State of Georgia Employee's Withholding Certificate
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Marital Status
If you do not wish to claim an allowance, enter "0" in the fields beside your marital status.
A: Single
Please Select
0
1
B: Married Filing Joint, both spouses working:
Please Select
0
1
C. Married Filing Joint, one spouse working:
Please Select
0
1
D. Married Filing Separate:
Please Select
0
1
E. Head of Household
Please Select
0
1
4. Dependent Allowances
Please Select
0
1
2
3
4
6. Additional Withholding
Total Allowances
Do you claim exemption from withholding?
Please Select
Yes
No
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: