Form Sf W-4 - Employees Withholding Certificate For City Income Tax - City Of Springfield
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1EMPLOYEES WITHHOLDING CERTIFICATE
FOR CITY OF SPRINGFIELD INCOME TAX
SF W-4
1. Print Full Name
Social Security Number
Springfield Resident? Yes
No
2. Address, Number and Street
City, Township or Village where you reside
State
Zip Code
Enter number
YOUR WITHHOLDING
Check
Regular
Age 65 & Older
{
of exemptions
3. Exemptions for yourself:
Blind
Deaf
EXEMPTION
Boxes
Exemption
or Disabled
checked
that
Enter number
Regular
Age 65 & Older
apply
of exemptions
4. Exemptions for your spouse:
Blind
Deaf
Exemption
or Disabled
checked
Enter total
EMPLOYEE: File this form with your employer.
Number
Exemptions for your other
Number
5. (a) Exemptions for your children
5. (b)
of line 5
Otherwise your employer must withhold
dependents
(a plus b)
Springfield income tax from your earnings
6. Add the number of exemptions which you have claimed on lines 3, 4, 5, 6 a & b above and write the total
without exemption.
EMPLOYER: Keep this certificate with your
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief.
records. If the information submitted by the
employee is not believed to be true, correct and
7. Date
Signature
complete; the SPRINGFIELD INCOME TAX
DIVISION must be so advised.
SEE INSTRUCTIONS ON REVERSE SIDE
EMPLOYEES WITHHOLDING CERTIFICATE
FOR CITY OF SPRINGFIELD INCOME TAX
SF W-4
1. Print Full Name
Social Security Number
Springfield Resident? Yes
No
2. Address, Number and Street
City, Township or Village where you reside
State
Zip Code
Enter number
YOUR WITHHOLDING
Check
Regular
Age 65 & Older
{
of exemptions
3. Exemptions for yourself:
Blind
Deaf
EXEMPTION
Boxes
Exemption
or Disabled
checked
that
Enter number
Regular
Age 65 & Older
apply
of exemptions
4. Exemptions for your spouse:
Blind
Deaf
Exemption
or Disabled
checked
Enter total
EMPLOYEE: File this form with your employer.
Number
Exemptions for your other
Number
5. (a) Exemptions for your children
5. (b)
of line 5
Otherwise your employer must withhold
dependents
(a plus b)
Springfield income tax from your earnings
6. Add the number of exemptions which you have claimed on lines 3, 4, 5, 6 a & b above and write the total
without exemption.
EMPLOYER: Keep this certificate with your
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief.
records. If the information submitted by the
employee is not believed to be true, correct and
7. Date
Signature
complete; the SPRINGFIELD INCOME TAX
DIVISION must be so advised.
SEE INSTRUCTIONS ON REVERSE SIDE
EMPLOYEES WITHHOLDING CERTIFICATE
FOR CITY OF SPRINGFIELD INCOME TAX
SF W-4
1. Print Full Name
Social Security Number
Springfield Resident? Yes
No
2. Address, Number and Street
City, Township or Village where you reside
State
Zip Code
Enter number
YOUR WITHHOLDING
Check
Regular
Age 65 & Older
{
of exemptions
3. Exemptions for yourself:
Blind
Deaf
EXEMPTION
Boxes
Exemption
or Disabled
checked
that
Enter number
Regular
Age 65 & Older
apply
of exemptions
4. Exemptions for your spouse:
Blind
Deaf
Exemption
or Disabled
checked
Enter total
EMPLOYEE: File this form with your employer.
Number
Exemptions for your other
Number
5. (a) Exemptions for your children
5. (b)
of line 5
Otherwise your employer must withhold
dependents
(a plus b)
Springfield income tax from your earnings
6. Add the number of exemptions which you have claimed on lines 3, 4, 5, 6 a & b above and write the total
without exemption.
EMPLOYER: Keep this certificate with your
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief.
records. If the information submitted by the
employee is not believed to be true, correct and
7. Date
Signature
complete; the SPRINGFIELD INCOME TAX
DIVISION must be so advised.
SEE INSTRUCTIONS ON REVERSE SIDE
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