w4 – Gas/Convenient Store

Company Name: *

First name *

Last name *

Social Security Number *

Street Address *

Apartment, suite, etc

City/Town *

State *

Zip Code *

Tax Status *Check Head of Household, only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead of household

Step 2 Cont:

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependent and Other Credits

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

a. Multiply the number of qualifying children under age 17 by $2,200

b. Multiply the number of other dependents by $500

Add the amounts from Steps 3(a) and 3(b), plus the amount for other credits. Enter the total here

Step 4: Other Adjustments

(a) Other income (not from jobs).If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

(b) DeductionsUse the Deductions Worksheet on page 4 of current w4 (https://www.irs.gov/forms-pubs/about-form-w-4) determine the amount of deductions you may claim, which will reduce your withholding. (If you skip this line, your withholding will be based on the standard deduction.) Enter the result here

Step 5:

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Signature *Print your full name

Date *Must be today's date