Form Va-4 - Personal Exemption Worksheet
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1
2FORM VA-4
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF TAXATION
PERSONAL EXEMPTION WORKSHEET
1. If no one else can claim you as a dependent, and you wish to claim yourself, write "1" . . . . . . . . . _______________
2. If you are married and your spouse is not claimed on his/her own certificate, write "1" . . . . . . . . . . _______________
3. Exemptions for age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
(a) If you will be 65 or older on December 31, write "1" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
(b) If you claimed an exemption on line 2 and your spouse will be
65 or older on December 31, write "1" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
4. Exemptions for blindness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
(a) If you are legally blind, write "1" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
(b) If you claimed an exemption on line 2 and your spouse is legally blind, write "1" . . . . . . . . . . . _______________
5. Write the number of dependents you will be allowed to claim on your
income tax return (do not include your spouse) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
6. Total exemptions (add lines 1 through 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
----------------------Detach here and give the certificate to your employer. Keep the top portion for your records.--------------------------
FORM VA-4
EMPLOYEE'S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
Your social security number
Name
Street address
City
State
ZIP code
COMPLETE THE APPLICABLE LINES BELOW
1. If subject to withholding, enter the number of exemptions claimed on
line 6 of the Personal Exemption Worksheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________
2. Enter the amount of additional withholding requested (see instructions) . . . . . . . . . . . . . . . . . . _______________
3. I certify that I am not subject to Virginia withholding. l meet the conditions
set forth in the instructions (check here). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Signature
Date
EMPLOYER: Keep exemption certificates with your records. If you believe the employee has claimed too many exemptions,
notify the Department of Taxation, P.O. Box 1880, Richmond, Virginia 23282-1880, telephone (804) 367-8038.
VA DEPT OF TAXATION
2601064 REV 6/93
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