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Name _________________________________________ Date _______________ Class ____________
Review and complete the sample W-4 form.
Form W-4 (2011)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider completing a
new Form W-4 each year and when your
personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign
the form to validate it. Your exemption for 2011
expires February 16, 2012. See Pub. 505, Tax
Withholding and Estimated Tax.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot
claim exemption from withholding if your income
exceeds $950 and includes more than $300 of
unearned income (for example, interest and
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earners/multiple jobs situations.
Complete all worksheets that apply. However,
you may claim fewer (or zero) allowances. For
regular wages, withholding must be based on
allowances you claimed and may not be a flat
amount or percentage of wages.
Head of household. Generally, you may claim
head of household filing status on your tax return
only if you are unmarried and pay more than
50% of the costs of keeping up a home for
yourself and your dependent(s) or other
qualifying individuals. See Pub. 501, Exemptions,
Standard Deduction, and Filing Information, for
Tax credits. You can take projected tax credits
into account in figuring your allowable number of
withholding allowances. Credits for child or
dependent care expenses and the child tax
credit may be claimed using the Personal
Allowances Worksheet below. See Pub. 919,
How Do I Adjust My Tax Withholding, for
information on converting
your other credits into
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using
Form 1040-ES, Estimated Tax for Individuals.
Otherwise, you may owe additional tax. If you
have pension or annuity income, see Pub. 919 to
find out if you should adjust your withholding on
Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to
claim on all jobs using worksheets from only one
Form W-4. Your withholding usually will be most
accurate when all allowances are claimed on the
Form W-4 for the highest paying job and zero
allowances are claimed on the others. See Pub.
919 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2011. See Pub. 919,
especially if your earnings exceed $130,000
(Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A
B Enter “1” if:
• You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or . . .
Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E
F Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . .
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
$40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 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 below.
Cut here and give Form W-4 to your employer. Keep the top part for your records.
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
1 Type or print your first name and middle initial.
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
Single Married Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
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 line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6
7 I claim exemption from withholding for 2011, 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 . . . . . . . . . . . . . . .
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 is not valid unless you sign it.)
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
9 Office code (optional)
10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Cat. No. 10220Q
Form W-4 (2011)
Activity 23 Life Skills Workbook
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