Florida Form W-4 - Employee'S Withholding Allowance Certificate

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ST AT E O F F LO RIDA

EMPLOYEE:

OFFICE OF COMPTROLLER

PLEASE COMPLETE

UNSHADED AREAS ONLY

BUREAU O F ST AT E PAYRO LLS

S O C. SEC . NU M. ( 9 )

FIRST NAME (14)

M.I. (1)

LAST NAME (16)

A DD RESS (30 )

CITY (15)

STATE (2) ZIP CODE (5 OR 9)

OR FOREIGN COUNTRY (13)

MARITAL STATUS

FOR AGENCY USE ONLY

R ACE

NUMBER

(S=SI NGLE)

B IR TH D A TE

ORGANIZATION

C ODE

SEX

OF W /H

ADDI TIONAL

(M=MARRIED)

(S EE

(M=MALE)

ALLOW .

AMOUNT

OLO

(X=MARRIED CL AIMI NG SI NGLE)

D D

YYYY

BEL OW )

(F=FEMALE)

(2)

W HOLE DOLL ARS

(4)

(2)

.00

I claim exemption from withholding and I certify that I meet ALL of the conditions for

EXEMPT ION FROM W ITHHOLDING MAY BE CLAIMED ONLY IF:

exemption.

Las t ye ar yo u h ad a r i g ht t o a r ef un d of AL L F ed er al i nc om e

EFFECTIVE

YEAR

"EXEMPT"

t a x w i t hh el d b ec a us e yo u h a d N O t a x l i a bi l i t y; AN D

T his year you expect a refund of ALL Federal income tax withheld

<============>

because you expect t o have NO tax liability.

<============>

I f yo u m ee t bo t h o f t h e ab o ve c o ndi t i o ns e nt er ye a r ef f ec t i ve an d

"E X E MPT " .

UNDER PENALTIES OF PERJURY, I CERTIFY THAT I AM ENTITLED

TO THE NUMBER OF WITHHOLDING ALLOWANCES, CLAIMED ON THIS

R A C E

1 = W H I TE ( N O T H I S P A N I C )

2 = B L A C K ( N O T H IS P A N I C )

C O D E S

3 = H IS P A N IC

4 = A S IA N O R P A C IF I C

CERTIFICATE OR ENTITLED TO CLAIM EXEMPT STATUS.

5 = A M E R I C A N IN D IA N O R

IS L A N D E R

I UNDERSTAND THAT ANY EXEMPTION FROM WITHOLDING EXPIRES

A L A S K A N N A T I V E

8 = O T H E R

ON FEBRUARY 15TH OF THE FOLLOWING CALENDAR YEAR.

I f yo u r l ast n ame d iff ers f ro m th at on you r soci al secu rit y

card, ch eck h ere and call 1- 800- 772-1213 f o r mo re

i nfo rma ti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ATTACH COPY OF SOCIAL SECURITY CARD HERE.

SIGNATURE

DATE SIGNED

(DAA001

REV. OCT. 30, 1997)

OMB NO.

1545-0010