Ibmi Us State Tax Withholding Form

State Tax Form Fax completed form to: 919-543-4747 COMPLETE BOTH PERSONAL AND WORK ADDRESS SECTIONS Employee First Name: ____________________________________ Last Name: ______________________________________ Serial Number: _________________

Social Security Number : _________________________

Home Address: _________________________________________________

City: __________________________________

County*___________________________________ State _____________________________ Zip Code : _________________ =================================================================================================== Report all changes in work location within 10 days. Work Location Address: _________________________________________

City: __________________________________

County*______________________________________ State ___________________________ Zip Code ________________ If your work location is in one of the states listed below that do no have state income tax on wage payments, mark your work state with an “X”, sign and return this form. No election is required in the following section. ___ Alaska ___ New Hampshire ___ Texas

___ Florida ___ South Dakota ___ Washington

___ Nevada, ___ Tennessee ___ Wyoming.

Use the following worksheet to calculate the number of tax allowances you should select. (Please note: Only your spouse or dependents with a US Taxpayer ID are eligible when filing a US tax return.) 1. Personal allowance(s) enter “1” for you …................................................................................................................ ____ 2. If married, enter “1” for your „eligible‟ spouse if not separately claimed by spouse ……………………………………

____

3. Allowances for dependents (enter the total number of „eligible‟ dependents other than your spouse) ....…………..

____

4. Additional withholding if claimed on federal form W-4 (where applicable)…………………………………….………… ____ 5. Special withholding allowance if claimed on federal form W-4 (where applicable)…………………………………..… ____ (Add items 1-5) Enter this total as your ==Total Allowances== in the next section …………………………...............

____*

======================= Complete both the Marital Status and Total Allowances below =======================

Marital Status: (If married but legally separated, or spouse is nonresident alien, check “Single”) Select one of the following: __Single

__Married

__Head of Household

Total Allowances ____*

(Optional) I would like an additional State tax, in the amount of $________ withheld each pay period. =============== Do not complete the following section unless you are certain that it applies to you =============== ___ I am Exempt from withholding - Claim exemption from withholding only if appropriate, and complete the items b elow Check spaces below that apply: A. ____ Last year did not owe any state/city income tax and had a right to a full refund of all income tax withheld B. ___ This year do not expect to owe any state/city income tax and expect to have a right to a full refund of all income tax withheld. If b oth A and B apply, enter the year effective and "exempt" in applicab le spaces State _________________

Year __________

City _________________

Year __________

Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled, or, if claiming exemption from withholding, that I am entitled to claim the exempt status.

Employee Signature _____________________________________________

Date ____________________