Form C-25 Form W-4 - Employee'S Withholding Exemption Certificate

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FORM W-4

C-25

EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE

S ide 1

U.S. Treasury Department

Internal Revenue Service

1. Type

2. Social

3. Date of

Full Name _______________________________________

Security __________________________

Birth _________________________

Last

First

Middle

If your last nam e differs from that shown on your social security card, check here.

You m ust call 1-800-772-1213 for a new card.

5. Voting Address ___________________________________

City __________________________

State _______

Zip Code ____________

Mailing Address if

Other Than Above _________________________________

City __________________________

State _______

Zip Code __________

County Code ________

County _______________________________

6. Marital Status:

Single

Married

Married, but withhold at a single rate

NOTE: If married, but legally separated, or spouse is non-resident alien, check the Single box.

Total number of allowances you are claiming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Additional amount, if any, you want deducted from each pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. $

I claim exemption from withholding and I certify that I meet ALL of the following conditions for exemption:

•

Last year I had a right to a refund of ALL Federal income tax withheld because I had NO tax liability; AND

•

This year I expect a refund of ALL Federal income tax withheld because I expect to have NO tax liability;

If you meet all of the above conditions, enter the year effective and “EXEMPT” here . . . . . . . . . . . .

10.

U nder the penalties of perjury, I certify that I am entitled to the num ber of w ithholding allow ances claim ed on this certificate or entitled to claim exem pt status.

Employee’s signature

Date

11.

E m ployer’s nam e and address

State of Illinois, Comptroller, Withholding Agent, Springfield, IL 62706

S ide 2

Changes:

DATE

PAY CODE

Name

Address

Allowance(s)