017FormIT-2104hasbeenrevisedfortaxyear2017.Theworksheetonpage3andthechartsbeginningonpage4,usedtocomputewithholdingallowancesortoenteranadditionaldollaramountonline(s)3,4,or5,havebeenrevised.IfyoupreviouslyfiledaFormIT-2104andusedtheworksheetorcharts,youshouldcompleteanew2017FormIT-2104andgive it to your employer.

Who should file this form Thiscertificate,FormIT-2104,iscompletedbyanemployeeandgiventotheemployertoinstructtheemployerhowmuchNewYorkState(andNew York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

IfyoudonotfileFormIT-2104,youremployermayusethesamenumberofallowancesyouclaimedonfederalFormW-4.Duetodifferencesintax law, this may result in the wrong amount of tax withheld for New York State,NewYorkCity,andYonkers.CompleteFormIT-2104eachyearandfileitwithyouremployerifthenumberofallowancesyoumayclaim

isdifferentfromfederalFormW-4orhaschanged.CommonreasonsforcompletinganewFormIT-2104eachyearincludethefollowing:• You started a new job.• You are no longer a dependent.• Your individual circumstances may have changed (for example, you

were married or have an additional child).• You moved into or out of NYC or Yonkers.• You itemize your deductions on your personal income tax return.• YouclaimallowancesforNewYorkStatecredits.• Youowedtaxorreceivedalargerefundwhenyoufiledyourpersonal

income tax return for the past year.• Yourwageshaveincreasedandyouexpecttoearn$107,650ormore

during the tax year.• Thetotalincomeofyouandyourspousehasincreasedto$107,650or

more for the tax year.• Youhavesignificantlymoreorlessincomefromothersourcesorfrom

another job.• You no longer qualify for exemption from withholding.

Instructions

Employer: Keep this certificate with your records.Mark an XinboxAand/orboxBtoindicatewhyyouaresendingacopyofthisformtoNewYorkState (see instructions):

A Employeeclaimedmorethan14exemptionallowancesforNYS ............ A

B Employee is a new hire or a rehire ... B First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Aredependenthealthinsurancebenefitsavailableforthisemployee? ............. Yes No

IfYes,enterthedatetheemployeequalifies(mm-dd-yyyy):

IT-2104

Employment Application

Welcome to The Research Foundation for The State University of New York, a private nonprofit educational corporation. We appreciate your interest in our organization. Please provide all the information requested on this application. Thank you. We are an equal opportunity/affirmative action employer. Personnel are chosen on the basis of ability without regard to race, color, religion/creed, sex, age, national origin, citizenship, disability, marital status, military or veteran status, domestic violence victim status, sexual orientation or any other trait protected by federal, state, or local law.

Please return completed application to:

Position applied for: ____________________________________________Department/office: __________________________________

Name: ____________________________________________________ _____________________________________________ (Last) (First) (Middle Initial) Telephone Number:

Address: __________________________________________________________________________________________________ (Number & Street) (City) (State) (Zip Code)

Email address: _____________________________________________________________________________________________

Do you have the legal right to work in the United States? Yes No Are you under 18? Yes No Proof of identity and authorization to work in the United States are required prior to employment. Have you ever been employed by The Research Foundation for The State University of New York? Yes No If yes, please explain: _____________________________________________________________________________________________ Do you have a family member(s), relative(s), significant other, or member of your household working for the Research Foundation for SUNY? Yes No. If yes, please provide his/her name(s) and department(s) in which he/she works: _______________________________________________________________________________________________________________ Have you ever, or are you currently involved in any form of disciplinary/investigative process before any state licensing body or any accrediting body? Yes No If yes, please provide dates and details of circumstances. ____________________________________ _______________________________________________________________________________________________________________ Are you currently debarred, suspended or otherwise ineligible to work on any federally funded or state funded program? Yes No

My resume/curriculum vitae with employment history Is Is not attached.

If your resume/curriculum vitae is not attached, you must provide your education and employment history, beginning with your present or last employer, on the reverse side of this application or on additional sheets. The name, address, and telephone number of three references must be provided. I hereby authorize investigation of all statements contained in this application and attached resume, curriculum vitae, or other data/documentation as provided. I certify that such statements are true and understand that misrepresentation or omission of facts called for in this form or during the application, interviewing, or screening process may result in a decision not to hire me or, if I have been hired, to end my employment without notice. I hereby also agree to hold the Research Foundation harmless in divulging the information contained in this application form as well as any personnel records developed as a result of employment with the Research Foundation. A pre-employment examination by a Research Foundation designated physician may be required if physical condition is a job-related qualification. For some positions, a pre-employment physical examination is required by law. I also agree, if employed, to abide by all policies and procedures of the Research Foundation. I understand that if hired by The Research Foundation, my employment is terminable at will, with or without cause, based on the employment needs of The Research Foundation as it may determine in its sole discretion, unlessmy position is part of an employment

agreement signed by The Research Foundation President or Vice President for Human Resources.

