Form
(Rev. December 2020)
Department of the Treasury internal Revenue Service
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
a) First name and middle initial*
Last name*
Address*
City or Town, State and ZIP code*
(c)Single or Married filing separately.Married filing jointly (or Qualifying widow(er))Head of Household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
(b) Social security number*
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800 772 1213 or go to www.ssa.gov.
Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and steps 3 - 4) ; or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in step 4(c) below for roughly accurate withholding ; or
(c)If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld....
TIP : To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
Complete Steps 3-4(b) on Form W-4 for 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.)
If your total income will be $200,000 or less ($400,000 or less if married filling jointly):
Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $5,00
Add the amounts above and enter the total here............
3
(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) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here....
(c) Extra withholding. Enter any additional tax you want withheld each pay period.
4 (a)
4 (b)
4 (c)
$2000$4000$6000$8000$10000$12000Exempt
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee's signature* (This form is not valid unless you sign it.)
Date*
Employer's name and address
First date of employment
Employer identification number(EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2021)
1a. YOUR FULL NAME *
2a. HOME ADDRESS* (Number, Street, or Ruual Route) *
1b. YOUR SOCIAL SECURITY NUMBER *
2b. CITY, STATE AND ZIP CODE *
3. MARITAL STATUS
(If you do not wish to claim an allowance, enter "0" in the brackets beside your marital status.)
A. Single *: Enter 0 or 1
B. Married Filing Joint both spouses working * : Enter 0 or 1
c. Married Filing Joint, one spouse working * : Enter 0 or 1
D. Married Filing Joint, Separate * : Enter 0 or 1
E. Head of Household * : Enter 0 or 1
5. ADDITIONAL ALLOWANCES (worksheet below must be completed)
6. ADDITIONAL WITHHOLDINGS
(Must be completed in order to enter an amount on step 5)
1. COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:
Yourself : Age 65 or over Blind
Spouse : Age 65 or over Blind
Number of boxes checkedX 1300 =
2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS :
A . Federal Estimated Itemized Deductions (If Itemizing Deductions) .........................................................................................$
B . Georgia Standard Deduction (enter one)
Each Spouse
Single/Head of Household
$3000
c . Subtract Line B from Line A (If zero or less, enter zero ..............................................................................................$
D . Allowable Deductions to federal Adjusted Gross Income .........................................................................................$
E . Add the Amounts on Lines 1, 2C, and 2D.......................................................................................................................$
F . Estimate of Taxable Income not Subject to Withholding.............................................................................................$
G . Subtract Line F from Line E (If zero or less, stop here)................................................................................................$
H . Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above (If zero or less, stop here).........$
(this is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up)
7. LETTER USED (Marital Status A,B,C,D or E)*
(Employer: The letter indicates the tax tables in Employer's Tax Guide)
TOTAL ALLOWANCES (Total of Lines 3 - 5)*
8. EXEMPT: (Do not complete Lines 3 - 7 if claiming exempt) Read the Line 8 Instructions on page 2 before completing this section.
a) I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year.Check here
b) I certify i am not subject to Georgia withholding because i meet the conditions set forth under the Service members Civil Relief Act as provided on page 2. My state of residence is . My spouse's (service member) state of residence is The states of residence must be the same to be exempt.Check here
I certify under penalty of purjury that I am entitled to the number of withholding allowances or the exemption from withholding status claimed on this Form G-4. Also, I authorize my employer to deduct per day period the additional amount listed above.
Employee's signature*
Employer: Complete Line 9 and mail entire form only If the employee claims over 14 allowances or exempt from withholding. If necessary, mail from to: Georgia Department of Revenue, Withholding Tax Unit, 1800 Century Blvd NE, Suite 8200, Atlanta, GA 30345
EMPLOYER'S NAME AND ADDRESS:
EMPLOYER'S FEIN :
EMPLOYER'S WH# :
Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not accept forms claiming exempt if numbers are written on Lines 3 - 7.
OMB No. 1615-0047 Expires 10/31/2022
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employess must complete and sign Section 1 of Form I-9 no later than first day of employemt, but not before accepting a job offer.)
Last Name (Family Name)*
First Name (Given Name)*
Middle Initial*
Other Last Names Used (If any)*
Address (Street Number and Name)*
Apt. Number *
City or Town *
State *
Zip Code *
Date of Birth (mm/dd/yyyy)*
U.S. Social Security Number*
Employee's E-mail Address*
Employee's Telephone Number*
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that i am (check one of the following boxes):
1. A citizen of the United States*
2. A noncityzen national of the United States (See instructions)*
3. A lawful permanent resident(Alien Registration Number/USCIS Number) :
4. An alien authorized to work(until (expiration date, if applicable, mm/dd/yyyy) :
QR Code - Section 1 Do Not Write In This Space
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An alien Registration Number/USCIS Number OR Form I-9 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number : OR
2. Form I-9 Admission Number : OR
3. Foreign Passport Number :
Country of issuance :
Signature of Employee*
Today's Date (mm/dd/yyyy)*
I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator *
Today's Date (mm/dd/yyyy) *
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
Zip Code
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.)
Employee Info from Section 1
M.I*
Citizenship/Immigration Status
List A
Identity and Amployment Authorization
OR
List B Identity
AND
List C Amployment Authorization
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Additional Information
QR Code - Section 2 & 3 Do Not Write In This Space
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) The above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy) : (See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Middle Initial
Date (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge. this employee is authorized to work in the United States, and if the employee presented document(s). The document(s) I have examined appear to be genuine and to relate to the individual.
Name of Employer or Authorized Representative
This document must be signed by the employee requesting automatic deposit of paychecks and will be retained by Gusto.
This authorizes ZenPayroll, Inc., dba Gusto ("Gusto") to send credit entries (and appropriate debit, reversal and adjustment entries), electronically or by any other commercially accepted method, to my account and to other accounts I identify in the future on the Gusto platform (the "Account"). This authorizes the financial institution holding the Account to post all the ACH transactions authorized herein shall comply with all applicable United States Laws. This authorization will be in effect until you delete the direct deposit account information from the Gusto platform and Gusto has had a reasonable opportunity to act on this change.
Authorized Signature :
Print name :
Date :
Background Screening ($25.00)
Safety Glasses ($5.00)
Drug Screening ($10.00)
ID badge ($7.00)
Safety Vest ($10.00)
Gloves ($3.50)
I,* have been issued the equipment checked above and am notified that the related cost of will be deducted from my pay check.
Printed Name*
Associate Signature*
