Form Nc-4 - 2009 Employee'S Withholding Allowance Certificate
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1
2Employee’s Withholding
NC-4
Web
Allowance Certificate
12-09
North Carolina Department of Revenue
Social Security Number
Marital Status
Single
Head of Household
Married or Qualifying Widow(er)
First Name
M.I.
Last Name
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Address
County
(Enter first five letters)
City
State
Zip Code (5 Digit)
Country (If not U.S.)
(See Form NC-4 Instructions before completing this form)
1. Total number of allowances you are claiming
(From Line F of the Personal Allowances Worksheet on Page 2)
.
,
2.
Additional amount, if any, you want withheld from each pay period
00
(Enter whole dollars)
3.
I certify that I am not subject to North Carolina withholding because I meet the following two conditions:
• Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and
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• This year I expect a refund of all State income tax withheld because I expect to have no tax liability.
4.
I certify that I am not subject to North Carolina withholding because I meet the requirements
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of the Military Spouses Residency Relief Act and I am legally domiciled in the state of
____________________________________________.
(Enter state of domicile)
2 0
If line 3 or line 4 above applies to you, enter the year effective
and write “EXEMPT” here
5. I certify that I no longer meet the requirements for exemption on line 3
or line 4
(Check applicable box)
Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax
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based on the number of allowances entered on line 1 and any amount entered on line 2.
CAUTION: If you furnish an employer with an Employee’s Withholding Allowance Certificate that contains information which has no reasonable basis
and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a
penalty of 50% of the amount not properly withheld.
Employee’s Signature
Date
I certify, under penalties provided by law, that I am entitled to the number of withholding
allowances claimed on line 1 above, or if claiming exemption from withholding, that I am
entitled to claim the exempt status on line 3 or 4, whichever applies.
(Employer: Complete below only if sending to the North Carolina Department of Revenue. Submit the original and keep a copy for your records.)
Employer’s Name
(USE CAPITAL LETTERS)
FEIN
Employer’s Address
County
(Enter first five letters)
City
State
Zip Code (5 Digit)
Country (If not U.S.)
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