A4 FORM

A4 FORM
ALABAMA DEPARTMENT OF REVENUE
Employee’s Withholding Tax Exemption Certificate
Every employee, on or before the date of commencement of employment, shall furnish his or her employer with a signed Alabama with- holding exemption certificate relating to the number of withholding exemptions which he or she claims, which in no event shall exceed the number to which the employee is entitled. In the event the employee inflates the number of exemptions allowed by this Chapter on Form A4, the employee shall pay a penalty of five hundred dollars ($500) for such action pursuant to Section 40-29-75.
Part I – To be completed by the employee
EMPLOYEE NAME
EMPLOYEE SOCIAL SECURITY NUMBER
STREET ADDRESS
CITY
State
ZIP CODE
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
1. If you claim no personal exemption for yourself and wish to withhold at the highest rate, write the figure “0”,
2. If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed. Write the letter “S” if claiming the SINGLE exemption or “MS” if claiming the MARRIED FILING SEPARATELY exemption
3. If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed. Write the letter “M” if you are claiming an exemption for both yourself and your spouse or “H” if you are single with qualifying dependents and are claiming the HEAD OF FAMILY exemption
4. Number of dependents (other than spouse) that you will provide more than one-half of the support for during the year. See dependent qualification below.
5. Additional amount, if any, you want deducted each pay period
Employee’s Signature
Under penalties of perjury, I certify that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Signature

Clear
Date

MonthDayYear
Date
DEPENDENTS: To qualify as your dependent (Line 4 above), a person must receive more than one-half of his or her support from you for the year and must be related to you as follows: Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son-in-law, or daughter-in-law; Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law; Your brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, or sister-in-law; Your uncle, aunt, nephew, or niece (but only if related by blood
Should be Empty:

A4 FORM

ALABAMA DEPARTMENT OF REVENUE

Employee’s Withholding Tax Exemption Certificate

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

Employee’s Signature