In Lieu of
Form W-4
(Rev. FORM)

Withholding Exemption Certificate

19___



Type or print your First Name, Middle Initial, Last Name


Postal location (number and street or rural route)


City or town, County, complete name of State

1 Pursuant to IRC Sec.3402(n)-1, 26 CFR Sec.31.3402(n)-1, 26 CFR Sec.31.3402(f)(2)-1, I certify that I am EXEMPT from withholding for the year of 19___. I certify that:
  • I incurred no liability for income tax imposed under subtitle A of Title 26 the Internal Revenue Code for the preceding taxable year.
  • I anticipate that I will incur no liability from income tax imposed under subtitle A for the current taxable year.

  • I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

    Signature and Date
    8 Employer's name and address


    9 Office Code


    10 Employer ID#






    Title 26, Internal Revenue Code, Sec.3402(n)-1, CFR Sec.31.3402(n)-1 -- Employees incurring no income tax liability. --Not withstanding any other provision of this section, an employer shall not be required to deduct and withhold any tax under this chapter upon a payment of wages to an employee if there is in effect with respect to the payment, a withholding exemption certificate furnished to the employer by the employee which states that--
  • (a) The employee incurred no liability for income tax imposed under subtitle A of the Code for his preceding taxable year; and
  • (b) the employee anticipates that he will incur no liability for income tax imposed by subtitle A for his current taxable year.
  • 26 CFR Sec.31.3402(f)(2)-1 -- Withholding exemption certificates. --(a) On commencement of employment. On or before the date on which an individual commences employment with an employer, the individual shall furnish the employer with a signed exemption certificate...OR if the statements described in Sec.31.3402(n)-1 are true with respect to an individual, he may furnish his employer with a signed withholding exemption certificate which contains such statements in lieu of the first mentioned [W-4] certificate.