Employment Form (USA W-4)


 
 

  1   Type in your first name and middle initial
    Last name
  2   Your social security number
    Home address (number and street or rural route)
    City or town, state, and ZIP code

 
  3   Please choose one of the following. (Note: If married, but legally separated, or
 spouse is a nonresident alien, select "Single")
Single  
Married  
Married, but withhold at higher single rate.  
 
  4   Does your last name differ from that on your social security card?
Yes (you must call 1-800-772-1213 for a new card)  
No  
 

  5   Total number of allowances you are claiming
  6   Additional amount, if any, you want withheld from each paycheck               $

 
I claim exemption from withholding for 2004, 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.

  7   If you meet both conditions, type "Exempt" here

 
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status.

    Employee name
    Date

 

  8   Employer name
    Employer Address
  9   Office code (optional)
  10   Employer identification number