5 Total number of allowances you are claiming (from page 1 or page 2 of the federal worksheet)
6 Additional amount, if any, you want withheld from each paycheck ......................................................................................................
7 I claim exemption from withholding for 2012, 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
• is 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...........................................................................
1 Tax ling status Fill in only one: Single Married ling jointly Married ling separately Head of household
Married ling separately on same return
2 Total number of withholding allowances from DC worksheet
3 Additional amount, if any, you want withheld from each paycheck
4 If you are claiming exemption from withholding, read below and write “EXEMPT” in this box.
I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and
this year I do not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt
status on federal Form W-4.
If claiming exemption, are you a full-time student? Yes No
Employee Withholding Allowance Certicate
FOR MARYLAND STATE GOVERNMENT EMPLOYEES
RESIDING IN WASHINGTON, D.C.
Form W-4
Department of the Treasury
Internal Revenue Service
Form D-4
Oce of Tax and Revenue
Government of the District of Columbia
Please complete form in black ink. 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.
Section 2 - Federal Withholding Form W-4
Section 1 - Employee Information
e federal worksheet is available online at http://www.irs.gov/pub/irs-pdf/fw4.pdf
Section 3 - District of Columbia Withholding Form D-4
e District of Columbia worksheet is available online at http://otr.cfo.dc.gov/otr/frames.asp?doc=/otr/lib/otr/tax/forms/D-4.pdf
Section 4 - Employee Signature
Date
Under penalties of perjury/law, I declare that I have examined this certicate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(Form is not valid
unless you sign it.)
Important: e information you supply must be complete. is form will replace in total any certicate you previously submitted.
Web Site - http://compnet.comp.state.md.us/cpb
RG
CT UM
Agency Number
Payroll System (check one)
Name of Employing Agency
Social Security Number
Home Address (number and street or rural route)
Employee Name
Address Continued (apartment number, if any)
City
Washington
State
DC
Zip Code
7
3 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.
4 If your last name diers from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card.
5
6
$
52-6002033
$
Employer’s name and address (including zip code) (For employer use only)
Central Payroll Bureau
P.O. Box 2396
Annapolis, MD 21404
Federal Employer identication number
2012
(For State of Maryland - CPB use only)
