Tax Withholding Form

Employee Information

Filing Status (Check One)

Number Of Allowances (Enter the number of allowances you are claiming):

3 allowances

Additional Withholding (Optional)

If you want to request additional withholding, please specify the additional amount per pay period: [Amount]

Exemption From Withholding (If applicable)

• I claim exemption from withholding because I had no tax liability last year and expect none this year. (If you meet these conditions, write "Exempt" here: )

[Signature]       

Date: [MM/DD/YYYY]

Employee's Certification

I [Employee Name] certify that the information provided on this form is accurate to the best of my knowledge, and I understand that providing false information may result in penalties.

[Signature]       

Date: [MM/DD/YYYY]

Employer Use Only

[Signature]       

Date: [MM/DD/YYYY]

Please return this completed form to the Payroll Department by [Month Day, Year]. If you have any questions or need assistance, please contact the HR Department.

[Your Company Name]

[Your Company Address]

[Your Company Number]

[Your Company Email]

[Your Company Website]

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