Form W-4 (Form D-4 Form) - Employee Withholding Allowance Certificate - Maryland State Government Employees Residing In Washington, D.c. - 2016

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Employee Withholding Allowance Certificate

2016 6

FOR MARYLAND STATE GOVERNMENT EMPLOYEES

Form W-4

Form D-4

RESIDING IN WASHINGTON, D.C.

Department of the Treasury

Office of Tax and Revenue

Internal Revenue Service

Government of the District of Columbia

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.

Section 1 - Employee Information

Payroll System (check one)

Name of Employing Agency

Social Security Number

Employee Name

Agency Number

Address Continued (apartment number, if any)

Home Address (number and street or rural route)

City

State

Zip Code

Washington

Section 2 - Federal Withholding Form W-4

The federal worksheet is available online at

4 If your last name differs from that shown on your social security card,

3 3

Single

Married

Married, but withhold at higher Single rate

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

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

5 Total number of allowances you are claiming (from page 1 or page 2 of the federal worksheet)

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

7 I claim exemption from withholding for 2016, and I certify that I meet

7 I claim exemption from withholding for 2016, and I certify that I meet both

both of the following conditions for exemption.

of the following conditions for exemption.

• • Last year I had a right to a refund of

Last year I had a right to a refund of all all federal income tax withheld because I had

federal income tax withheld because I had no

no tax liability

tax liability and

and

• This year I expect a refund of

This year I expect a refund of all all federal income tax withheld because I expect to have

federal income tax withheld because I expect to have no

no tax liability.

tax liability.

If you meet both conditions, write “Exempt” here...........................................................................

Section 3 - District of Columbia Withholding Form D-4

The District of Columbia worksheet is available online at

1 1 Tax filing status Fill in only one

Tax filing status Fill in only one:

Single

Married/Domestic Partners filing jointly/qualifying Widower with dependent child

Head of Household

Married filing separately

Married/Domestic Partners filing separately on same return

Total number of withholding allowances from DC worksheet

Additional amount, if any, you want withheld from each paycheck

If you are claiming exemption from withholding, read below and write “EXEMPT” in this box.

I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and

this year I do not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt

status on federal Form W-4.

If claiming exemption, are you a full-time student?

Yes

Section 4 - Employee Signature

Under penalties of perjury/law, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature

(Form is not valid

Date

unless you sign it.)

Employer’s name and address (including zip code) (For employer use only)

Federal Employer identification number

Central Payroll Bureau

52-6002033

P.O. Box 2396

Annapolis, MD 21404

(For State of Maryland - CPB use only)

Important: The information you supply must be complete. This form will replace in total any certificate you previously submitted.