%PDF-1.2 %âãÏÓ 1 0 obj << /Producer (OmniForm Converter for PDF) /Creator (OmniForm) /ModDate (D:20050301111721-06'00') /CreationDate (D:20050301111721-06'00') >> endobj 2 0 obj << /Type /Catalog /Pages 3 0 R /AcroForm 40 0 R /Metadata 45 0 R >> endobj 3 0 obj << /Type /Pages /Count 1 /Kids [ 5 0 R ] /MediaBox [ 0 0 612 792 ] >> endobj 5 0 obj << /Type /Page /Parent 3 0 R /Resources << /ProcSet [ /PDF /Text /ImageB ] /Font << /F0 8 0 R /F1 11 0 R /F2 14 0 R >> /XObject 17 0 R >> /MediaBox [ 0 0 612 792 ] /Contents 6 0 R /Annots 33 0 R >> endobj 6 0 obj << /Length 7 0 R >> stream BT /F0 7 Tf 0 g 33.602 767.503 Td (FORM) Tj /F1 9 Tf 207.655 -2.877 Td (ALABAMA DEPARTMENT OF REVENUE) Tj -69.205 -13.691 Td /F1 16 Tf (Employee's Withholding Exemption Certificate) Tj /F1 18 Tf -143.252 1.196 Td (A-4) Tj /F2 6 Tf 35.759 -5.026 Td 95 Tz (REV. 1/99) Tj ET .50 w 0 G 2 J 23.76 744.959 m 600 744.959 l S BT 373.439 735.347 Td 80 Tz (SOCIAL SECURITY NO.) Tj -348.239 -0.482 Td 79 Tz (FULL NAME) Tj 492.239 -11.52 Td 80 Tz (ZIP CODE) Tj -83.999 -0.238 Td 75 Tz (STATE) Tj -132.239 0 Td 78 Tz (CITY) Tj -276 -0.24 Td 79 Tz (HOME ADDRESS) Tj ET 23.76 717.84 m 99.839 717.84 l 99.839 563.28 l 23.76 563.28 l S 99.839 717.84 m 600.239 717.84 l 600.239 563.28 m 99.839 563.28 l 99.839 717.84 l S BT /F2 7 Tf 106.319 710.623 Td 82 Tz (If you had no Alabama income tax liability last year and you anticipate no Alabama income tax liability this year, you may claim ''exempt'' from Alabama withholding tax.) Tj -0.479 -8.88 Td 83 Tz (To claim exempt status, check this block, sign and date this form and file it with your employer. Employees claiming exempt status are not required to complete Lines I through 5) Tj /F0 7 Tf -80.399 -0.24 Td 90 Tz (EMPLOYEE:) Tj ET [1] 0 d 562.32 702 m 573.338 702 l S BT /F2 6 Tf 37.202 692.864 Td 100 Tz (File this form with) Tj /F0 7 Tf 227.999 -0.24 Td (HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS) Tj /F2 6 Tf -240 -7.679 Td (your employer. Other-) Tj /F2 7 Tf 81.36 -1.443 Td 83 Tz (1. IF YOU ARE SINGLE, $1,500 personal exemption is allowed.) Tj /F2 6 Tf -81.36 -7.676 Td 100 Tz (wise, Alabama income) Tj /F2 7 Tf 90 -0.482 Td 80 Tz (\(a\) if you claim full personal exemption \($1,500\) write a lefter ''S'') Tj 0.24 -9.839 Td 81 Tz (\(b\) if you claim no personal exemption write the figure ''O'' \(Note: If you claim no personal) Tj /F2 6 Tf -90.24 1.922 Td 100 Tz (tax must be withheld) Tj 0 -8.16 Td (from your wages with-) Tj /F2 7 Tf 90.96 -3.603 Td 81 Tz (exemption on Lines 1 or 2, you cannot claim dependents on Line 3.\)) Tj ET 292.32 656.88 m 529.639 656.88 l S BT /F2 6 Tf 25.2 650.146 Td 100 Tz (out exemption.) Tj /F2 7 Tf 81.119 -2.645 Td 82 Tz (2. IF YOU ARE MARRIED or SINGLE CLAIMING HEAD OF FAMILY, $3,000 personal exemption is allowed.) Tj 9.122 -8.64 Td (\(a\) if you claim exemption for both spouses \($3,000\), write the letter V') Tj /F0 7 Tf -90 -2.639 Td 91 Tz (EMPLOYER:) Tj /F2 7 Tf 90 -6.48 Td 80 Tz (\(b\) if you are single claiming head of family \($3,000\), write the letter ''H'' \(see ''head of family'' instructions on back of this form\)) Tj 0 -8.88 Td 81 Tz (\(c\) it you claim exemption for yourself only \($1,500\) write the letter ''S'') Tj /F2 6 Tf -78.239 6.724 Td 100 Tz (Keep this certificate) Tj -12.24 -8.399 Td (with your records. If the) Tj /F2 7 Tf 90.238 -7.685 Td 78 Tz (\(d\) if you claim no personal exemption write the figure ''O'' \(see note under 1 \(b\).