NC-4
Web 12-09

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