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Jan 24th, 2019
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  1. orm W-4
  2.  
  3. Department of the Treasury
  4.  
  5. Internal Revenue Service
  6. Employee's Withholding Allowance Certificate
  7.  
  8. Whether you are entitled to claim a certain number of allowances or exemption from withholding is
  9.  
  10. subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
  11.  
  12. OMB No. 1545-0074
  13.  
  14.  
  15.  
  16. 2019
  17.  
  18.  
  19. 1. First Name
  20.  
  21. Francis
  22. Middle Name
  23.  
  24. Joseph
  25. Last Name
  26.  
  27. Tusick
  28. 2. Social Security Number
  29.  
  30. 285-02-1905
  31. 3 Single or Married?
  32.  
  33. Home Address
  34.  
  35. 80 E 14th Avenue
  36. City or Town
  37.  
  38. Columbus
  39. State
  40. Ohio
  41. Zip/Postal Code
  42.  
  43. 43201
  44. 4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.
  45.  
  46.  
  47.  
  48. 5 Total number of allowances you are claiming (from the applicable worksheet on the following pages)
  49.  
  50.  
  51. 5. Required
  52.  
  53.  
  54.  
  55. 6 Additional amount, if any, you want withheld from each paycheck
  56.  
  57.  
  58. 6
  59.  
  60.  
  61.  
  62. 7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
  63.  
  64. • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
  65.  
  66. • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
  67.  
  68. If you meet both conditions, write “Exempt” here
  69.  
  70.  
  71. 7
  72.  
  73.  
  74.  
  75. Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
  76.  
  77.  
  78. This form will not be considered complete until a physical signature is received.
  79.  
  80.  
  81.  
  82.  
  83.  
  84.  
  85. Personal Allowances Worksheet (Keep for your records.)
  86.  
  87.  
  88.  
  89.  
  90. A Enter “1” for yourself
  91.  
  92.  
  93. A
  94.  
  95. 1
  96.  
  97.  
  98. B Enter "1" if you will file as married filing jointly
  99.  
  100.  
  101. B
  102.  
  103.  
  104.  
  105. C Enter “1” if you will file as head of household
  106.  
  107.  
  108. C
  109.  
  110.  
  111.  
  112. D Enter "1" if:
  113.  
  114. {You're single, or married filing separately, and have only one job; or}
  115. {You're married filing jointly, have only one job, and your spouse doesn't work; or}
  116. {Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.}
  117.  
  118. D
  119.  
  120. 1
  121.  
  122.  
  123. E Child Tax credit. See Pub. 972, Child Tax Credit, for more information.
  124.  
  125. If your total income will be less than $71,201 ($103,351 if married filing jointly), enter "4" for each eligible child.
  126. If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter "2" for each eligible child.
  127. If your total income will be from $179,050 to $200,000 ($345,851 to $400,000 if married filing jointly), enter "1" for each eligible child.
  128. If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter "-0-".
  129.  
  130. E
  131.  
  132.  
  133.  
  134. F Credits for other dependents.
  135.  
  136. If your total income will be less than $71,201 ($103,351 if married filing jointly), enter "1" for each eligible dependent.
  137. If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter "1" for every two dependents (for example, "-0-" for one dependent, "1" if you have two or three dependents, and "2" if you have four dependents).
  138. If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter "-0-".
  139.  
  140. F
  141.  
  142.  
  143.  
  144. G Other Credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here
  145.  
  146.  
  147. G
  148.  
  149.  
  150.  
  151. H Add lines A through G and enter total here.
  152.  
  153.  
  154. H
  155.  
  156.  
  157.  
  158. For accuracy,complete all worksheets that apply.
  159.  
  160.  
  161.  
  162. • If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount
  163.  
  164. of nonwage income and want to increase your withholding, see the Deductions and Adjustments Worksheet on page 2.
  165.  
  166.  
  167.  
  168. • If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined
  169.  
  170. earnings from all jobs exceed $53,000 ($24,500 if married), see the Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.
  171.  
  172.  
  173.  
  174. • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 above.
  175.  
  176.  
  177.  
  178.  
  179. Deductions and Adjustments Worksheet
  180.  
  181.  
  182.  
  183.  
  184. Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
  185.  
  186.  
  187. 1 Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See Pub. 505 for details
  188. 1 $
  189.  
  190.  
  191.  
  192. 2 Enter:
  193.  
  194. {$24,400 if you're married filing jointly or qualifying widow(er)}
  195.  
  196. {$18,350 if you're head of household}
  197.  
  198. {$12,200 if you're single or married filing separately}
  199.  
  200.  
  201. 2 $
  202.  
  203.  
  204.  
  205. 3 Subtract line 2 from line 1. If zero or less, enter “-0-”
  206.  
  207.  
  208. 3 $
  209.  
  210.  
  211.  
  212. 4 Enter an estimate of your 2019 adjustments to income and any additional standard deduction for age or blindness (see Pub. 505 for additional information about these items)
  213.  
  214.  
  215. 4 $
  216.  
  217.  
  218.  
  219. 5 Add lines 3 and 4 and enter the total.
  220.  
  221.  
  222. 5 $
  223.  
  224.  
  225.  
  226. 6 Enter an estimate of your 2019 nonwage income (such as dividends or interest)
  227.  
  228.  
  229. 6 $
  230.  
  231.  
  232.  
  233. 7 Subtract line 6 from line 5. If zero, enter "-0-". If less than zero, enter the amount in parentheses.
  234.  
  235.  
  236. 7 $
  237.  
  238.  
  239.  
  240. 8 Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter in parentheses. Drop any fraction.
  241.  
  242.  
  243. 8
  244.  
  245.  
  246.  
  247. 9 Enter the number from the Personal Allowances Worksheet, line H above.
  248.  
  249.  
  250. 9
  251.  
  252.  
  253.  
  254. 10. Add lines 8 and 9 and enter the total here. If zero or less, enter "-0-". If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1, page 4. Otherwise, stop here and enter this total on Form W-4, line 5, page 1.
  255.  
  256.  
  257. 10
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