_________________________________________________________________________________________________________ Applicant’s Signature Date

Education High School: (Name and Location) Course: Graduate: Yes No ______________________________________________________________________________________________________________ Business or Trade Schools: (Name and Location) Course: Graduate: Yes No ______________________________________________________________________________________________________________ Special Skills or Training: Licenses Held: ______________________________________________________________________________________________________________ College: (Name and Location) ______________________________________________________________________________________________________________ Degree: Major: Graduate: Yes No ______________________________________________________________________________________________________________ Graduate School: (Name and Location) Graduate: Yes No ______________________________________________________________________________________________________________ Degree: Major: ______________________________________________________________________________________________________________

Employment List your employment record starting with your present or last employer first. Show all employment and periods of unemployment if more than one month. Include military service. Use additional sheets if necessary.

Employer One Date From: Month/Year Employer’s Name Department, Division, or Section _______________________________________________________________________________________________________________ To: Month/Year Address Supervisor Telephone Number

_______________________________________________________________________________________________________________ Title: Starting Salary Last Salary _______________________________________________________________________________________________________________ Briefly describe the duties of your position: _______________________________________________________________________________________________________________ Reason for leaving: May we contact this employer? Yes No _______________________________________________________________________________________________________________ Employer Two Date From: Month/Year Employer’s Name Department, Division, or Section _______________________________________________________________________________________________________________ To: Month/Year Address Supervisor Telephone Number _______________________________________________________________________________________________________________ Title: Starting Salary Last Salary _______________________________________________________________________________________________________________ Briefly describe the duties of your position: _______________________________________________________________________________________________________________ Reason for leaving: May we contact this employer? Yes No _______________________________________________________________________________________________________________

Employer Three Date From: Month/Year Employer’s Name Department, Division, or Section _______________________________________________________________________________________________________________ To: Month/Year Address Supervisor Telephone Number _______________________________________________________________________________________________________________ Title: Starting Salary Last Salary _______________________________________________________________________________________________________________ Briefly describe the duties of your position: _______________________________________________________________________________________________________________ Reason for leaving: May we contact this employer? Yes No _______________________________________________________________________________________________________________

References Give name, address, and telephone number of three work-related references. Attached Not Attached

CRIMINAL HISTORY DISCLOSURE FORM

Criminal history may be considered as part of the overall screening process of potential applicants. A conviction or pending criminal charges is not an automatic bar from employment. Each case is considered and evaluated on its individual merits in relation to the duties and responsibilities of the position for which you are applying. Please respond fully to the questions below. In your responses, please be sure to include Motor Vehicle Traffic misdemeanors, but do not include information regarding: any youthful offender adjudication; any conviction for a sealed violation; or any criminal charges that were resolved in your favor (e.g., dismissal). 1a. Have you ever been convicted of, or pled guilty or no contest to, a crime (felony or misdemeanor)? Yes No. If yes, please give specifics about the nature of the crime, location of the jurisdiction, the year of conviction, and any information regarding rehabilitation or other information you wish us to consider.

Do you have any criminal charges pending against you? Yes No If yes, please give specifics:

I certify that the above disclosures are true and complete. I understand that misrepresentation or omission of relevant facts may result in a decision not to hire me or, if I have been hired, to end my employment without notice. I hereby authorize investigation of all statements contained in this disclosure and any attached data provided. I hereby also agree to hold the Research Foundation harmless in divulging the information contained in this application form as well as any personnel records developed as a result of application or employment with the Research Foundation.

_________________________________________ _______________________________ Applicant Signature Date

The Research Foundation of SUNY Buffalo State College, Bishop Hall B 14

Personnel Employee Information

Name First M.I. Last

SSN - - Working Title

Local Address Street City, State, Zip Phone E-Mail

Project Information

Work Address- Specific Office Location of Assignee Directors Name e.g. 61 Broadway, NYC , Floor #3

Supervisors Name

Floor #

Phone # For CDHS Employees Only On or Off BSC Campus (for indirect cost rate)

On Campus

Off Campus

Fax # E-Mail Address

Emergency Contact Information

Name Relationship

Address Phone # Work Phone#

Please return to: RESEARCH FOUNDATION, Human Resources, Bishop Hall B 14 Revised 8/18/16

The Research Foundation of Buffalo State College Authority to Release Information

To Whom It May Concern: I herby authorize the Research Foundation of Buffalo State College to do a review of and full disclosure of all records concerning myself to the Research Foundation, its agents and representatives, whether the said records are of a public, private or confidential nature. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information, and I do herby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release the Research Foundation, its agents and representatives, from any and all liability which may be incurred as a result of collecting such information. Should there be any questions as to the validity of this release, you may contact the Research Foundation Human Resource Office at 716-878-4046. Please return completed form to Gruarisl@buffalostate.edu or fax form to 716-878-3046. I have read and fully understand the contents of this “Authority to Release Information”. _________________________________________________ Print Full Name ____________ ____________________________________________ Date Applicant Signature ______________________ __________________ ______________________ Social Security Number Date of Birth Driver’s License No. __________________________________________________ Address _______________________ ___________ ______________ City State Zip Code Rev 12/14