Fillable Form Ia W4 - Employee Withholding Allowance Certificate

Please Print or Type

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:

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: _______________________

I OWA

IA W4 1999

d e p a r t m e n t o f Reve nu e a n d F i n a n c e

Employee Withholding Allowance Certificate

Employers: Detach this part and keep in your records unless more than 22 withholding allowances are claimed.

See Employer Withholding Requirements on the back of this form.

EMPLOYEE ONLY

Marital status:

Single

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

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

Home Address (number and street or rural route) _________________________________________________________________________________

City ____________________________________________________________ State __________ Zip Code ________________________

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. _____________

7. 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: _______

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 8 and 9 below only if you are sending this part to the Iowa Department of Revenue and Finance because the employee is claiming more than 22 total allowances.

8. Employer’s name and address ____________________________________________________ 9. FEIN ____________________________________

44-019a (11/98)