Department of the Treasury · Internal Revenue Service
OMB No. 1545-0074Tax Year 2019
1
Employee Info
2
Personal Allowances
3
Deductions Worksheet
4
Withholding Summary
5
Signature & Certify
👤 Employee Personal
Information
Required
Required
Required (XXX-XX-XXXX)
Required
Required
Required
Required
📝 Filing Status
(Box 3 — check one)
Single
Married
Married, but withhold at higher
Single rate
Note: If married filing separately, check "Married,
but withhold at higher Single rate."
✓
Box 4: If your last name differs from that shown
on your Social Security card, check here. You must call
800-772-1213 for a replacement card. ▶
📊 Personal Allowances
Worksheet
Keep this worksheet for your records. Use it to determine your total
withholding allowances.
A
Personal allowance — Enter "1" for yourself.
B
Married filing jointly — Enter "1" if you will
file as married filing jointly.
C
Head of household — Enter "1" if you will file as
head of household.
D
Single/sole-job allowance — Enter "1" if you're
single or married with only one job, or your spouse doesn't work.
E
Child tax credit
Select your income tier and number of eligible children.
F
Credit for other dependents
Enter based on your income tier and dependent count.
G
Other credits — Enter the amount from Worksheet
1-6 if applicable.
H
Total allowances — Add lines A through G and
enter the total here.
Line H Total — Your Withholding Allowances This number goes on Form W-4, Line 5
1
📋 Deductions, Adjustments
& Additional Income Worksheet
📌
Use this worksheet only if you plan to itemize
deductions, claim certain adjustments to income, or have
significant nonwage income. Otherwise, skip this step.
✓
Skip this worksheet — I don't itemize deductions
or have significant nonwage income
1
Estimated itemized deductions.
2
Standard deduction.
3
Subtract line 2 from line 1.
4
Adjustments to income.
5
Add lines 3 and 4.
6
Estimated nonwage income.
7
Subtract line 6 from line 5.
8
Divide line 7 by $4,200.
9
Enter line H from the Personal Allowances Worksheet.
10
Add lines 8 and 9.
📄 Form W-4 — Withholding
Summary
5
Total number of allowances you're claiming From the applicable worksheet
1
6
Additional amount withheld from each paycheck Enter a flat dollar amount (optional)
7
Exemption from withholding I claim
exemption from withholding for 2019 if I meet both conditions
below.
✓
Check if exempt. Write "Exempt" on your form if you meet both
conditions.
⚠️ If you claim exempt:
complete ONLY lines 1, 2, 3, 4, and 7 and sign
the form.
⚖️ Employee Certification
Under penalties of perjury, I declare that I have examined this
certificate and, to the best of my knowledge and belief, it is true,
correct, and complete.
This form is not valid unless you sign it.
Employee Signature *
✍️ Sign here with mouse or touch
Required
✅
Form W-4 Submitted
Your Employee's Withholding Allowance Certificate has been
completed. Print a copy and give it to your employer. Keep the
worksheets for your records.