sa VA-4

FORM VA-4 EMPLOYEE'S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE

Your Social Security Number *

First Name *

M.I.

Last Name *

Suffix

Address (Number and Street) *

Apt Number

City *

State *

ZIP Code *

Link to VA-4 for instructions and worksheet (for reference only)

COMPLETE THE APPLICABLE LINES BELOW

1. If subject to withholding, enter the number of exemptions claimed on:

(a) Subtotal of Personal Exemptions - line 4 of the Personal Exemption Worksheet.

(b) Subtotal of Exemptions for Age and Blindness line 7 of the Personal Exemption Worksheet

(c) Total Exemptions - line 8 of the Personal Exemption Worksheet

2. Enter the amount of additional withholding requested (see instructions)

3. I certify that I am not subject to Virginia withholding. l meet the conditions set forth in the instructions

Check here

4. I certify that I am not subject to Virginia withholding. l meet the conditions set forth Under the Service member Civil Relief Act, as amended by the Military Spouses Residency Relief Act

Check here

Signature *

clear

Date *