Form G-4 - Employee'S Withholding Allowance Certificate printable pdf download

Form G-4 (Rev. 4/14)

STATE OF GEORGIA EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

1a. YOUR FULL NAME

1b. YOUR SOCIAL SECURITY NUMBER

2a. HOME ADDRESS

2b. CITY, STATE AND ZIP CODE

(Number, Street, or Rural Route)

PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING LINES 3 – 8

3. MARITAL STATUS

(If you do not wish to claim an allowance, enter “0” in the brackets beside your marital status.)

A. Single: Enter 0 or 1 .......................................[ ]

4. DEPENDENT ALLOWANCES

[ ]

B. Married Filing Joint, both spouses working:

Enter 0 or 1 .... ...........................................[ ]

5. ADDITIONAL ALLOWANCES

C. Married Filing Joint, one spouse working:

[ ]

Enter 0 or 1 or 2 ...........................................[ ]

(worksheet below must be completed)

D. Married Filing Separate:

Enter 0 or 1 .... ...........................................[ ]

E. Head of Household:

6. ADDITIONAL WITHHOLDING $___ ___ ______

Enter 0 or 1 .... ...........................................[ ]

WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES

(Must be completed in order to enter an amount on step 5)

1. COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:

Yourself:

Age 65 or over

Blind

Spouse:

Age 65 or over

Blind

Number of boxes checked _____ x 1300...............$______________

2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS:

A. Federal Estimated Itemized Deductions......................................................................... $______________

B. Georgia Standard Deduction (enter one):

Single/Head of Household

$2,300

Each Spouse

$1,500

$______________

C. Subtract Line B from Line A................................................................................................................$______________

D. Allowable Deductions to Federal Adjusted Gross Income .................................................................$______________

E. Add the Amounts on Lines 1, 2C, and 2D ..........................................................................................$______________

F. Estimate of Taxable Income not Subject to Withholding ...................................................................$______________

G. Subtract Line F from Line E (if zero or less, stop here)......................................................................$______________

H. Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above ................................ ______________

(This is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up)

7. LETTER USED

TOTAL ALLOWANCES

(Marital Status A, B, C, D, or E) ___________

(Total of Lines 3 - 5) ___________

(Employer: The letter indicates the tax tables in the Employer’s Tax Guide)

8. EXEMPT: (Do not complete Lines 3 - 7 if claiming exempt)

Read the Line 8 instructions on page 2 before completing this section.

a) I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to

have a Georgia income tax liability this year. Check here

b) I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers

Civil Relief Act as amended by the Military Spouses Residency Relief Act as provided on page 2. My state of residence is

________________ My spouse’s (servicemember) state of residence is ________________ The states of residence

must be the same to be exempt. Check here

I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status

claimed on this Form G-4. Also, I authorize my employer to deduct per pay period the additional amount listed above.

Employee’s Signature________________________________________________________ Date __________________

Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding.

If necessary, mail form to: Georgia Department of Revenue, Withholding Tax Unit, P.O. Box 49432, Atlanta, GA 30359.

9. EMPLOYER’S NAME AND ADDRESS:

EMPLOYER’S FEIN:____________________________

EMPLOYER’S WH#:____________________________

Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not

accept forms claiming exempt if numbers are written on Lines 3 - 7.

Form G-4 - Employee'S Withholding Allowance Certificate

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