Tax Withholding Form HR
Tax Withholding Form
Employee Information
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Name |
Jane Rodgers |
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Address |
Boston, Massachusetts, 02108 |
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Social Security Number (SSN) |
019-24-XXXX |
|
Employee ID |
14-13128 |
Filing Status (Check One)
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Single |
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Married filing jointly |
|
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Married filing separately |
|
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Head of household |
|
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Qualifying widow(er) with dependent child |
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
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Tax Filing Status: |
Married filing separately |
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Number of Allowances Claimed: |
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Additional Withholding: |
[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]
