Employee Withholding Exemption Certicate (L-4)
Louisiana Department of Revenue
Purpose: Complete form L-4 so that your employer can withhold the correct amount of state income tax from your salary.
Instructions: Employees who are subject to state withholding should complete the personal allowances worksheet indicating the number of withholding
personal exemptions in Block A and the number of dependency credits in Block B.
of the death of a spouse or a dependent.
Penalties will be imposed for willfully supplying false information or willful failure to supply information that would reduce the withholding exemption.
income tax from the employee’s wages without exemption.
Note to Employer:Keepthiscerticatewithyourrecords.Ifyoubelievethatanemployeehasimproperlyclaimedtoomanyexemptionsordependencycredits,please
forward a copy of the employee’s signed L-4 form with an explanation as to why you believe that the employee improperly completed this form and any other supporting docu-
• Enter“0”toclaimneitheryourselfnoryourspouse,andcheck“No exemptions or dependents claimed”undernumber3below.
Cut here and give the bottom portion of certicate to your employer. Keep the top portion for your records.
Employee’s Withholding Allowance Certicate
1. Typeorprintrstnameandmiddleinitial Last name
2. SocialSecurityNumber 3. Selectone
4. Home address (number and street or rural route)
5. City State ZIP
6. Total number of exemptions claimed in Block A 6.
7. Total number of dependents claimed in Block B 7.
Employee’s signature Date
The following is to be completed by employer.
9. Employer’s name and address 10. Employer’s state withholding account number