Fillable W-4 Exemption Acknowledgment 2019 form

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W-4 Exemption Acknowledgment 2019 form

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W-4 EXEMPTION ACKNOWLEDGMENT
1
OFFICE OF THE STATE COMPTROLLER
ACTIVE & PENSION PAYROLL SERVICES DIVISION
Last Name
First Name
Employee ID #
Agency/Department
W-4 EXEMPTION ACKNOWLEDGMENT
Please check the box if you meet BOTH conditions to claim exemption
I claim exemption from withholding for 2019, and I certify that I meet both of the
following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I
had no tax liability, AND
• This year I expect a refund of all federal income tax withheld because I expect
to have no tax liability.
CERTIFICATION
I, ___________________________________________, certify that, I have examined this
acknowledgment and to the best of my knowledge and belief, it is true, correct and complete
statements that I have consulted the statutes, administrative rules and other sources of law
applicable to my exemption, and I have exercised reasonable care in assuring that my claim for
exemption is valid under federal law. In the event this exemption is disallowed, I accept full
responsibility for the payment of any penalty and fees, including any accrued interest.
Signature: _______________________________ Date: __________________
1
The information contained in this acknowledgement does not constitute legal or tax advice. If you have questions regarding
specifically related to your circumstances, you should consult with your own personal tax advisor.
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W-4 Exemption Acknowledgment 2019 form

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Completed 1 February 2020

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