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Form W-4 (2011)

Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

Enter an estimate of your

2011

itemized deductions. These include qualifying home mortgage interest,

charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income,' and

miscellaneous de'ductions .

$11,600

if married filing jointly or qualifying widow(er)

Enter:

$8,500

if head of household

$5,809

if single or married filing separately

Subtract line 2 from line 1. If zero or less, enter "-0-"

Enter an estimate of your

2011

adjustments to income and any additional standard deduction (see Pub. 91-9)

Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Wnhholding Allowf3nces for 2011 Form W-4 Worksheet in Pub. 919.)

Enter an estimate of your 2011 nonwage income (such as dividends or interest) .

Subtract line 6 fmm line 5. If zero or less, enter "-0-"

Divide the amounfon line 7 by $3,700 and enter the result here. Drop any fraction

Enter the number :from the Personal Allowances Worksheet, line H, page 1 .

Add lines 8 and 9 Gnd enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

. .

Two··Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page

i.}

~ote.

Use this worksheet only if the instructions under line H on page 1 direct you here.

Enter the number frorn line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)

Find the number

Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are

$65,000

or less, do not enter more

than "3"

If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter

"-0-") and on Forn) W-4, line 5, page 1. Do not use the rest of this worksheet.

Page

Note. If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Co'mplete lines 4 through 9 below to figure the additional

withholding amount necessary to avoid a year-end tax bill.

Enter.the number {rom line 2 of this worksheet

Enter the number'from line 1 of this worksheet

Subtract line 5 from line 4 .

Find the amount in Table' 2 below that applies to the HIGHEST paying job and enter it here

Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed

...:-$ _ _ _ _

..'--.$ _ _ _ _

Divide line 8 by

th,3

number of pay periods remaining in 2011. For example, divide by

if you are paid

every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,

line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1

Table 2

Married Filing Jointly

If wages from LOWEST

paying Job are-

$0 - $5,000 -

5,001 - 12,000 -

12,001. - 22,000 -

22.001. - 25,000 ,"

c'2~:aOl

- 30,000 -

30,001 - 40,000 -

40,001 -' 48,000 -

48,001 - 55,000 .

55,001 - 65,000 -

65,001 - 72,000 -

72,001 - 85,000 -

85,001 . 97,000 -

97,001 -110,000 -

110,001 -120,000 -

120,001 -135,000 -

135.001 and over

Enter on

line '2' above

,·0

'. ':.:"3

' " .4

.. 5

.•. .8

".1.1

.,14

"' 5

All Others

If wages from LOWEST

Enter on

paying job are-

line 2 above

$0 - $8,000 -

8,001 - 15,000 -

15,001 - 25,000 -

25,001 - 30,000 -

30,001 . 40,000 -

40,001 - 50,000 -

50,001 - 65,000 -

65,001 - 80,000 -

80,001 - 95,000 -

95,001 -120,000 .

120,001 and over

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to

carry out the Intemal Revenue laws of the United States. Intemal Revenue Code sections

3402(0(2) and 6109 and their regulations require you to provide this information; your employer

uses it to determine your federal incoine tax Withholding. Failure to provide a properly

completed form will result in your being treated as a single person who claims no withholding

allowances; providing fraudulent Information may subject you to penalties. Routine uses of this

information .Include giving it to the Oepartment of Justice for civil and criminal litigation, to

cities, states, the District of Columbi[1, and U.S. commonwealths and PQssessions for use in

administering their tax laws; and to the Department of Health and Human Services for use in

the National Directory of New Hires.

Vie

may also disclose this information to other countries

under a tax treaty. to federal and state agencies to enforce federal nontax criminal laws, or to

!ederallaw enforcement and intellig,e[lCe agencies to combat terrorism.

Married Filing Jointly

All Others

If wages from HIGHEST

Enter on

If wages from HIGHEST

Enter on

paying job are-

line 7 above

payin'g job are-

line 7 above

$0 - $65,000

$560

$0 - $35,000

$560

65,001 - 125,000

930

35,001 -

90,000

930

125,001 - 185,000

1,040

90,001 - 165,000

1,040

185,001 - 335,000

1,220

165,001 - 370,000

1,220

335,001 and over'

1,300

370,001 and over

1,300

:.'

You are not required to provide the information requested on a form that is

subject to the Paperwork Reduction Act unless the form displays a valid OMB

control number. Books or records relating to a form or its instructions must be

retained as long as their contents may became material in the administration of

any Internal Revenue law. Generally. tax returns and return information are

confidential. as required by Code section 6103.

The average time and expenses required to complete and file this form will vary

depending on individual circumstances. For estimated averages, see the

instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear

from I/ou. See the instructions for your income tax return.

Form Wh-4 - Employee'S Withholding Exemption And County Status Certificate - Indiana Page 3

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