Form Ia W4 - Employee Withholding Allowance Certificate - 2005

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Centralized Employee Registry Reporting Form
Mail this portion of the page to Centralized Employee
Registry, PO Box 10322, Des Moines IA 50306-0322; or
TO BE COMPLETED BY THE EMPLOYER within 15 days of
fax it to 1-800-759-5881. You may complete this online
hire. Please Print or Type
instead at icer.dhs.state.ia.us/
EMPLOYER INFORMATION
_
_
( __________ ) _________ — ____________
Phone: Area Code + Telephone Number
FEIN plus last 3-digit suffix as shown on your Iowa label or return.
Name: ____________________________________________________________________________________________
Street Address: ____________________________________________________________________________________
____________________________________________________________________________________
_
City: __________________________________ State:
Zip Code:
Questions: For A through D below, please see instructions on back for definitions and clarification.
A. Is dependent health care available? Yes
or No
B. Approximate date this employee qualifies for coverage:
MM
DD
YYYY
C. Employee start date:
MM
DD
YYYY
D. Address where income withholding and garnishment orders should be sent, if different than above address.
Street Address: ________________________________________________________________________________
_______________________________________________________________________________
_
City: _____________________________ State:
Zip Code:
EMPLOYEE INFORMATION
_
_
Employee’s Date of Birth:
Employee’s Social Security Number:
MM
DD
YYYY
Last Name: ____________________________ First Name: ______________________ Middle Initial: _______
Street Address: ____________________________________________________________________________________
____________________________________________________________________________________
City: __________________________________ State: ______________ Zip Code: _______________________
Iowa Department of Revenue
IA W4 2005
Employee Withholding Allowance Certificate
Employers: Detach this part and keep in your records unless more than 22 withholding allowances are claimed.
To be completed
See Employer Withholding Requirements on the back of this form.
by the employee.
EMPLOYEE ONLY
Marital status:
Single
Married (If married but legally separated, check Single.)
Print your full name: ______________________________________________________________ Social Security No.: ___________________________
Home Address (No. and St. or RR) _____________________________________ City _______________ State ____ Zip Code _________________
EXEMPTION FROM WITHHOLDING. If you do not expect to owe any Iowa income tax this year, and expect to have a right to a full refund of
ALL income tax withheld, enter “EXEMPT” here: ____________________ and the year effective here: _______
If you are not exempt, complete the following:
1. Personal allowances .................................................................................................................. 1. _____________
2. Allowances for dependents ...................................................................................................... 2. _____________
3. Allowances for itemized deductions ........................................................................................ 3. _____________
4. Allowances for child and dependent care credit .................................................................... 4. _____________
5. Total allowances. Add lines 1 through 4. ................................................................................ 5. _____________
6. Additional amount, if any, you want deducted each pay period ........................................... 6. _____________
I certify that I am entitled to the number of withholding allowances claimed on this certificate, or if claiming an exemption from withholding, that I am
entitled to claim the exempt status.
Employee Signature _____________________________________________________________ Date ___________________
Employer: Complete below only if you are sending this part to the Iowa Department of Revenue because the employee is claiming more than 22 total allowances.
Employer’s name and address _________________________________________________________ FEIN ___________________________________
44-019a (10/4/04)

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