Out-of-State Income Tax Withholding Form Complete this form if Complete this form if you will be working for the University for more than in a state other than California or if you wish to cancel state income tax withholding for another state. See Instructions. NOTE: INTERNET EXPLORER DOES NOT SUPPORT THIS FORM SUBMISSION. PLEASE COMPLETE THIS FORM IN A FIREFOX, SAFARI OR CHROME WEB BROWSER. Employee First Name Employee Last Name Employee CWID Work Street Address Department City State Zip Email Address hr IF YOU ARE A NONRESIDENT OF CALIFORNIA, COMPLETE THIS SECTION: I have claimed exemption from California income tax withholding on my Form DE 4 and am earning compensation while working in the following city, county, and state: City County State Began Earning Compensation I began earning compensation in the state listed above Expect to continue earning And expect to continue working in the state until approximately I Understand nonresident I understand that I must complete a new Out-of-State Income Tax Withholding form when my assignment ends. hr IF YOU ARE A RESIDENT OF CALIFORNIA, COMPLETE THIS SECTION: I am a resident of the State of California but am temporarily working in the city, county, and state listed below: City County State Began Earning Compensation Resident I began earning compensation in the state listed above on Expect to continue earning Resident and expect to continue working in this state until approximately I understand that I may be subject resident hr IF YOU WORK IN MORE THAN ONE STATE, COMPLETE THIS SECTION California % State Name state_1_percent State Name state_2_percent % TO CANCEL OUT-OF-STATE INCOME TAX WITHHOLDING, COMPLETE THIS SECTION: Please cancel my income tax withholding for the state of Effective I am earning compensation while working in the state of Employee Certification By checking this box, I certify, to the best of my knowledge, that the above information is true, correct, and complete.