Form D-4 - Dc Withholding Allowance Certificate - 2017
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This is a FILL-IN format. Please do not handwrite any data on this form other than your signature.
Government of the
2017
D-4 DC Withholding Allowance Certificate
District of Columbia
Social security number
First name
Last name
M.I.
(number, street and suite/apartment number if applicable)
Home address
City
State
Zip code +4
jointly/qualifying widow(er) with dependent child
(Fill in only one)
1
Tax fi ling status
Single
Married/domestic partners fi ling
Head of household
Married fi ling separately
Married/domestic partners fi ling separately on same return
2
Total number of withholding allowances from worksheet below.
Enter total from Sec. A,
Line i
Enter total from Sec. B,
Line m
Total number of withholding allowances ,
Line n
0
0
3
Additional amount, if any, you want withheld from each paycheck
$
4
Before claiming exemption from withholding, read below. If qualifi ed, write “EXEMPT” in this box.
5
My domicile is a state other than the District of Columbia
If yes, give name of state of domicile __________________
Yes
No
I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and this year I do
not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt status on federal Form W-4.
If claiming exemption from withholding, are you a full-time student?
Yes
No
Signature
Under penalties of law, I declare that the information provided on this certifi cate is, to the best of my knowledge, correct.
Employee’s signature
Date
Employer
Keep this certifi cate with your records. If 10 or more exemptions are claimed or if you suspect this certifi cate contains false information
please send a copy to: Offi ce of Tax and Revenue, 1101 4th St., SW, Washington, DC 20024 Attn: Compliance Administration
Detach and give the top portion to your employer. Keep the bottom portion for your records.
D-4 DC Withholding Allowance Worksheet
Government of the
District of Columbia
Section A Number of withholding allowances
a Enter 1 for yourself
a
b
Enter 1 if you are filing as a head of household
b
c
Enter 1 if you are 65 or over
c
d Enter 1 if you are blind
d
e
Enter number of dependents
e
f
Enter 1 for your spouse or registered domestic partner filing jointly or filing separately on same return
or if you are a qualifying widow(er)
f
with dependent child
g
g
Enter 1 if married or registered domestic partner filing jointly or filing separately on same return and your spouse or registered domestic
partner is 65 or over
h
h
Enter 1 if married or registered domestic partner filing jointly
or filing separately on same return and your spouse or registered domestic
partner is blind
i
0
i
Number of allowances
Add Lines a through h, enter here and on Line 2 above, next to "Enter total from Sec. A, Line i".
If you want to claim additional withholding allowances, complete Section B below.
Section B Additional withholding allowances
j
j
Enter estimate of your itemized deductions
k E nter $5,650 if single, married/registered domestic partners filing separately or a dependent. Enter $7,800 if
head of household. Enter $10,275 if married/registered domestic partner filing jointly, married filing separately
k
on the same return,
or qualifying widow(er) with dependent child.
l
l
Subtract Line k from Line j
Divide Line l by $1,775. Round to the nearest whole number, enter here and on Line 2 above, next to "Enter total from Sec.B, Line m".
m
m
n
n
Add Lines
m
and i, enter here and on Line 2 above, next to "Total number of withholding allowances, Line n".
0
2017 D-4 P1
12/2016
Revised
DC Withholding Allowance Certifi cate
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