Employee Withholding Exemption Certicate (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.
• Employeesmustleanewwithholdingexemptioncerticatewithin10daysifthenumberoftheirexemptionsdecreases,exceptifthechangeistheresult
of the death of a spouse or a dependent.
• Employeesmayleanewcerticateanytimethenumberoftheirexemptionsincreases.
• Line8shouldbeusedtoincreaseordecreasethetaxwithheldforeachpayperiod.Decreasesshouldbeindicatedasanegativeamount.
Penalties will be imposed for willfully supplying false information or willful failure to supply information that would reduce the withholding exemption.
Thisformmustbeledwithyouremployer.Ifanemployeefailstocompletethiswithholdingexemptioncerticate,theemployermustwithholdLouisiana
income tax from the employee’s wages without exemption.
Note to Employer:Keepthiscerticatewithyourrecords.Ifyoubelievethatanemployeehasimproperlyclaimedtoomanyexemptionsordependencycredits,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-
mentation.TheinformationshouldbesenttotheLouisianaDepartmentofRevenue,CriminalInvestigationsDivision,POBox2389,BatonRouge,LA70821-2389.
Block A
• Enter“0”toclaimneitheryourselfnoryourspouse,andcheckNo exemptions or dependents claimedundernumber3below.
Youmayenter“0”ifyouaremarried,andhaveaworkingspouseormorethanonejobtoavoidhavingtoolittletaxwithheld.
Enter“1”toclaimyourself,andcheckSingleundernumber3below.ifyoudidnotclaimthisexemptioninconnectionwithother
employment,orifyourspousehasnotclaimedyourexemption.Enter“1”toclaimonepersonalexemptionifyouwillleashead
ofhousehold,andcheck“Single”undernumber3below.
• Enter“2”toclaimyourselfandyourspouse,andcheck“Married”undernumber3below.
A.
Block B
• Enterthenumberofdependents,notincludingyourselforyourspouse,whomyouwillclaimonyourtaxreturn.Ifnodependents
areclaimed,enter“0.
B.
Cut here and give the bottom portion of certicate to your employer. Keep the top portion for your records.
Form L-4
Louisiana
Department of
Revenue
Employee’s Withholding Allowance Certicate
1. Typeorprintrstnameandmiddleinitial Last name
2. SocialSecurityNumber 3. Selectone
NoexemptionsordependentsclaimedSingleMarried
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.
8.Increaseordecreaseintheamounttobewithheldeachpayperiod.Decreasesshouldbeindicatedasanegativeamount. 8.
Ideclareunderthepenaltiesimposedforlingfalsereportsthatthenumberofexemptionsanddependencycreditsclaimedonthiscerticatedonotexceed
thenumbertowhichIamentitled.
Employee’s signature Date
The following is to be completed by employer.
9. Employers name and address 10. Employer’s state withholding account number
R-1300(4/11)
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