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