sa MD MW507

First Name *

MI

Last Name *

Suffix

Social Security Number *

Address (Number and Street) *

Apt Number

County of residence *

City *

State *

ZIP *

Link to MD MW507 (for instructions and reference only)

Filing Status *

Single

Married (surviving spouse or unmarried Head of Household Rate

Married, but withhold at Single rate

1. Total number of exemptions you are claiming not to exceed line f in Personal Exemption Worksheet (link provided above).

2. Additional withholding per pay period under agreement with employer.

3. I claim exemption from withholding because I do not expect to owe Maryland tax. See instructions above and check boxes that apply.

a. Last year I did not owe any Maryland income tax and had a right to a full refund of all income tax withheld and

b. This year I do not expect to owe any Maryland income tax and expect to have the right to a full refund of all income tax withheld. (This includes seasonal and student employees whose annual income will be below the minimum filing requirements).

c. Both a. and b.

Enter year applicable (year effective) *

Enter "EXEMPT" here *

4. I claim exemption from withholding because I am domiciled in one of the following states. Check state that applies.

District of Columbia

Virginia

West Virginia

I further certify that I do not maintain a place of abode in Maryland as described in the instructions above. Enter “EXEMPT” here.

5. I claim exemption from Maryland state withholding because I am domiciled in the Commonwealth of Pennsylvania and I do not maintain a place of abode in Maryland as described in the instructions on Form MW507. Enter “EXEMPT” here.

6. I claim exemption from Maryland local tax because I live in a local Pennysylvania jurisdiction within York or Adams counties. Enter “EXEMPT” here.

7. I claim exemption from Maryland local tax because I live in a local Pennsylvania jurisdiction that does not impose an earnings or income tax on Maryland residents. Enter “EXEMPT” here.

8. . I certify that I am a legal resident of another state and am not subject to Maryland withholding because l meet the requirements set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Enter “EXEMPT” here.

Other state *

Under the penalty of perjury, I further certify that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption from withholding, that I am entitled to claim the exempt status on whichever line(s) I completed.

Employee's signature *

clear

Date *