Form K-4e 42a804-E - Special Withholding Exemption Certificate

Form K-4e 42a804-E - Special Withholding Exemption Certificate - 2010

2010

K-4E

Form

Special Withholding Exemption Certiﬁ cate

42A804-E (11-10)

Date

Commonwealth of Kentucky

(For use by employees who anticipate no tax liability for the current year.)

DEPARTMENT OF REVENUE

Type or Print Full Name

Social Security Number

Expires (see instructions)

Home Address (Number and Street)

City, State and ZIP Code

Employee’s Certiﬁ cation—I certify under the penalties of perjury that I anticipate

Employee—File this certiﬁ cate with your employer.

no Kentucky income tax liability and that my modiﬁ ed gross income combined

Otherwise Kentucky income tax must be withheld from

with my spouse’s modiﬁ ed gross income, if married, will not exceed the threshold

your wages.

amount for my family size for the year.

Employer—Keep this certiﬁ cate with your records. This

certiﬁ cate may be used instead of Form K-4 by those

employees qualiﬁ ed to claim the exemption.

Signature

Date

42A804-E (K-4E)(11-10).indd 1

11/5/2010 10:41:22 AM

Form K-4e 42a804-E - Special Withholding Exemption Certificate - 2010