Form Nc-4ez - Employees Withholding Allowance Certificate
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8-16
NC-4EZ
Employee's Withholding
Allowance Certificate
Social Security Number
Marital Status
, Singfe
Head of Household
MJ.
Last Name
. Married of Surviving Spouse
Address
County lejfer&s? n^i&^t^
Crty
State
Zip Code f$Qgff)
Country pa*as.;
FORM NC-4EZ: Please use this form if you:
- Plan to claim the N.C. standard deduction
- Plan to claim no tax credits or only the credit for children
- Prefer not to complete the extended Form NC-4
- Qualify to claim exempt status (See lines 3 or 4 below)
Important: If you are a nonresident alien you must use Form NC-4 NRA.
You may complete Form NC-4, if you plan to claim N.C. itemized deductions, federal adjustments to income, or N.C. deductions.
If you do not plan to daim the credit for children, enter zero (0) on line 1. If you plan to claim the credit for children, use the table below for your filing status,
amount of income, and number of children under age 17 to determine the number of allowances to enter on line 1. For married taxpayers, only 1 spouse
may claim the allowance for the credit for each child.
Single & Married Filing Separately
# of Children under age 17
1 2 3 4 5 6 7 8 9 1 0
# of Allowances
0 - 2 0 , 0 0 0
0 1 2 3 4 5 6 7 8 8
2 0 , 0 0 1 * 5 0 , 0 0 0 0 1 2 2 3 4 5 5 6 7
Married Filing Jointly & Surviving Spouse
# of Children under age 17
1 2 3 4 5 6 7 6 9 1 0
# of Allowances
0*40,000
0 1 2 3 4 5 6 7 8 8
4 0 , 0 0 1 - 1 0 0 , 0 0 0 0 1 2 2 3 4 5 5 6 7
Head of Household
# of Children under age 17
1 2 3 4 5 6 7 6 9 1 0
# of Allowances
Q~32
t
OQQ
0 1 2 3 4 5 6 7 6 8
32,001-80,000 0 1 2 2 3 4 5 5 6 7
1. Total number of allowances you are claiming (Enter zero (0), or the number of allowances from the table above)
2. Additional amount, if any, withheld from each pay period (Enter whole dollars)
3. I certify that I am exempt from North Carolina withholding because I meet both of the following conditions:
• Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and
• This year, I expect a refund of all State income tax withheld because I expect to have no tax liability
4. I certify that I am exempt from North Carolina withholding because I meet the requirements
of the Military Spouses Residency Relief Act and I am legally domiciled in the state of
(
Enterstate
of domicile)
If line 3 or line 4 above applies to you, enter the effective year 2 0
_
5. I certify that I no longer meet the requirements for exemption on line 3 Q or line 4 | | (Check applicable box)
Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax based on the
number of allowances entered on line 1 and any amount entered on line 2.
..00
Check Here
. Check Here
Check Here
CAUTION: If you furnish an employer with an Employee's Withholding Allowance Certificate that contains information which has no
reasonable basts and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable
information, you are subject to a penalty of 50% of the amount not property withheld.
Employee's Signature
Date
/ certify, under penalties provided bylaw, that I am entitled to #?e number of withholding allowances claimed on line 1 above,
or if claiming exemption from withholding, that I am entitled to claim the exempt status on line 3 or 4
t
whichever applies.
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