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Form W-4 (2011) .

Purpose. Complete Form W-4 so that your

employer can withhold the correct federal

income tax from your pay. Consider completing a

new Form W-4 each year and when your

personal or financial situation changes.

Exemption from withholding. If you are exempt,

complete only lines 1, 2, 3, 4, and 7 and sign

the form to validate it. Your exemption for 2011

expires February 16, 2012. See Pub. 505, Tax

Withholding and Estimated Tax.

Note. If another person can claim you as a

dependent on his or her tax return, you cannot

claim exemption from withholding If your Income

exceeds.$950 and incluaesmore than $300 of

unearned Income (for example, interest and

dividends).

Complete all worksheets that apply. However,

you may claim fewer (or zero) allowances. For

regular wages, withholding must be based on

allowances you claimed and may not be a flat

amount or percentage of wages.

Head of household. Generally, you may claim

head of household filing status on your tax return

only If you are unmarried and pay more than

50% of the costs of keeping up a home for

yourself and your dependent(s) or other

qualifying Individuals. See Pub. 501, Exemptions,

Standard Deduction, and Filing Information, for

Information.

Tax credits. You can take projected tax credits

Into account in figuring your allowable number of

withholding allowances. Credits for child or

dependent care expenses and the child tax

credit may be claimed using the Personal

Allowances Worksheet below. See Pub. 919,

How Do I Adjust My Tax Withbolding, for

information on converting your other credits into

withholding allowances.

Basic instructions. If you are not exempt,

complete the Personal Allowances Worksheet

below. The worksheets on page 2 further adjust

your withholding allowances based on Itemized

Nonwage income. If you have a large amount of

deductions, certain credits, adjustments to

nonwage income, such as Interest or,dlvidends,

income, or two-earners/multiple jobs situations.

consider making estimated tax payments using

Form 1040-ES, Estimated Tax for Individuals.

Otherwise, you may owe additional tax. If you

have pension or annuity Income, see Pub. 919 to

find out If you should adjust your withholding on

Form W-4 orW-4P.

Two earnerS or multiple jobs. If you have a

working spouse or more than one job, figure the

total number-of allowances you are entitled to

claim on all jobs using worksheets from only one

Form W-4. Y9ur withholding usually will be most

accurate when all allowances are claimed on the

Form W-4 for the highest paying job and zero

allowances a're claimed on the others. See Pub.

919 for

detall~.

Nonresident alien. If you are a nonresident alien,

see Notice 1392, Supplemental Form W-4

Instructions for Nonresident Aliens, before

completing this form.

Check your withholding. After your Form W-4

takes effect, use Pub. 919 to see how the

amount you are having withheld compares to

your projected total tax for 2011. See Pub. 919,

especially if your earnings exceed $130,000

(Single) or $180,000 (Marrie.d).

Personal Allowances Worksheet (Keep for your records.)

Enter "1" for yourself if no one else can claim you as a dependent .

{

• You are single and have only one Job; or ,

)

Enter "1

if:

• You are married, have only one job, and your spouse does not work; or

• Your wages from a second job or your spouse's wages (or the total of both) are

$1,500

or less.

Enter "1" for your sJlouse. But, you may choose to enter

"-0-"

if you are married and have either a working spouse or more

than one Job. (Enteri!1g "-0-" may help you avoid having too little tax withheld.) .

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return.

Enter "1" If you will file as head of household on your tax return (see conditions under Head of household

above)

FEnter

"1"

If you have at least

$1,900

of child or dependent care expenses for which you plan to claim a credit

(Note. Do not include child support payments. See Pub.

503,

Child and Dependent Care Expenses, for details.)

Child Tax Credit (Including additional child tax credit). See Pub.

972,

Child Tax Credit, for more information.

• If your total incorre

\1\411 be

less than $61,000

($90,000 If

rnanied),

enter "2" for each eligible child; then less "1" If you have three or more eligible children.

• If your total income will be between

$61,000

and

$84,000 ($90,000

and

$119,000

If married), enter

"1"

for each eligible

child plus "1

additional if you have six or more eligible children .

Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)

For accuracy,

I ·

If you plan t6 itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

complEtte all

and Adjustments Worksheet on page 2.

worksheets

• If you have more than one job or are married and you and your spouse both work and the combined earnings from all Jobs exceed

that apply

$40,000 ($10,000

if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

•

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

---------------------------------.

Cut here and give Form W-4 to your employer. Keep the top part for your records.

---------------------------------.

Form

W-4

Employee's Withholding Allowance Certificate

OMS No. 1545-2159

Department

the Treasury

Whether you are entitled to claim a certain number of allowances or exemption from withholding is

~@11

Internal Revenue

Service

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

Type or print your first name and middle Initial.

Last name

Your social security number

Home address (numoer and street or rural route)

Single

Married

Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse Is a nonresident allen, check the "Single" box.

City or town, state, and' ZIP code

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

check here. You must <:aIl1-800-772-1213 for a replacement card. ~

Total number of al!t>wances you are claiming (from line H above or from the applicable worksheet on page 2)

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

I claim exemption 'from withholding for 2011, and I certify that I meet both of the following conditions for exemption.

;~.,:~;:,

• Last year I had

right to a refund of all federal income tax withheld because I had no tax liability and

I·:).:~~[

~r:~':,

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

.;\':'i

If you meet both conditions, write "Exempt" here.

~ /7 "

Under penalties of perjury, 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

(This form is not valid unless you sign It.) ...

Date ...

Employer's name and address (Employer: Complete lines 8 and 10 only If sending to the IRS.)

9 Office code (optional)

Employer Identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No.1 0220Q

Form

W-4

(2011)

Form Wh-4 - Employee'S Withholding Exemption And County Status Certificate - Indiana Page 2

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