(NC-4) Employee’s Withholding Allowance Certificate

FirstName*

MiddleName*

LastName*

Street*

City*

State*

Zip*

County*

Social Security Number*

Filing Status (Mark one box only)*

Single or Married Filing SeparatelyMarried Filing Jointly or Surviving SpouseHead of Household

Instructions. Use Form NC-4EZ if you:

Plan to claim the N.C. Standard Deduction
Plan to claim the N.C. Child Deduction Amount (but no other N.C. deductions)
Do not plan to claim N.C. tax credits
Qualify to claim exempt status (See Lines 3 or 4 below)

Important. If you plan to claim N.C. itemized deductions or plan to claim other N.C. deductions (other than the N.C. Child Deduction Amount), you mustcomplete Form NC-4. If you are a nonresident alien, you must complete Form NC-4 NRA. In general, a nonresident alien is an alien (not a U.S. citizen)whohasnot passed the green card test or the substantial presence test. (See Publication 519, U.S. Tax Guide for Aliens, for more information on the green card test and the substantial presence test

Ifyou plan to claim the N.C. Child Deduction Amount, use the table below for your filing status, amount of income, and number of children under age 17 to determine the number of allowances to enter on Line 1. For married taxpayers, only one spouse may claim the allowance for the N.C. Child Deduction Amount for each child.

1. Total number of allowances you are claiming (Enter zero (0), or the number of allowances from the table above)*

2. Additional amount, if any, you want withheld from each pay period (Enter whole dollars)

3. I certify that I am exempt from North Carolina withholding because I meet both of the following conditions: Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and This year, I expect a refund of all State income tax withheld because I expect to have no tax liability.

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4. I certify that I am exempt from North Carolina withholding because I meet the requirements set forth in the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act and Veterans Benefits and Transition Act. See Form D-401, North Carolina Individual Income Tax Instructions, for more information

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If an exemption on Line 3 or Line 4 applies to you, enter the year the exemption became effective

5. I certify that I no longer meet the requirements for an exemption on

Line 3Line 4

Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax based on the number of allowances entered on Line 1 and any additional amount entered on Line 2.

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CAUTION: If you furnish an employer with an Employee's Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information,you are subject to a penalty of 50% of the amount not properly withheld.

Certification:*

I certify, under penalties provided by law, that / am entitled to the number of withholding allowances claimed on Line 1 above, or if claiming exemption from withholding, that / am entitled to claim the exempt status on Line 3 or 4, whichever applies.

Employee's Signature*

I certify, under penalties provided by law, that / am entitled to the number of withholding allowances claimed on Line 1 above, or if claiming exemption from withholding, that / am entitled to claim the exempt status on Line 3 or 4, whichever applies.

Date*

Date

Mobile Phone Number*

E-mail Address*

Birth Date*

Date

Date Hired*

Date

Start Date (First Day of Work)*

Date

Sex

NCDOR NC-4EZ