Rev. 10/07
A. Douglas
Baruch College—Office of Human Resources
REQUEST FOR EXEMPTION FROM SOCIAL SECURITY AND MEDICARE TAXES FORM
Name:
SS#:
Title:
Department:
I am requesting exemption from paying Social Security and Medicare taxes for the following
reason. Please check the appropriate box.
I am a parttime employee at AND a fulltime undergraduate/graduate student or a part
time undergraduate/graduate student in my last semester of studies at CUNY. I
understand that I must provide proof of my student status for each semester I wish
to be exempt.
I am a fulltime international undergraduate/graduate student/trainee ( F1 Visa holder)
AND an employee at CUNY (please complete a nonresident alien statement and
attach a copy of your visa (s) and INS I20 form(s) ).
I am an International Visitor (J1 visa holder) at CUNY (please complete a nonresident
alien statement and attach a copy of your visa (s) and INS IAP66 or DS2019 form
(s) ).
Please submit this form to Office of Human Resources. Telephone requests will not be accepted.
The Medicare and Social Security taxes exemption will be processed upon receipt of the signed
form. Any tax withheld because the required tax information was not provided before will
not be refunded.