sa WV IT-104

First Name *

Last Name *

Suffix

Social Security Number *

Address (Number and Street) *

Apt Number

City *

State *

ZIP *

1. If SINGLE, and you claim
an exemption, enter "1".
If you do not, enter "0"

2. If MARRIED, one exemption each for husband and wife if not claimed on another certificate.
       (a) If you claim both of these exemptions, enter "2"
       (b) If you claim one of these exemptions, enter "1"
       (c) If you claim neither of these exemptions, enter "0"

3. If you claim exemptions for one or more dependents, enter the number of such exemptions

4. Add the number of exemptions which you have claimed above and enter the total

5. If you are Single, Head of Household, or Married and your spouse does not work, and you are receiving wages from only one job, and you wish to have your tax withheld at a lower rate

check here

6. Additional withholding per pay period under agreement with employer, enter amount here

Note that special wihholding allowances provided on Federal Form W-4 may not be claimed on your West Virginia Form WV/IT-104. I CERTIFY, under penalties provided by law, that the number of exemptions claimed in this certificate is not in excess of those to which I am entitled.

Date *

Signature *

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