Form Ia W-4 - Employee Withholding Allowance Certificate - 2009

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Centralized Employee Registry Reporting Form
Submit this information online at
TO BE COMPLETED BY THE EMPLOYER
within 15 days of hire. Please Print or Type.
...or mail this portion of the page to Centralized
Employee Registry, PO Box 10322, Des Moines IA
50306-0322; or fax it to 1-800-759-5881.
Please include your FEIN.
EMPLOYER INFORMATION - FEIN Required
_
( ______ ) _______ — _____________
Phone: Area Code + Telephone Number
Name: __________________________________________________________________________________________
Street Address: ___________________________________________________________________________________
___________________________________________________________________________________
_
City: ________________________________
State:
Zip Code:
Questions: For A through D below, please see instructions on back for definitions and clarification.
A. Is dependent health care coverage available? Yes
or No
B. Approximate date this employee qualifies for coverage:
MM
DD
YYYY
C. Employee start date:
MM
DD
YYYY
D. Address where income withholding and garnishment orders should be sent, if different than above address.
Street Address: ________________________________________________________________________________
_______________________________________________________________________________
_
City: _____________________________ State:
Zip Code:
EMPLOYEE INFORMATION
_
_
Employee’s Date of Birth:
Employee’s Social Security Number:
MM
DD
YYYY
Last Name: __________________________ First Name: ______________________ Middle Initial: _______
Street Address: ___________________________________________________________________________________
____________________________________________________________________________________
City: ________________________________ State: ______________ Zip Code: _______________________
Iowa Department of Revenue
IA W4 2009
Employee Withholding Allowance Certificate
To be completed by the employee
Marital status:
Single
Married (If married but legally separated, check Single.)
Print your full name: ______________________________________________________________ Social Security No.: ___________________________
Home Address: ______________________________________________________ City _______________ State ____ Zip Code __________________
EXEMPTION FROM WITHHOLDING. If you do not expect to owe any Iowa income tax this year, and expect to have a right to a full refund of ALL
income tax withheld, enter “EXEMPT” here: _______________ and the year effective here: ________ Nonresidents may not claim exemption.
IF YOU ARE NOT EXEMPT, COMPLETE THE FOLLOWING:
1. Personal allowances ................................................................................................................................................................... 1. ______________
2. Allowances for dependents ........................................................................................................................................................ 2. ______________
3. Allowances for itemized deductions .......................................................................................................................................... 3. ______________
4. Allowances for adjustments to income ...................................................................................................................................... 4. ______________
5. Allowances for child and dependent care credit ....................................................................................................................... 5. ______________
6. Total allowances. Add lines 1 through 5. .................................................................................................................................. 6. ______________
7. Additional amount, if any, you want deducted each pay period ............................................................................................. 7. ______________
I certify that I am entitled to the number of withholding
Employers:
Detach this part and keep in your records unless more than 22
withholding allowances are claimed. If more than 22 allowances are claimed,
allowances claimed on this certificate, or if claiming an
complete the section below and send it to the Iowa Department of Revenue.
exemption from withholding, that I am entitled to claim the
See Employer Withholding Requirements on the back of this form.
exempt status.
Employer’s name / address: ______________________________________
Employee Signature _________________________________________
___________________________________ FEIN: ____________________
Date ___________________________
44-019a (8/12/08)

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