Form Va-4p - Virginia Withholding Exemption Certificate For Recipients Of Pension And Annuity Payments Page 2

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FORM VA-4P
LINE BY LINE INSTRUCTIONS
PERSONAL EXEMPTION WORKSHEET
In order to compute the proper amount of Virginia income tax withheld, your payer must know the number of personal
exemptions you are entitled to claim. The Personal Exemption Worksheet is designed to allow you to review all of the possible
exemptions so that you can choose the appropriate number to report to your payer.
You may not claim more exemptions on Form VA-4P than you are entitled to claim on your income tax return, unless you
have received written permission to do so from the Department of Taxation.
Line 1. You may claim an exemption for yourself.
Line 2. You may claim an exemption for your spouse if he or she is not already claimed on his or her own certificate.
Line 3. Enter the number of dependents you are allowed to claim on your income tax return.
NOTE: A spouse is not a dependent.
Line 5. If you will be age 65 or over by January 1, you may claim one exemption on Line 5(a). If you claim an exemption
for your spouse on Line 2, and your spouse will also be age 65 or over by January 1, you may claim an additional
exemption on Line 5(b).
Line 6. If you are legally blind, you may claim an exemption on Line 6(a). If you claimed an exemption for your spouse on
Line 2, and your spouse is legally blind, you may claim an exemption on Line 6(b).
Retain this worksheet for your records.
FORM VA-4P
Be sure to enter your name, address and social security number in the spaces provided. Your payer must have this information
to properly identify your withholding liability.
Line 1. If you are subject to withholding, enter the number of exemptions from:
(a) Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet
(b)
Subtotal of Exemptions for Age and Blindness - line 7 of the Personal Exemption Worksheet
(c) Total Exemptions - line 8 of the Personal Exemption Worksheet
Line 2. If you wish to have an additional amount withheld from your payment, enter the amount on Line 2.
Line 3. If you elected “no withholding” for federal purposes, but wish to have Virginia income tax withheld, enter the amount
you want withheld from each payment on Line 3.
Line 4. If you are not subject to Virginia withholding, check the box on Line 4. You are not subject to Virginia withholding if
you meet any of the following conditions:
(a)
You elected “no withholding” for federal purposes; or
(b)
You are not a resident of Virginia; or
(c)
You incurred no income tax liability for last year and do not expect to incur a liability for this year; or
(d)
You expect your Virginia adjusted gross income to be less than the amount shown below for your filing
status:
Taxable Years
Taxable Years
Taxable Years
Taxable Years
2005, 2006
2008 and
2010 and
2012 and
and 2007
2009
2011
Beyond
Single
$7,000
$11,250
$11,650
$11,950
Married
$14,000
$22,500
$23,300
$23,900
Married, filing a separate
$7,000
$11,250
$11,650
$11,950
return
Sign Form VA-4P, cut at the line indicated, and file the completed form with your payer.

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