Government of the
District of Columbia
Employer Keep this certificate with your records. If 10 or more exemptions are claimed or if you suspect this certificate contains false information
please send a copy to: Office of Tax and Revenue, 1101 4th St., SW, Washington, DC 20024 Attn: Compliance Administration
Signature Under penalties of law, I declare that the information provided on this certificate is, to the best of my knowledge, correct.
Employee’s signature Date
D-4 Employee Withholding Allowance Worksheet
Government of the
District of Columbia
Section A Number of withholding allowances
a Enter 1 for yourself and a
b Enter 1 if you are filing as a head of household and b
c Enter 1 if you are 65 or over and c
d Enter 1 if you are blind d
e Enter number of dependents e
f Enter 1 for your spouse/registered domestic partner if filing jointly f
g Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is 65 or over and g
h Enter 1 if married/registered domestic partners filing jointly and your spouse/registered domestic partner is blind h
i Number of allowances Add Lines a through h and enter on Line 2 above. If you want to claim additional withholding i
allowances, complete section B below.
$
Section B Additional withholding allowances
j Enter estimate of your itemized deductions j
k Enter $2,000 if married/registered domestic partners filing separately; all others enter $4,000 k
l Subtract Line k from Line j l
m Multiply $1,675 by the number of allowances on Line i m
n Divide Line l by Line m. Round to the nearest whole number. n
o Add Lines n and i and enter on Line 2 above. o
Revised 12/10
Social security number
Your first name M.I. Last name
Home address (number and street)
City State Zip code +4
1 Tax filing status Fill in only one: Single Married/domestic partners filing jointly Married filing separately
Head of household Married/domestic partners filing separately on same return
2
Total number of withholding allowances from worksheet below
3
Additional amount, if any, you want withheld from each paycheck
4 Before claiming exemption from withholding, read below and, if qualified, write “EXEMPT” in this box. 4
5 My domicile is a state other than the District of Columbia Yes No If yes, give name of state of domicile ____________________
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 from withholding, are you a full-time student? Yes No
D-4 Employee Withholding
Allowance Certificate
D-4 P1
Employee Withholding Allowance Certificate
Enter Year
Detach and give the top portion to your employer. Keep the bottom portion for your records.
