AR4EC - Employee's Withholding Exemption Certificate
Original Document
You are encouraged to review the original document prior to completing this form. Your answers will be embedded on the PDF form and submitted to the proper department.
Full Name
Social Security Number
Address
Home Address
Street Address Line 2
City
State
Zip
H
o
w to Claim
Y
our
W
ithholding
See instructions below
1. CHECK ONE OF THE FOLLOWING FOR EXEMPTIONS CLAIMED
CHECK ONE
Number of Exemptions Clamed
a) You claim yourself, (Enter 1 exemption)
b) You claim yourself and your spouse. (Enter two exceptions)
c) Head of Household, and you claim yourself. (Enter two exemptions)
2. NUMBER OF CHILDREN or DEPENDENTS (Enter one exemption per dependent)
3. TOTAL EXEMPTIONS (Add Lines 1a, b, c, and 2)
4. Additional amount, if any, you want to deducate from each paycheck. (Enter dollar amount)
5. I qualify for the low-income tax rates (See below for details)
Yes
No
Filing Status
Single
Married Filing Jointly
Head of Household
Signature
Date
-
Month
-
Day
Year
Date
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