Form Va-4 - Personal Exemption Worksheet
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1
2FORM VA-4
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF TAXATION
PERSONAL EXEMPTION WORKSHEET
(See back for instructions)
1. If you wish to claim yourself, write “1” ..............................................................
2. If you are married and your spouse is not claimed
on his or her own certifi cate, write “1” ...............................................................
3. Write the number of dependents you will be allowed to claim
on your income tax return (do not include your spouse) ...................................
4. Subtotal Personal Exemptions (add lines 1 through 3) .....................................
5. Exemptions for age
(a)
If you will be 65 or older on January 1, write “1” ..................................
(b)
If you claimed an exemption on line 2 and your spouse
will be 65 or older on January 1, write “1” ............................................
6. Exemptions for blindness
(a)
If you are legally blind, write “1” ...........................................................
(b)
If you claimed an exemption on line 2 and your
spouse is legally blind, write “1” ...........................................................
7. Subtotal exemptions for age and blindness (add lines 5 through 6) ...................................................
8. Total of Exemptions - add line 4 and line 7 .........................................................................................
Detach here and give the certificate to your employer. Keep the top portion for your records.
FORM VA-4
EMPLOYEE’S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
Your Social Security Number
Name
Street Address
City
State
Zip Code
COMPLETE THE APPLICABLE LINES BELOW
1. If subject to withholding, enter the number of exemptions claimed on:
(a)
Subtotal of Personal Exemptions - line 4 of the
Personal Exemption Worksheet...........................................................................................
(b)
Subtotal of Exemptions for Age and Blindness
line 7 of the Personal Exemption Worksheet .......................................................................
(c)
Total Exemptions - line 8 of the Personal Exemption Worksheet.........................................
2. Enter the amount of additional withholding requested (see instructions)..........................................
3. I certify that I am not subject to Virginia withholding. l meet the conditions
set forth in the instructions ................................................................................. (check here)
4. I certify that I am not subject to Virginia withholding. l meet the conditions set forth
Under the Service member Civil Relief Act, as amended by the Military Spouses
Residency Relief Act .......................................................................................... (check here)
Signature
Date
EMPLOYER: Keep exemption certificates with your records. If you believe the employee has claimed too many exemptions, notify the Department of
Taxation, P.O. Box 1115, Richmond, Virginia 23218-1115, telephone (804) 367-8037. Note: Employers may establish a system to electronically receive
Forms VA-4 from employees, provided the system meeets Internal Revenue Service requirements as specified in 31.3402(f)(5)-1(c) of the Treasury
Regulations (26 CFR).
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