| FormW-4 (Rev. December 2020) Department of the Treasury internal Revenue Service |
Employee’s Withholding Certificate
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OMB No. 1545-0074 | ||
2021 |
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Step 1 :Enter Personal Information |
(a) First name and middle initial*: [wfirstmiddle] |
Last name* : [Lastname] |
(b) Social security number*: [Socialsecuritynumber] |
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Address * : [waddress] |
Does your name match the name on your social security card? If not,
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City or Town, State and ZIP code * : [wcitystatzip] |
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| (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.) |
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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.
Step 2 :Multiple Jobs or Spouse Works |
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) 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.)
Step 3 :
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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 …. $ [childunderage] Multiply the number of other dependents by $500 ………. $ [childdependents] Add the amounts above and enter the total here………… |
3 $ [totalamount] |
Step 4 :
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(a) Other income (not from jobs). If you want tax withheld for other income youexpect this year that won’t have withholding, enter the amount of other income here. (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) $ [Otherincome] 4(b) $ [Deductions] 4(c) $ [Extrawithholding] |
Step 5 :
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Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
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Employers
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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)
STATE OF GEORGIA EMPLOYEE’S WITH HOLING ALLOWANCE CERTIFICATE
| 1a. YOUR FULL NAME * : [YOURFULLNAME] | 1b. YOUR SOCIAL SECURITY NUMBER * : [YOURSOCIALSECURITYNUMBER] |
| 2a. HOME ADDRESS* (Number, Street, or Ruual Route) : [HOMEADDRESS] | 2b. CITY, STATE AND ZIP CODE * : [CITYSTATEANDZIPCODE] |
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING LINES 3 – 8
| 3. MARITAL STATUS
(If you do not wish to claim an allowance, enter “0” in the brackets beside your marital status.) |
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| A. Single *: Enter 0 or 1 …………………….[ [single] ] | 5. ADDITIONAL ALLOWANCES * : [ [ADDITIONALALLOWANCES] ] (worksheet below must be completed) |
| B. Married Filing Joint both spouses working * : Enter 0 or 1 ………….[ [MarriedFilingJointbothspousesworking] ] | |
| C. Married Filing Joint, one spouse working * : Enter 0 or 1 ………….[ [MarriedFilingJointonespouseworking] ] | |
| D. Married Filing Joint, Separate * : Enter 0 or 1 ……………. [ [MarriedFilingJointSeparate] ] |
6. ADDITIONAL WITHHOLDINGS *
$ [ADDITIONALWITHHOLDINGS] |
| E. Head of Household * : Enter 0 or 1 ………… [ [HeadofHousehold] ] | |
WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES(Must be completed in order to enter an amount on step 5) |
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| 2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS : | ||
| $ | ||
| B . Georgia Standard Deduction (enter one) Each Spouse |
Single/Head of Household $4,600
$3000 |
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| $ | ||
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$
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$
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$
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$
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$
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| (this is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up) | ||
| [LETTERUSED]
(Employer: The letter indicates the tax tables in Employer’s Tax Guide) |
[TOTALALLOWANCES] |
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 [stateresidence]. My spouse’s (service member) state of residence is [spouseresidence] 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.
| [secEmployeessignature] | [purjuryemdate] |
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
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.
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Employment Eligibility Verification
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USCIS
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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.) | ||||
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[solastname] |
[sofirstname] |
[somiddleinitial] |
[solastnameother] |
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[soaddress] |
[soaptnumber] |
[socitytown] |
[sostate] |
[sozipcode] |
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[DateofBirth] |
[ussocialSecurityNumber] |
[soememail] |
[soemtelnumber] |
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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):
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[AcitizenoftheUnitedStates] |
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[AnoncityzennationaloftheUnitedStatesSeeinstructions] |
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[Alawfulpermanentresident] |
[AlienRegistrationNumberUSCISNumber] | |
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[Analienauthorizedtowork] |
[untilexpirationdateifapplicable] | 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. | ||
| [AlienRegistrationNumber] | ||
| [FormI-9AdmissionNumber] | ||
| [ForeignPassportNumber] | ||
| [Countryofissuance] | ||
| [SignatureofEmployee] | [TodaysDate] | |
Preparer and/or Translator Certification (check one): |
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I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1 |
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| (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.
| : [signSignatureofPreparerorTranslator] | Today’s Date (mm/dd/yyyy)* : [preparersigndate] | ||
| Last Name (Family Name) | First Name (Given Name) | ||
| Address (Street Number and Name) | City or Town | State | Zip Code |
Employer Completes Next Page
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Employment Eligibility Verification
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USCIS
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Section 2. Employer or Authorized Representative Review and Verification(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.) |
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| Employee Info from Section 1 | Last Name (Family Name)* : [eminlastname] | First Name (Given Name)* : [eminfirstname] | M.I* : [eminmiddleinitial] | Citizenship/Immigration Status |
| OR | List B Identity |
AND : [AND] | List C Amployment Authorization |
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Document Title |
Document Title |
Document Title |
| Issuing Authority | Issuing Authority | Issuing Authority |
| Document Number | Document Number | Document Number |
| Expiration Date (if any) (mm/dd/yyyy) | Expiration Date (if any) (mm/dd/yyyy) | Expiration Date (if any) (mm/dd/yyyy) |
| Document Title |
Additional Information
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QR Code – Section 2 & 3 Do Not Write In This Space; |
| Issuing Authority | ||
| Document Number | ||
| Expiration Date (if any) (mm/dd/yyyy) | ||
| Document Title | ||
| Issuing Authority | ||
| Document Number | ||
| Expiration Date (if any) (mm/dd/yyyy) |
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.
| Signature of Employer or Authorized Representative
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Today’s Date (mm/dd/yyyy)
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Title of Employer or Authorized Representative
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| Last Name of Employer or Authorized Representative
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First Name of Employer or Authorized Representative
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Employer’s Business or Organization Name
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Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) |
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| A. New Name (if applicable) | B. Date of Rehire (if applicable) | ||
| Last Name (Family Name)
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First Name (Given Name)
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Middle Initial
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Date (mm/dd/yyyy)
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| 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. | ||
| Document Title
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Document Title
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Expiration Date (if any) (mm/dd/yyyy)
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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.
| Signature of Employer or Authorized Representative
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Today’s Date (mm/dd/yyyy)
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Name of Employer or Authorized Representative
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Direct Deposit Authorization |
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Instructions
This document must be signed by the employee requesting automatic deposit of paychecks and will be retained by Gusto.
Authorization
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 : [inausign] | |
| [Printname] | Date : [inaudate] |
Screening Fees & Equipment Acknowledgement
| [BackgroundScreening] | [SafetyGlasses] | |
| [DrugScreening] | [IDbadge] | |
| [SafetyVest] | [Gloves] | |
| I,* [eqknowledge] have been issued the equipment checked above and am notified that the related cost of will be deducted from my pay check. | ||
| Printed Name* : [eqprintedname] | Associate Signature* : [AssociateSignature] | Date* : [eqdate] |