Form G-4 - State Of Georgia Employee'S Withholding Allowance Certificate
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1
2Form G-4
(Rev 1/13}
STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE
1a.
YOUR FULL NAME
1b. YOUR SOCIAL SECURITY NUMBER
2a.
HOME ADDRESS
(Number,
Street,
or Rural
Route)
2b. CITY,
STATE AND ZIP CODE
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING
LINES
3
-
8
3. MARITAL STATUS
(If
you do not
wish
to claim
an
allowance,
enter
"0"
in
the brackets beside
your
marital status.)
I
I
A.
Single:
Enter 0 or
1.......................................[
4.
DEPENDENT ALLOWANCES
[
B.
Married
Filing
Joint,
both
spouses
working:
I
Enter 0 or 1 ...............................................[
I
C.
Married Filing
Joint,
one spouse
working:
5. ADDITIONAL ALLOWANCES
[
I
Enter 0 or
1
or 2 ...........................................[
(worksheet
below must be
completed)
D.
Married Filing
Separate:
I
Enter
0 or 1 ...............................................[
E.
Head
of
Household:
6. ADDITIONAL WITHHOLDING
$
_
I
Enter
0 or 1 ...............................................[
WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES
(Must be completed
in
order
to
enter an amount on step 5)
1
.
COMPLETE THIS
LINE
ONLY
IF
USING
STANDARD
DEDUCTION:
0
0
Yourself:
Age
65 or over
Blind
Spouse:
0
Age
65
or
over
0
Blind
Number of boxes
checked
x
1300...............$.
_
2.
ADDITIONAL ALLOWANCES FOR
DEDUCTIONS:
A. Federal Estimated Itemized
Deductions.........................................................................
$
_
B.
Georgia Standard Deduction
(enter
one):
Single/Head
of
Household
$2,300
Each
Spouse
$1,500
$
_
C.
Subtract
Line B from
Line A................................................................................................................$
_
D.
Allowable
Deductions
to
Federal Adjusted Gross Income
.................................................................$
_
E.
Add
the Amounts on Lines
1, 2C,
and
2D ..........................................................................................$
_
F.
Estimate
of
Taxable Income not
Subject to
Withholding
...................................................................$
_
G.
Subtract Line F
from
Line E
(if
zero or
less,
stop here)......................................................................$
_
H.
Divide
the
Amount
on Line G
by
$3,000.
Enter
total here and
on Line 5
above
................................
(This
is
the
maximum number of additional
allowances
you
can
claim. If the remainder
is over $1,500
round
up)
7.LETTER USED (Marital
Status A,
B.
C, D,
or E)
TOTAL ALLOWANCES
(Total
of
Lines
3-
5)
__
(Employer:
The
letter
indicates the
tax
tables
in
the Employer's Tax Guide)
8. EXEMPT:
(Do
not
complete
Lines 3
-
7
if claiming
exempt)
Read
the
Line
instructions on page
before
completing
this
section.
8
2
a)
I claim
exemption
from withholding because I incurred no
Georgia income tax
liability
last
year
and
I do
not
expect to
have
a
Georgia
income
tax
liability this
year.
Check here
b) I
certify
that I
am
not subject to Georgia withholding because I meet the
conditions
set
forth
under the
Service members
Civil
Relief
Act
as amended
by the Military
Spouses
Residency Relief
Act as provided
on
page
2.
My
state of
residence
is
-- -,---
-My spouse's
(service member)
state of
residence
is
The states of
residence
must
be
the same to be exempt.
Check here
I
certify
under penalty
of
perjury that
I
am
entitled
to the
number of withholding
allowances
or
the
exemption
from withholding status
claimed
on this Form
G-4.
Also,
I
authorize my employer to deduct per pay period the additional
amount
listed
above.
Employee’s Signature:
Date:
Employer:
Complete
Line
9 and mail entire form only if the
employee claims
over 14 allowances or exempt from
withholding.
If
necessary,
mail
form
to:
Georgia Department
of
Revenue,
Withholding Tax
Unit, P. 0.
Box
49432, Atlanta,
GA
30359.
9.EMPLOYER'S NAME AND ADDRESS:
EMPLOYER'S
FEIN:
_
EMPLOYER'S WH#:.
_
Do not accept forms
claiming
additional allowances unless the worksheet
has
been
completed.
Do not
accept forms
claiming
exempt if numbers are written on Lines 3- 7.
Page 9
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