W4 Data Collection

First Name and Middle Initial*

Last Name*

SSN*

Street Address *

City, State, Zip*

Marital Status*

Single Married Married, but withhold at higher Single rate

Note, if married filing separately, check "Married but withhold at higher Single Rate"

Different name than social security card

Yes

If you last name differs from that shown on your social security card, check here. You must call 800-772-1213 for a replacement card.

# of Allowances*

Additional Withholding, if any $

Withholding Exemption

I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption. 1. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and 2.This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write “Exempt” here

Employer Name*

Employer Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Street Address (Employer)*

City, State, Zip (Employer)*

Today's Date*

Date Of Employment*

Employer's Name

(Employer: Complete boxes Employer's Name and EIN if sending to IRS and complete boxes Employer's Name, First Date of Employment, and EIN if sending to State Directory of New Hires.)

Employer's Address

Address Line 1

Address Line 2

City

State

ZIP Code

First Date of Employment

Employer Identification Number (EIN)