Revenue Form K-4 - Employee'S Withholding Exemption Certificate

Revenue Form K-4

KENTUCKY DEPARTMENT OF REVENUE

Payroll No. __________________________

42A804 (11-09)

EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE

Print Full Name ________________________________________________________________________

Social Security No. ___________________________

Print Home Address ____________________________________________________________________________________________________________________

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

I certify that I am not subject

1. If SINGLE, and you claim an exemption, enter “1, ” if you do not, enter “0” ............................................................... ________

to Kentucky withholding

2. If MARRIED, one exemption each for you and spouse if not claimed on another certiﬁ cate.

under the Military Spouses

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(a) If you claim both of these exemptions, enter “2”

Residency Relief Act. See

(b) If you claim one of these exemptions, enter “1”

................................................................................................ ________

instructions on the back of

3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents):

Form K-4 before checking

(a) If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption,

this box.........................

enter “2”; if both will be 65 or older, and you claim both of these exemptions, enter “4” .................................. ________

(b) If you or your spouse are blind, and you claim this exemption, enter “2”; if both are blind, and you claim

both of these exemptions, enter “4” ......................................................................................................................... ________

EMPLOYER:

4. If you claim exemptions for one or more dependents, enter the number of such exemptions ................................ ________

5. National Guard exemption (see instruction 1) ............................................................................................................... ________

Keep this certiﬁ cate with

6. Exemptions for Excess Itemized Deductions (Form K-4A) ............................................................................................ ________

your records.

7. Add the number of exemptions which you have claimed above and enter the total .................................................

8. Additional withholding per pay period under agreement with employer. See instruction 1 ...........................$ _____________

I certify that the number of withholding exemptions claimed on this certiﬁ cate does not exceed the number to which I am entitled.

Date _________________________________

Signed___________________________________________________________________________________