Form Ia W4 - Employee Withholding Allowance Certificate

Centralized Employee Registry Reporting Form

Submit this information online at

TO BE COMPLETED BY THE EMPLOYER

within 15 days of hire. Please Print or Type.

...or mail this portion of the page to Centralized Employee

Registry, PO Box 10322, Des Moines IA 50306-0322; or fax

it to 1-800-759-5881. Please include your FEIN.

EMPLOYER INFORMATION

FEIN Required

Phone: ( _____ ) _______ — ___________

Area Code + Telephone Number

FEIN plus last 3-digit suffix used when filing Iowa withholding tax.

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 coverage available? Yes

or No

B. Approximate date this employee qualifies for coverage:

YYYY

C. Employee start date:

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:

YYYY

Last Name: __________________________ First Name: ______________________ Middle Initial: _______

Street Address: ___________________________________________________________________________________

____________________________________________________________________________________

City: ________________________________ State: ______________ Zip Code: _______________________

Iowa Department of Revenue

2010 IA W-4

Employee Withholding Allowance Certificate

To be completed by the employee

Marital status:

Single

Married (If married but legally separated, check Single.)

Print your full name: ______________________________________________________________ Social Security No.: ___________________________

Home Address: ______________________________________________________ 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: ________ Nonresidents may not claim this exemption.

Check this box if you are claiming exemption from Iowa tax based on the Military Spouses Residency Relief Act of 2009.

If claiming the military spouse exemption, enter your state of domicile 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 adjustments to income ...................................................................................................................................... 4. ______________

5. Allowances for child and dependent care credit ....................................................................................................................... 5. ______________

6. Total allowances. Add lines 1 through 5. .................................................................................................................................. 6. ______________

7. Additional amount, if any, you want deducted each pay period ............................................................................................. 7. ______________

I certify that I am entitled to the number of withholding allowances

Employers: Detach this part and keep in your records unless more than 22

withholding allowances are claimed. If more than 22 allowances are claimed,

claimed on this certificate, or if claiming an exemption from

complete the section below and send it to the Iowa Department of Revenue.

withholding, that I am entitled to claim the exempt status.

See Employer Withholding Requirements on the back of this form.

Employer’s name / address: ______________________________________

Employee Signature: _________________________________________

___________________________________ FEIN: ____________________

Date: ___________________________

44-019a (12/14/09)