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Full Name(Required)

Social Security Number or ITIN(Required)

Home Address(Required)

City(Required)

State(Required)

ZIP Code(Required)

Indiana County of Residence as of January 1:

(See instructions)

Indiana County of Principal Employment as of January 1: _

(See instructions)

How to Claim Your Withholding Exemptions

1. You are entitled to one exemption. If you wish to claim the exemption, enter “1”

Nonresident aliens must skip lines 2 through 7. See instructions

2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1”

3. You are allowed one (1) exemption for each dependent. Enter number claimed

4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or (b) if you and/or your spouse are legally blind. Check box(es) for additional exemptions:

You are 65 or older

or blind

Spouse is 65 or older

or blind

Enter the total number of boxes checked

5. Add lines 1, 2, 3, and 4. Enter the total here

6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions).

7. You are entitled to claim an additional exemption for each adopted qualifying dependent (see instructions)

8. Enter the amount of additional state withholding (if any) you want withheld each pay period .

9. Enter the amount of additional county withholding (if any) you want withheld each pay period

I hereby declare that to the best of my knowledge the above statements are true

Signature(Required)

Date(Required)

WH-4

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