Form D-4 - Employee Withholding Allowance Certificate

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D-4 Employee Withholding

Government of the

Year

Allowance Certificate

District of Columbia

Your first name

Last name

M.I.

Home address (number and street)

Apartment number

Social security number

City

State

Zip code +4

Tax filing status

Single

Married/domestic partners filing jointly

Married filing separately

Fill in only one:

Head of household

Married/domestic partners filing separately on same return

Total number of withholding allowances from worksheet below

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

If claiming exemption from withholding, read below and, if qualified, write “EXEMPT” in this box.

I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and this year I do

not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt status on federal Form W-4.

If claiming withholding exemption, are you a full-time student?

Yes

Signature

Under penalties of law, I declare that I have completed this certificate and, to the best of my knowledge, it is correct.

Employee’s signature

Date

Employer Keep this certificate with your records. If 10 or more exemptions are claimed or if you suspect this certificate contains false information

please send a copy to: Office of Tax and Revenue, 941 North Capitol St., NE, Washington, DC 20002-4259 Attn: Compliance Administration

Detach and give the top portion to your employer. Keep the bottom portion for your records.

D-4 Employee Withholding Allowance Worksheet

Government of the

District of Columbia