Circle City ABA W-4 Form

Form W-4
An image of Form W-4 is displayed below. This image is meant to be used for informational purposes only. You will be required to enter your total number of allowances from Form W-4 in the section below the image. Please use the information from the image to help you obtain your total number of allowances.
W-4 Employee's Withholding Allowance Certificate
Name*

First NameMiddle NameLast Name
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status*

SingleMarriedMarried, but withhold at higher Single rate
Note: If married, but legaly separated, or spouse is a nonresident alien, check the "Single" box.
Does your last name (surname) differ from the one shown on your Social Security Card

YesNo
I claim exemption from withholding for 2017, 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 and income tax because I had no tax liability

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 above, check here.

EXEMPT
Total number of allowances you are claiming (from line H above or from the applicable worksheet pictured below).*
Additional Amount, if any, you want withheld from each paycheck:
Under penalties of perjury, I declare that I have examined this certificate (Form W4 Section of this application) and, to the best of my knowledge and belief, it is true, correct, and complete. *Note: this form is not valid unless you sign it.
Employee Electronic Signature for Form W-4 (Use your mouse or finger to sign below)*
Office Location*
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Form W-4

W-4 Employee's Withholding Allowance Certificate