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- orm W-4
- Department of the Treasury
- Internal Revenue Service
- Employee's Withholding Allowance Certificate
- Whether you are entitled to claim a certain number of allowances or exemption from withholding is
- subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
- OMB No. 1545-0074
- 2019
- 1. First Name
- Francis
- Middle Name
- Joseph
- Last Name
- Tusick
- 2. Social Security Number
- 285-02-1905
- 3 Single or Married?
- Home Address
- 80 E 14th Avenue
- City or Town
- Columbus
- State
- Ohio
- Zip/Postal Code
- 43201
- 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.
- 5 Total number of allowances you are claiming (from the applicable worksheet on the following pages)
- 5. Required
- 6 Additional amount, if any, you want withheld from each paycheck
- 6
- 7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
- • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
- • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
- If you meet both conditions, write “Exempt” here
- 7
- 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.
- This form will not be considered complete until a physical signature is received.
- Personal Allowances Worksheet (Keep for your records.)
- A Enter “1” for yourself
- A
- 1
- B Enter "1" if you will file as married filing jointly
- B
- C Enter “1” if you will file as head of household
- C
- D Enter "1" if:
- {You're single, or married filing separately, and have only one job; or}
- {You're married filing jointly, have only one job, and your spouse doesn't work; or}
- {Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.}
- D
- 1
- E Child Tax credit. See Pub. 972, Child Tax Credit, for more information.
- If your total income will be less than $71,201 ($103,351 if married filing jointly), enter "4" for each eligible child.
- 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.
- 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.
- If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter "-0-".
- E
- F Credits for other dependents.
- If your total income will be less than $71,201 ($103,351 if married filing jointly), enter "1" for each eligible dependent.
- 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).
- If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter "-0-".
- F
- G Other Credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here
- G
- H Add lines A through G and enter total here.
- H
- For accuracy,complete all worksheets that apply.
- • If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount
- of nonwage income and want to increase your withholding, see the Deductions and Adjustments Worksheet on page 2.
- • 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
- 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.
- • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 above.
- Deductions and Adjustments Worksheet
- Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
- 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
- 1 $
- 2 Enter:
- {$24,400 if you're married filing jointly or qualifying widow(er)}
- {$18,350 if you're head of household}
- {$12,200 if you're single or married filing separately}
- 2 $
- 3 Subtract line 2 from line 1. If zero or less, enter “-0-”
- 3 $
- 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)
- 4 $
- 5 Add lines 3 and 4 and enter the total.
- 5 $
- 6 Enter an estimate of your 2019 nonwage income (such as dividends or interest)
- 6 $
- 7 Subtract line 6 from line 5. If zero, enter "-0-". If less than zero, enter the amount in parentheses.
- 7 $
- 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.
- 8
- 9 Enter the number from the Personal Allowances Worksheet, line H above.
- 9
- 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.
- 10
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