W-4 Employee’s Withholding Certificate

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First name and middle initialType

ex. First-Name Middle-Name

2

Last nameType

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Social security numberType

4

AddressType number and street

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City or town, state, and ZIP codeType

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Marital StatusSelect one

Single or Married filing separately

Married filing jointly or Qualifying widow(er)

Head of household Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual

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If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheldSkip if not applicable

Option

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Multiply the number of qualifying children under age 17 by $2,000ex. 2 Children = 2 x 2000 = 4000

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Multiply the number of other dependents by $500ex. 2 Dependents = 2 x 2000 = 4000

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Add the amounts above (Children + Dependents) and enter the total hereex.2000 + 2000 = 4000

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Other income (not from jobs)If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

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DeductionsIf you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

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Extra withholdingEnter any additional tax you want withheld each pay period

14

Signature

Clear

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Date