Virginia FORM VA-4

Virginia FORM VA-4
COMMONWEALTH OF VIRGINIA DEPARTMENT OF TAXATION

PERSONAL EXEMPTION WORKSHEET
Click the link below to view a downloadable version to view and follow along with.

Virginia Form VA-4
1. If you wish to claim yourself, write “1”
2. If you are married and your spouse is not claimed on his or her own certificate, write “1”
3. Write the number of dependents you will be allowed to claim on your income tax return (do not include your spouse)
4. Subtotal Personal Exemptions (add lines 1 through 3)
5 - A. Exemptions for your age If you will be 65 or older on January 1, write “1”
5 - B. If you claimed an exemption on line 2 and your spouse will be 65 or older on January 1, write "1"
6 - A. Exemptions for blindnessIf you are legally blind, write “1”
6 - B. Exemptions for blindnessIf you claimed an exemption on line 2 and your spouse is legally blind, write “1”
7. Subtotal exemptions for age and blindness (add lines 5 through 6)
8. Total of Exemptions - add line 4 and line 7
FORM VA-4 EMPLOYEE’S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
Your Social Security Number*
Full Name (First, Middle, Last)*
Your Email*
Street Address*
City*
State*
Zip Code*
1 - A. If subject to withholding, enter the number of exemptions claimed on:Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet
1 - A. If subject to withholding, enter the number of exemptions claimed on:Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet
1 - C. Total Exemptions - line 8 of the Personal Exemption Worksheet
2. Enter the amount of additional withholding requested (see instructions)
3. I certify that I am not subject to Virginia withholding. l meet the conditions

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4. I certify that I am not subject to Virginia withholding. l meet the conditions set forth

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Signature*

Clear
Date*

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Date
Should be Empty:

Virginia FORM VA-4

COMMONWEALTH OF VIRGINIA DEPARTMENT OF TAXATION

FORM VA-4 EMPLOYEE’S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE