UNDER REVIEW
                       CONTACT ACCOUNTING
                                
             UNIVERSITY OF CALIFORNIA, SANTA BARBARA
                        Accounting Office
                                
  ALIEN'S CERTIFICATE TO CLAIM EXEMPTION FROM WITHHOLDING TAX ON SCHOLARSHIP
                          OR FELLOWSHIP
                                
                                                    File
  Name of Grantee                                   Date
  Department
  Citizen of                                   Resident of
  Status in the University - Candidate for degree?  Yes                 No
  Scholarship or fellowhip for which tax exemption is hereby claimed:
  
       Agency                        Total amount $
       Monthly Amount $                   Period:  From              To
  
  Total number of months since December 31, 19   , during which claimant is
  entitled to receive benefit of withholding tax exemption on first $300 per
  month received while not a candidate for a degree. . . . . . . . . . . . .
  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  . . . . . . . .  36
  
  Less the total number of months since December 31, 19   , (whether or not
  consecutive) during which the claimant has received the benefit of such an
  exemption while not studying for a degree at the University of California
  or elsewhere. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  . . . .
  
  Number of remaining months during which claimant may receive the benefit of
  the withholding tax exemption described above. . . . . . . . . . . . . . .
  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  
  
  I certify that the foregoing is a correct statement of the facts concerning
  my eligibility for exemption from withholding tax on the scholarship or
  fellowship described aabove.
  
  I agree to notify the Accounting Office (Payroll Division) promptly if
  there is a change in my status as described above or if I determine that
  the total number of months deducted above is incorrect.
  
  I understand that if the period of eligibility to exemption, shown as the
  total figure above, expires during the period of the grant, withholding tax
  will be applicable to all payments after such expiration.
  
  I declare under the penalties of perjury that this statement has been
  examined by me and, to the best of my knowledge and belief, is true and
  correct.
  
            Signature of Claimant

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Last Modified By: HMW, 5/21/97

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