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 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--
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.