8-810-2019 Rev. 12-2020
Supersedes 8-810-2019 Rev. 11-2019
Employee’s Nebraska Withholding Allowance Certificate
• Whether you are entitled to claim a certain number of allowances or exemption from withholding
is subject to review by the Nebraska Department of Revenue (DOR). Your employer may be
required to send a copy of this form to DOR.
FORM
W-4N
Your First Name and Initial Last Name Your Social Security Number
Current Mailing Address (Number and Street or PO Box)
City State Zip Code
1 Total number of allowances you are claiming (from line 4g on the worksheet below). ..................... 1
2 Additional amount, if any, you want withheld from each paycheck for Nebraska income tax withheld ......... 2
3 I claim exemption from withholding and I can provide satisfactory evidence to my employer that I meet both
of the following conditions for exemption.
• Last year I had a right to a refund of all Nebraska income tax withheld because I had no tax liability, and
• This year I expect a refund of all Nebraska income tax withheld because I expect to have no tax liability.
If you can provide evidence that you can meet both conditions, write “Exempt” here ..................... 3
Single Married
Note: If married, but legally separated, or spouse is a nonresident alien,
check the “Single” box. Individuals filing income tax returns with a “Head
of Household” status check the "Single" box.
sign
here
Employee's Signature Date
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is correct and complete.
Personal Allowances Worksheet
• Keep for your records.
Allowances approximate tax deductions that may reduce your tax liability. The number of allowances is determined by many factors
including, but not limited to, filing status, how many jobs you have, tax credits, and how many children or dependents that you claim on
your tax return.
Allowances claimed on the Form W-4N are used by your employer to determine the Nebraska state income tax withheld from your wages
to meet your Nebraska state income tax obligation.
4 a Enter “1” for yourself if no one else can claim you as a dependent............................... 4a _______
b Enter “1” if:
• You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or
• Your wages from a second job or your spouse’s wages (or the total of both for the year) are
$1,500 or less...................................................................... 4b _______
c Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a
working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld) .. 4c _______
d Enter number of Nebraska personal exemptions (other than your spouse or yourself) you will claim on
your Nebraska tax return. This is the number of children and dependents you will list on your Nebraska
return that qualify for either the child or dependent tax credit on the federal return ................... 4d _______
e Enter “1” if you will file as head of household on your tax return ................................ 4e _______
f Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim
a credit.............................................................................. 4f _______
g Enter total of lines a through f here and on line 1 above. (Note: This may be different from the number of
exemptions you claim on your Nebraska tax return)..................................................... 4g
Employer’s Name and Address (Employer: Complete employer information if sending to DOR) Nebraska ID Number
Separate here and give Form W-4N to your employer. Keep the bottom part for your records.
