Fillable Retired Scdps Membership Form (Page 3 of 3) in pdf

Form P-4 (Rev. 9-00)

COMPTROLLER GENERAL'S OFFICE

PRINT OR TYPE

EMPLOYEE'S WITHHOLDING & DEDUCTIONS

SC Department of Public Safety

K05

DEPARTMENT NAME

DEPT. NO (3 Positions)

CHANGE

NEW

EFFECTIVE DATE

(01) SOCIAL SECURITY

(02) NAME

Middle Initial

First

(20 Positions)

Last

(20 Positions)

(03)STREET

(25 Positions)

(04) CITY/STATE

(05) ZIP

(20 Positions)

(06) MARITAL STATUS

NUMBER WITHHOLDING EXEMPTIONS

MARRIED

(07)FEDERAL

SINGLE

(08)STATE

W-4

Employee's Withholding Allowance Certificate

OMB No. 1545-0010

Form

Department of the Treasury

Internal Revenue Service

For Privacy Act and Paperwork Reduction Act Notice, see reverse.

2 Your social security number

1 Type or print your first name and middle initial

Last name

Home address (number 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 alien, check the Single box.

City or town, state, and ZIP Code

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

. . . . .

here and call 1-800-772-1213 for a new card

5 Total number of allowances you are claiming (from line G above or from the worksheets on page 2 if they apply)

. . . . . . . . . . . . . .

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

7 I claim exemption from withholding for 2002 and I certify that I meet BOTH of the following conditions for exemption:

• Last year I had a right to a refund of ALL Federal income tax withheld because I had NO tax liability; AND

• This year

expect a refund of ALL Federal income tax withheld because

expect to have NO tax liability.

"EXEMPT"

. . . . . . . . . . . . .

If you meet both conditions, enter

here

Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to claim exempt status

Employee's signature >

Date >

,20

8 Employer's name and address (Employer: Complete 8 and 1 0 only if sending to the IRS)

9 Office code

10 Employer Identification number

(optional)

INSURANCE AND OTHER DEDUCTIONS

DEDUCTION

AMOUNT

CODE

DEDUCTION

AMOUNT

CODE

SC Troopers Association

6.00

662

Retired Duty Deduction

I hereby authorize my employer to deduct from my earnings the amounts indicated above to enable me to participate in the above salary deduction plans. I reserve the right to

revoke the authorization at any time by giving written notice to my employer.

Authorized Agency Signature

Date

_______________________________________

Employee's Signature

Title