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W-4

Please review and answer the following questions regarding completion of Form W-4.

First Name

Last Name

Please enter email provided on original application.

2. Social Security Number

3. Filing Status

Note. If married, but legally separated, or spouse is a nonresident alien, select "Single".

4. Last Name Differs:

If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5. Allowances

Total number of allowances you are claiming (use line H on Form W-4 or applicable worksheet from Form W-4)

6. Additional Amount

Additional Amount, if any, you want withheld from each paycheck.

7. Exemption

I claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption. 1. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and 2. This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions write "Exempt" here.

Signature

I have reviewed the W-4 attached and I have answered all questions for the Employee's Withholding Allowance Certificate

State Withholding

GA-4

Georgia Employee's Withholding Allowance Certificate: Please review and answer the following questions regarding completion of the Form GA-4.

4. Dependent Allowances

5. Additional Allowances

(worksheet on Certificate must be completed and sent to CFAIA office)

6. Additional Withholding $

Additional amount, if any, you want withheld from each pay period (Enter whole dollars)

7. Letter Used

Marital Status A, B, C, D, or E

Total Allowances

Total of Lines 3-5

8. EXEMPT

a). I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year.

b). I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act as provided on Page 2. The status of residence must be the same to be exempt.

Do not complete lines 3-7 if claiming exempt. Read the Line 8 Instructions on Page 2 of the Certificate before completing this section.

8. b. My state of residence

8. b. My spouse's (Servicemember) State of residence

If Exempt status is checked because you meet the requirement of the Military Spouses Residency Relief Act, please Enter Your State of Residence

Certification

I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status claimed. I authorize my employer to deduct per pay period the additional amount listed above.

Direct Deposit

Yes

Would you like for us to directly deposit your paycheck into your bank account?

Bank Name

Please enter Your Bank Name

Direct Deposit Routing

If yes, please enter the Routing Number for your bank account.

Direct Deposit Account

If yes, please enter the Account Number for your bank account.

Direct Deposit Type

Checking

Savings

If yes, please choose type of account.

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Apply to Payroll Information - Georgia