EmailMe Form - W-4 EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE

Tax Year

Name *

First Last

Last Four Digits of your Social Security Number *

If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213

Check Here

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Select One of the Following:
Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single" box. *

Single

Married

Married, but withhold at higher Single rate

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) *

Additional amount, if any, you want withheld from each paycheck *

$ Dollars . Cents

I claim exemption from withholding for the tax year selected above, 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:

Todays Date *

MM / DD / YYYY

Signature *

Clear

Use your finger if you are using a Mobile Phone or Tablet. You can also use your computer mouse to sign your name.