I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Employees may upload one selection from List "A" OR a combination of one selcetion from List "B" AND one selection from List "C"

Please see the list of acceptable documents below

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Your withholding is subject to review by the IRS.

Please note that the way you write your name and address on this form, is the way your name and address will appear on your payroll checks and W2 forms.

TIP: To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.