Employee Withholding Allowance Certicate
FOR MARYLAND STATE GOVERNMENT EMPLOYEES
RESIDING IN 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.
Form WV/IT 104
State Tax Department
West Virginia
2019
Form
W-4
Department of the Treasury
Internal Revenue Service
Section 1 - Employee Information
Payroll System (check one) Name of Employing Agency
Agency Number Social Security Number Employee Name
Home Address (number and street or rural route) (apartment number, if any)
City State Zip Code
Section 2 - Federal Withholding Form W-4
The federal worksheet is available online at https://www.irs.gov/pub/irs-prior/fw4--2019
.pdf
Employer’s name and address (Employer: Complete name, address & EIN only if sending to IRS)
Central Payroll Bureau
P.O. Box 2396
Annapolis, MD 21404
Federal Employer identication number (EIN)
Important: e information you supply must be complete. is form will replace in total any certicate you previously submitted.
Web Site - http://comptroller.marylandtaxes.gov/government_services/state_payroll_services/
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
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
RG CT UM
5.
6. $
5. T
otal number of allowances you’re claiming (from the applicable worksheet on the following pages) .................................
6. Additional amount, if any, you want withheld from each paycheck ...........................................................
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.
3. Single Married Married, but withhold at higher Single rate.
Note: If married ling separately, check “Married, but withhold at higher Single rate.”
4. If your last name diers from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.
WV
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, tat the number of exemptions claimed in this certicate is not in excess of those to which I am entitled. (is form is not valid unless
you sign it.)
________________________________________________________________________ ________________________________ _______________________________________
Employee’s signature Date Daytime Phone Number
(in case CPB needs to contact you regarding your W-4)
