Part I – To be completed by the employee
EMPLOYEE NAME EMPLOYEE SOCIAL SECURITY NUMBER
STREET ADDRESS CITY STATE ZIP CODE
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
1. If you claim no personal exemption for yourself and wish to withhold at the highest rate, write the figure “0”,
sign and date Form A4 and file it with your employer................................................................
2. If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed.
Write the letter “S” if claiming the SINGLE exemption or “MS” if claiming the MARRIED FILING SEPARATELY exemption .......
3. If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed.
Write the letter “M” if you are claiming an exemption for both yourself and your spouse or “H” if you are
single with qualifying dependents and are claiming the HEAD OF FAMILY exemption.....................................
4. Number of dependents (other than spouse) that you will provide more than one-half of the support for during
the year. See dependent qualification below. ......................................................................
5. Additional amount, if any, you want deducted each pay period.......................................................$
6. This line to be completed by your employer: Total exemptions (example: employee claims “M” on line 3 and
“2” on line 4. Employer should use column M-2 (married with 2 dependents) in the withholding tables) .......................
Under penalties of perjury, I certify that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and
complete.
Employee’s Signature _________________________________________________________ Date __________________________
Part II – To be completed by the employer
EMPLOYER NAME EMPLOYER IDENTIFICATION NUMBER (EIN)
ADDRESS CITY STATE ZIP CODE
Employers are required to keep this certificate on file. If the employee is believed to have claimed more exemption than legally entitled or
claims 8 or more dependent exemptions, the employer should contact the Department at the following address or phone number for ver-
ification: Alabama Department of Revenue, Withholding Tax Section, P.O. Box 327480, Montgomery, AL 36132-7480, by phone at (334)
242-1300, or by fax at (334) 242-0112. If the employee does not qualify for the exemptions claimed upon verification, the employer is re-
quired to withhold at the highest rate until the employee submits a corrected Form A4 reflecting the proper exemption they are entitled to
claim.
DEPENDENTS: To qualify as your dependent (Line 4 above), a person must receive more than one-half of his or her support from you
for the year and must be related to you as follows:
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son-in-law, or daughter-in-law;
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law;
Your brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, or sister-in-law;
Your uncle, aunt, nephew, or niece (but only if related by blood).
THIS FORM MAY BE REPRODUCED
Every employee, on or before the date of commencement of employment, shall furnish his or her employer with a signed Alabama with-
holding exemption certificate relating to the number of withholding exemptions which he or she claims, which in no event shall exceed the
number to which the employee is entitled. In the event the employee inflates the number of exemptions allowed by this Chapter on Form
A4, the employee shall pay a penalty of five hundred dollars ($500) for such action pursuant to Section 40-29-75.
ALABAMA DEPARTMENT OF REVENUE
50 North Ripley Street • Montgomery, AL 36104 • InfoLine (334) 242-1300
www.revenue.alabama.gov
Employee’s Withholding Tax Exemption Certificate
FORM
A4
(REV. 3/2014)
Gadsden State Community College
1001 George Wallace Drive
