•Failure to complete this form will result in the highest amount of taxes to be deducted and may
result in a $500 fine.
•You must complete Name, SSN, Address, and
Marital Status portion.
•Name listed on form must be same as listed
on Social security card.
•Please list the total
number of allowances you wish to claim – this can be any number from 0-9,
the higher the number, the LESS taxes that come out of your
check.
•If you want additional taxes withheld,
please list the amount.
•Most employees will not complete the
remaining boxes, but please read carefully to be sure.
•Sign and date the form at the bottom; the
form will not be accepted without a signature.
•If you have any questions regarding the
completion of this form, please contact the payroll department.
•