Unformatted text preview: 15 315 9/15/05 11:44:51 AM Cut here and give the certificate to your employer. Keep the top portion for your records. W-4 Form
Department of the Treasury
Internal Revenue Service Employee’s Withholding Allowance Certificate OMB No. 1545-0010 For Privacy Act and Paperwork Reduction Act Notice, see reverse.
Last Name 1 Type or print your first name and middle initial Emily M. Home address (number and street or rural route) 809 East Main Street Kardos
Status City or town, state, and ZIP code Sacramento, CA 94230 20 -- 2 Your social security number 201-XX-XXXX
Married Married, but withhold at higher Single rate
Note: If married, but legally separated, or spouse is a
nonresident alien, check the Single box. 4 Total number of allowances you are claiming (from line G above or from the Worksheets on back if they apply) . . . 4
5 Additional amount, if any, you want deducted from each pay . . . . . . . . . . . . . . . .
6 I claim exemption from withholding and I certify that I meet ALL of the following conditions for exemption:
• Last year I had a right to a refund of ALL federal income tax withheld because I had NO tax liability: AND
• This year I expect a refund of ALL Federal income tax withheld because I expect to have NO tax liability; AND
• This year if my income exceeds $500 and includes nonwage income, another person cannot claim me as a dependent.
If you meet all of the above conditions, enter the year effective and “EXEMPT” here . . . .
7 Are you a full-time student? (Note: Full-time students are not automatically exempt.) . . . . . . . . .
Yes 0 No Under penalty of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to claim exempt status. Employee’s signature Emily M. Kardos Date 8 Employer’s name and address (Employer: Complete 8 and 10 only if sending to IRS) Roadrunner Delivery Service 155 Gateway Blvd.
Sacramento, CA 94230 9 Office
code January 3 (optional) • -- 31-8042398 Figure 12–3 Employee’s Withholding Allowance Certificate—Form W-4
• 20 10 Employee identification number income tax to be withheld...
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