Form Wh-4 - Employee'S Withholding Exemption And County Status Certificate

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State of Indiana
Form WH-4
Employee’s Withholding Exemption and County Status Certificate
State Form 48845
This form is for the employer’s records. Do not send this form to the Department of Revenue.
(R3 / 5-15)
The completed form should be returned to your employer.
Full Name _______________________________________________________
Social Security Number or ITIN __________________________
Home Address ________________________________
City _______________________
State ______
Zip Code ______________________
Indiana County of Residence as of January 1: ________________________________________
(See instructions)
Indiana County of Principal Employment as of January 1: _______________________________
(See instructions)
___________________________________________________________________________
How to Claim Your Withholding Exemptions
1. You are entitled to one exemption. If you wish to claim the exemption, enter “1” ..............................................................................
___________
Nonresident aliens must skip lines 2 through 6. See instructions
2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter “1” ...................................................
___________
3. You are allowed one (1) exemption for each dependent. Enter number claimed ...............................................................................
___________
4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or
(b) if you and/or your spouse are legally blind.
Check box(es) for additional exemptions: You are 65 or older
or blind
Spouse is 65 or older
or blind
Enter the total number of boxes checked ...........................................................................................................................................
___________
5. Add lines 1, 2, 3, and 4. Enter the total here ..................................................................................................................................... ►
6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions) .................................................. ►
7. Enter the amount of additional state withholding (if any) you want withheld each pay period ...........................................................
$ __________
8. Enter the amount of additional county withholding (if any) you want withheld each pay period .........................................................
$ __________
I hereby declare that to the best of my knowledge the above statements are true.
Signature: ______________________________________________________________________
Date: __________________________

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