W4 - English

First name and middle initial

Last name

Social security number

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Address

City or town, state, and ZIP code

Marital Status

Single or Married filing separately

Married filing jointly or Qualifying widow(er)

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

I agree to add/update my tax information in our payroll system as well as I will update our payroll system with this information(Required)

Yes

Employee's Signature

Date