DIY Legal Forms

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Withholding Tax Information

Employee:

Address:

Position:

Supervisor:

Date Hired:

Payroll Date:

Taxation Identification Number:

Number of Dependents:

Number of Excemptions:

Spouse's Taxation Identification. Number:

Exemptions from Federal/State taxes:

[Attach Certificates of Exemption]

The number of dependents claimed is accurate and I shall notify the personnel department of any change in dependents.

Date:

Signature

Name of Employee

Change in Number of Dependents

Employee

Date

Dependents [List All Dependents].

Have each dependent initial beside their name [If at all Possible].

*** If Required By State Law ***

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [Date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

[Signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)