Indiana State Form WH-4
Employee’s Withholding Exemption and County Status Certificate
Full Name
*
Social Security Number or ITIN
*
Home Address
*
City
*
State
*
Zip Code
*
Indiana County of Residence as of January 1
*
Indiana County of Principal Employment as of January 1
*
Line 1 – Exemption for yourself
Line 2 – Spouse’s exemption
Line 3 – Number of dependents
You are 65 or older
Yes
You are blind
Yes
Spouse is 65 or older
Yes
Spouse is blind
Yes
Line 4 – Total number of additional exemptions
Line 5 – Total exemptions
Line 6 – Additional exemption(s) for qualifying dependents
Line 7 – Additional state withholding per pay period
Line 8 – Additional county withholding per pay period
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: