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A-4 Withholding Exception Certificate
"
*
" indicates required fields
Your Information
ALL QUESTIONS MUST BE ANSWERED BEFORE THE FORM WILL SUBMIT SUCCESSFULLY.
Name
*
First
Last
Email
*
Social Security Number
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Employer Information
ALL QUESTIONS MUST BE ANSWERED BEFORE THE FORM WILL SUBMIT SUCCESSFULLY.
Employer Name
*
Pyro Shows of Alabama
Select the only choice available.
Employer FEIN
*
81-1172593
Select the only choice available.
Employer State ID
*
0816023422
Select the only choice available.
Withholding Exemptions
ALL QUESTIONS MUST BE ANSWERED BEFORE THE FORM WILL SUBMIT SUCCESSFULLY.
If you claim no personal exemption for yourself and wish to withhold at the highest rate, select "0". If not, select "N/A".
*
0
N/A
If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed. Select“S” if claiming the SINGLE exemption or “MS” if claiming the MARRIED FILING SEPARATELY exemption. If none of those apply, select "N/A".
*
S
MS
N/A
If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed. Select “M” if you are claiming an exemption for both yourself and your spouse or “H” if you are single with qualifying dependents and are claiming the HEAD OF FAMILY exemption. Select "N/A" if none apply.
*
M
H
N/A
Number of dependents (other than spouse) that you will provide more than one-half of the support for during the year.
*
Please enter a number from
0
to
9
.
Use "0" if this question does not apply to you.
Additional amount, if any, you want deducted each pay period
Please enter a number from
0
to
999
.
Today's Date
*
MM slash DD slash YYYY
Signature
*
Name
This field is for validation purposes and should be left unchanged.
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