Rev. 12/09
Name________________________________________ Social Security Number ____________________________________
City________________________________________ State_____________________ Zip Code ____________________
1. If SINGLE, and you claim an exemption, enter “1”, if you do not, enter “0 ..........................................
2. If MARRIED, one exemption each for husband and wife if not claimed on another certificate.
(a) If you claim both of these exemptions, enter “2”
(b) If you claim one of these exemptions, enter “1”
(c) If you claim neither of these exemptions, enter “0”
3. If you claim exemptions for one or more dependents, enter the number of such exemptions. ...........
4. Add the number of exemptions which you have claimed above and enter the total............................
5. If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving
wages from only one job, and you wish to have your tax withheld at a lower rate, check here ...........
6. Additional withholding per pay period under agreement with employer, enter amount here ..............$
Note that special withholding allowances provided on Federal Form W-4 may not be claimed on your West Virginia Form WV/IT-104 I CERTIFY,
under penalties provided by law, that the number of exemptions claimed in this certificate is not in excess of those to which I am entitled.
Date__________________________ Signature____________________________________________
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Complete this form and present it to your employer to avoid any delay in adjusting the amount of state
income tax to be withheld from your wages.
If you do not complete this form, the amount of tax that is now being withheld from your pay may not be
sufficient to cover the total amount of tax due the state when filing your personal income tax return after the
close of the year. You may be subject to a penalty on tax owed the state.
Individuals are permitted a maximum of one exemption for themselves, plus an additional exemption for
their spouse and any dependent other than their spouse that they expect to claim on their tax return.
If you are married and both you and your spouse work and you file a joint income tax return, or
if you are working two or more jobs, the revised withholding tables should result in a more accurate
amount of tax being withheld.
If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving
wages from only one job, and you wish to have your tax withheld at a lower rate, you must check the box on
line 5.
When requesting withholding from pension and annuity payments you must present this completed form
to the payor. Enter the amount you want withheld on line 6.
If you determine the amount of tax being withheld is insufficient, you may reduce the number of
exemptions you are claiming or request additional taxes be withheld from each payroll period. Enter the
additional amount you want to have withheld on line 6.
Rev. 12/09
This form is to be completed by employees who reside in Kentucky, Maryland, Ohio, Pennsylvania, Virginia or by an employee who is a Military
Spouse exempt from income tax on wages.
If you are a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia and your only source of income from West Virginia is wages or salaries,
you are exempt from West Virginia Personal Income Tax Withholding. Upon receipt of this form, properly completed, your employer is authorized
to discontinue the withholding of West Virginia Income Tax from your wages or salaries earned in West Virginia.
If you are a military spouse and (a) your spouse is a member of the armed forces present in West Virginia in compliance with military orders; (b)
you are present in West Virginia solely to be with your spouse; and (c) you maintain your domicile in another State and you are claiming exemption
under the Servicemember Civil Relief Act, enter your state of domicile (legal residence) on the following statement and attach a copy of your
spousal military identification card.
I certify that I am a legal resident of the state of ____________ and am not subject to West Virginia withholding because l meet the requirements
set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act.
Name________________________________________ Social Security Number ____________________________________
City________________________________________ State_____________________ Zip Code ____________________
I hereby certify, under penalties provided by law, that I am not a resident of West Virginia, that I reside in the State of________________and live
at the address shown on this certificate, and request is hereby made to my employer to NOT withhold West Virginia income tax from wages paid
to me. If at any time hereafter I become a resident of West Virginia, or otherwise lose my status of being exempt from West Virginia withholding
taxes, I will properly notify my employer of such fact within ten (10) days from the date of change so that my employer may then withhold West
Virginia income tax from my wages.
I certify that the above statements are true, correct, and complete.
Date__________________________ Signature____________________________________________
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