DE4-California Tax Withholding Form

First, Middle, Last Name

Social Security Number

Address

City, State, and ZIP Code

Filing Status

SINGLE or MARRIED (with two or more incomes)

MARRIED (one income)

HEAD OF HOUSEHOLD

Total Number of Allowances you’re claiming (Use Worksheet A for regular withholdingallowances. Use other worksheets on the following pages as applicable, Worksheet A+B).

Additional amount, if any, you want withheld each pay period (if employer agrees), (Worksheet B and C)

I claim exemption from withholding for 2020, and I certify I meet both of the conditions for exemption.

Exempt

I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions setforth under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Actand the Veterans Benefits and Transition Act of 2018.

Yes

I agree to add/update my tax information in our payroll system(Required)

Yes

Employee

Date