Employee Withholding Allowance Certicate
FOR MARYLAND STATE GOVERNMENT EMPLOYEES
RESIDING IN WASHINGTON, D.C.
Please complete form in black ink. Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS.
Your employer may be required to send a copy of this form to the IRS.
Form D-4
Oce of Tax and Revenue
Government of the District of Columbia
201
9
Form W-4
Department of the Treasury
Internal Revenue Service
Section 1 - Employee Information
Payroll System (check one) Name of Employing Agency
Agency Number Social Security Number Employee Name
Home Address (number and street or rural route) (apartment number, if any)
City State Zip Code
Section 2 - Federal Withholding Form W-4
The federal worksheet is available online at https://www.irs.gov/pub/irs-prior/fw4--2019
.pdf
Employer’s name and address (Employer: Complete name, address & EIN only if sending to IRS)
Central Payroll Bureau
P.O. Box 2396
Annapolis, MD 21404
Federal Employer identication number (EIN)
Important: e information you supply must be complete. is form will replace in total any certicate you previously submitted.
Web Site - http://comptroller.marylandtaxes.gov/government_services/state_payroll_services/
Section 3 - District of Columbia Withholding Form D-4 e District of Columbia worksheet is available online at https://otr.cfo.dc.gov/node/1296526
Under penalties of perjury/law, I declare that I have examined this certicate and to the best of my knowledge and belief, it is true, correct, and complete.
(is form is not valid unless it is signed.)
________________________________________________________________________ ________________________________ _______________________________________
Employee’s signature Date Daytime Phone Number
(In case CPB needs to contact you regarding your W-4)
1. Tax ling status (Fill in only one) Single Married/domestic partners ling jointly/qualifying widow(er) with dependent child
Head of household Married ling separately Married/domestic partners 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 qualied, 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
Section 4 - Employee Signature
RG CT UM
3. Single Married Married, but withhold at higher Single rate.
Note: If married ling separately, check “Married, but withhold at higher Single rate.”
4. If your last name diers from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.
5.
6. $
5. T
otal number of allowances you’re claiming (from the applicable worksheet on the following pages) ..................................
6. Additional amount, if any, you want withheld from each paycheck ............................................................
7. 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.
If you meet both conditions, write “Exempt” here ......................................................... 7.
DCWASHINGTON
