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.
Employee Withholding Allowance Certicate
FOR MARYLAND STATE GOVERNMENT EMPLOYEES
RESIDING IN WEST VIRGINIA
Form W-4
Department of the Treasury
Internal Revenue Service
Form WV/IT-104
State Tax Department
West Virginia
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 - West Virginia Withholding Form WV/IT-104
Tax information is available online at http://www.state.wv.us/taxrev/uploads/it100-1-a.pdf
Section 4 - Employee Signature
Date
Under penalties of perjury, I declare that I have examined this certicate and to the best of my knowledge and belief, it is true, correct, and complete. I
further certify, under penalties provided by the law, that the number of exemptions claimed in this certicate is not in excess of those to which I am entitled.
Employee’s signature
(Form is not valid
unless you sign it.)
Employer’s name and address (including zip code) (For employer use only)
Federal Employer identication number
Central Payroll Bureau
P.O. Box 2396
Annapolis, MD 21404
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 State
WV
Zip Code
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...........................................................................
7
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
1. If SINGLE, and you claim an exemption, enter “1”, if you do not, enter “0”..............................................
2. If MARRIED, one exemption each for husband and wife if not claimed on another certicate.
(a) If you claim both of these exemptions, enter “2”
(b) If you claim one of these exemptions, enter “1” .....................................................................
(c) If you claim neither of these exemptions, enter “0”
3. If you claim exemptions for one or more dependents, enter the number of such exemptions ....................
4. Add the number of exemptions which you have claimed above and enter the total ..................................................................
5. If you are Single, Head of Household, or Married and your spouse does not work, and you are
receiving wages from only one job, and you wish to have your tax withheld at a lower rate, check here ......................
6. Additional withholding per pay period under agreement with employer .................................................................................. $
Note that special withholding allowances provided on Federal Form W-4 may not be claimed on your West Virginia Form WV/IT-104
2012
(For State of Maryland - CPB use only)
