Substitute W4 Form      Printable .PDF Version


Posted by TaxProSites.com - 10/8/04

 

NAME:

 

ADDRESS:

 

 

 

SOCIAL SECURITY #

                                                 DATE OF BIRTH:

PHONE #

 

 

COUNTY

 

SCHOOL DISTRICT

 

TWP or BORO

 

 

WITHHOLDING INFORMATION

CIRCLE ONE

SINGLE            MARRIED            MARRIED claiming single rate

 

# of exemptions claimed (if none, enter a “0”)

 

Enter added tax deduction per pay period, if any

 

Exempt from withholding (give reason)

 

 

DIRECT PAYROLL DEPOSIT INFORMATION

BANK NAME

 

BANK ADDRESS

 

 

 

 

CIRCLE ONE

CHECKING                    SAVINGS

 

BANK Number  (9 digit #, 1st # lower left corner of check)

 

ACCOUNT #

 

Please attach a photocopy of a blank check.  Write “VOID” on the photocopy.

 

You are paid every                                                                    .  If you have any problems, contact  .

Please sign & date below:

 

Signature:                                                                                              Date:

 

Office USE Only

Rate of Pay

Salary:

Hourly:

Commission:

Local Tax:           Yes           No

OPT Tax:       Yes               No

Other Deductions:

 

Other Income:

 

DATE OF HIRE: