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 DC Withholding Allowance Worksheet
Government of the
District of Columbia
Section A Number of withholding allowances
a Enter 1 for yourself
a
c Enter 1 if you are 65 or over c
d Enter 1 if you are blind d
e
e Enter number of dependents
f Enter 1 for your spouse or registered domestic partner filing jointly or filing separately on same return or if you are a qualifying widow(er)
with dependent child
f
g Enter 1 if married or registered domestic partner filing jointly or filing separately on same return and your spouse or registered domestic
partner is 65 or over
g
h
h Enter 1 if married or registered domestic partner filing jointly or filing separately on same return and your spouse or registered domestic
partner is blind
i Number of allowances Add Lines a through h, enter here and on Line 2 above, next to "Enter total from Sec. A, Line i".
If you want to claim additional withholding allowances, complete Section B below.
i
Revised 05/2015
Social security number
First name
M.I. Last name
Home address (number, street and suite/apartment number if applicable)
City State Zip code +4
Single
Married/domestic partners fi ling jointly/qualifying widow(er) with dependent child
Married fi ling separately
Head of household
Married/domestic partners fi ling separately on same return
2 Total number of withholding allowances from worksheet below.
Enter total from Sec. A, Line i Enter total from Sec. B, Line m
Total number of withholding allowances , Line n
3 Additional amount, if any, you want withheld from each paycheck
4 Before claiming exemption from withholding, read below. If quali ed, write “EXEMPT” in this box.
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 DC Withholding Allowance Certificate
2015 D-4 P1
DC Withholding Allowance Certificate
Detach and give the top portion to your employer. Keep the bottom portion for your records.
$
Section B Additional withholding allowances
j Enter estimate of your itemized deductions j
k Enter $5,200 if single, married/registered domestic partners filing separately or a dependent. Enter $6,500 if
head of household. Enter $8,350 if married/registered domestic partner filing jointly, married filing
separately on the same return, or qualifying widow(er) with dependent child.
k
n
1 Tax fi ling status (Fill in only one)
2015
m
Add Lines m and i, enter here and on Line 2 above, next to "Total number of withholding allowances, Line n".
l
m
n
b Enter 1 if you are filing as a head of household
b
Subtract Line k from Line j
l
Divide
Divide Line l by $1,775. Round to the nearest whole number, enter here and on Line 2 above, next to "Enter total from Sec.B, Line m".
This is a FILL-IN format. Please do not handwrite any data on this form other than your signature.
