Combined Form W-4 And Mw 507 2005

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2005

MPLOYEE

ITHHOLDING

LLOWANCE

ERTIFICATE

Form W-4

Form MW 507

Internal Revenue Service

Comptroller of Maryland

FOR STATE OF

ARYLAND EMPLOYEES

Department of the Treasury

Please complete form in black ink. Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Payroll System (check one)

Name of Employing Agency

1. Agency Number

Social Security Number

Employee Name

2. Home Address (number and street or rural route)

Address Continued (apartment number, if any)

City

State

Zip Code

County of Residence (required)

Single

Married

Married, but withhold at higher single rate

4. If your last name differs from that shown on your Social Security card,

check here. You must call 1-800-772-1213 for a new card.

Note: If married but legally separated, or spouse is non-resident alien, check the single box.

See instructions and worksheet to complete section below. Both federal and state must have an entry unless claiming exempt.

If you are not sure how to complete this form, call the Central Payroll Bureau at 410-260-7401.

IF TAXABLE, complete line 5 and, if applicable, line 6. If taxable in federal and exempt in state, or vice versa, complete sections 5 and 7 or 5 and 8.

This will complete all necessary tax information. Go to line 9 for signature.

State tax withheld for Maryland and West Virginia only

Federal

State

District of Columbia residents must use Form W-4/D-4

5. Total number of allowances you are claiming (from worksheet).

6. Additional amount, if any, you want deducted from each paycheck.

IF EXEMPT, complete line 7 and/or line 8. Go to line 9 for signature.

7. I claim exemption from withholding for 2005 and I certify that I meet BOTH of the following conditions for exemption:

a. Last year I had a right to a refund of ALL federal and/or state income tax withheld because I had NO tax liability; AND

b. This year I expect a refund of ALL federal and/or state income tax withheld because I expect to have NO tax liability.

(This includes seasonal and student employees whose annual income will be below the minimum filing requirement.)