NC-4
Web 10-12

North Carolina Department of Revenue
Marital Status

Employee’s Withholding Allowance Certificate

Social Security Number

Single
First Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) M.I. Last Name

Head of Household

Married or Qualifying Widow(er)

Address

County (Enter first five letters)

City

State

Zip Code (5 Digit)

Country (If not U.S.)

(See Form NC-4 Instructions before completing this form)
1. Total number of allowances you are claiming (From Line F of the Personal Allowances Worksheet on Page 2) 2. Additional amount, if any, you want withheld from each pay period (Enter whole dollars)

,

.00
Check Here Check Here

3. I certify that I am not subject to North Carolina withholding because I meet the following two conditions: • Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and • This year I expect a refund of all State income tax withheld because I expect to have no tax liability. 4. I certify that I am not subject to North Carolina withholding because I meet the requirements of the Military Spouses Residency Relief Act and I am legally domiciled in the state of ____________________________________________. (Enter state of domicile) If line 3 or line 4 above applies to you, enter the year effective

20

and write “EXEMPT” here

5. I certify that I no longer meet the requirements for exemption on line 3 or line 4 (Check applicable box) Therefore, I revoke my exemption and request that my employer withhold North Carolina income tax Check Here based on the number of allowances entered on line 1 and any amount entered on line 2.

CAUTION: If you furnish an employer with an Employee’s Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a penalty of 50% of the amount not properly withheld.

Employee’s Signature

I certify, under penalties provided by law, 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 line 3 or 4, whichever applies.

Date

(Employer: Complete below only if sending to the North Carolina Department of Revenue. Submit the original and keep a copy for your records.)
Employer’s Name
(USE CAPITAL LETTERS)

FEIN

Employer’s Address

County (Enter first five letters)

City

State

Zip Code (5 Digit)

Country (If not U.S.)

Page 2
NC-4 Web 10-12

Your Last Name (First 10 Characters)

Your Social Security Number

Personal Allowances Worksheet
A. Enter “1” for yourself if no one else can claim you as a dependent ..................................................... A. IN ADDITION TO A. ABOVE: Enter “1” if you are married and you expect your spouse’s wages to be from $1,000 to $3,500. Enter “2” if you are married and your spouse has no income or expects to earn less than $1,000 ..... B. C. Enter “1” if you are a qualifying widow(er). ........................................................................................... C. D. Enter the number of dependents (other than your spouse or yourself) you will claim on your tax return ...................................................................................................................................... D. E. F. If you plan to itemize, claim adjustments to income, or have allowable tax credits and want to reduce your withholding, complete the Deductions, Adjustments, and Tax Credits Worksheet below and enter number from line 14 ................................................................................................... E. Add lines A through E and enter total here and on line 1 of your Employee’s Withholding Allowance Certificate