Form G4 - Georgia Employee'S Withholding Allowance Certificate
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Form G-4 (Rev. 7/14)
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.)
4. DEPENDENT ALLOWANCES
A. Single: Enter 0 or 1...........................................[ ]
[ ]
B. Married Filing Joint, both spouses working:
Enter 0 or 1
..................................................[ ]
C. Married Filing Joint, one spouse working:
5. ADDITIONAL ALLOWANCES
[ ]
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 (Marital Status A, B, C, D, or E) ___________
TOTAL ALLOWANCES (Total of Lines 3 - 5) ___________
(Employer: The letter indicates the tax tables in 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:____________________________
58-6000198
BURKE CO BD OF EDUCATION 789 BURKE
EMPLOYER’S WH#:____________________________
1306880-DW
VETERANS PKWY WAYNESBORO GA 30830
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.
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