\)) Tj /F2 6 Tf -90.238 -0.955 Td 100 Tz (employee is believed to) Tj ET 324 611.759 m 528.140 611.759 l S BT /F2 7 Tf 106.08 602.382 Td 83 Tz (3. If during the year you will provide more than one-half of the support of persons closely related) Tj /F2 6 Tf -81.119 -0.238 Td 100 Tz (have claimed too many) Tj /F2 7 Tf 89.997 -8.643 Td 80 Tz (to you \(other than spouse\) write the number of such dependents. \(See instructions on other side.\)) Tj /F2 6 Tf -89.997 0.003 Td 100 Tz (exemptions, the Alabama) Tj ET 366.959 593.759 m 528.140 593.759 l S q 531.740 584.64 7.679 7.2 re W n 8 0 0 7 531.740 584.64 cm /im0 Do Q BT /F2 7 Tf 543.980 586.106 Td 86 Tz ($) Tj /F2 6 Tf -519.018 -1 Td 100 Tz (Department of Revenue) Tj /F2 7 Tf 81.119 -0.723 Td 83 Tz (4. Additional amount, if any, you want deducted each pay period) Tj ET 273.12 584.64 m 528.42 584.64 l S BT /F2 6 Tf 25.2 576.706 Td 100 Tz (should be so advised.) Tj /F2 7 Tf 80.88 -1.205 Td 82 Tz (THIS LINE TO BE COMPLETED BY EMPLOYER:) Tj 0 -8.878 Td (5. TOTAL EXEMPTIONS \(Example: Employee claims ''S'' on Line 2 and 'T' on line 3. Employer should use column headed S-1 in Withholding Tables.\)) Tj ET 493.679 566.88 m 526.141 566.88 l S BT 25.2 554.862 Td 94 Tz (I certify that the withholding exemptions claimed on this) Tj -0.24 -8.64 Td 96 Tz (certificate do not exceed the amount to which I am entitled ) Tj /F2 6 Tf (DATE) Tj /F1 6 Tf 281.25 2.449 Td 100 Tz (20) Tj /F2 6 Tf 35.07 -0.765 Td 80 Tz (SIGNED) Tj /F0 8 Tf -315.612 -51.891 Td 92 Tz (CHANGES IN EXEMPTIONS) Tj /F2 8 Tf 293.28 -0.479 Td (exemption from Alabama withholding tax.) Tj /F0 8 Tf 0.24 -10.559 Td 90 Tz (DEPENDENTS) Tj /F2 8 Tf -281.76 -0.24 Td 97 Tz (You may file a new certificate at any time it the number of your exemptions) Tj -11.52 -9.839 Td 89 Tz (INCREASES.) Tj 304.8 -0.72 Td 95 Tz (To qualify as your dependent \(Line 3 on other side\), a person must receive) Tj -11.76 -10.08 Td (more than 1/2 of his or her support from you for the year and must be related to) Tj -281.52 0.238 Td 92 Tz (You must file a new certificate within 1 0 days if the number of exemptions pre-) Tj 281.52 -10.08 Td 91 Tz (you as follows:) Tj -293.519 -0.238 Td 92 Tz (viously claimed by you DECREASES for any of the following reasons:) Tj 305.518 -10.32 Td 91 Tz (Your son or daughter \(including legally adopted children\), grandchild, stepson,) Tj -11.999 -9.6 Td (stepdaughter, son-in-law, or daughter-in-law;) Tj -281.04 8.88 Td 96 Tz (\(a\) Your spouse for whom you have been claiming exemption is divorced,) Tj -12.24 -9.839 Td 92 Tz (legally separated, or claims her or his own exemption on a separate certificate.) Tj 305.28 -10.32 Td 98 Tz (Your father, mother, grandparent, stepfather, stepmother, father-in-law, or) Tj -11.758 -8.16 Td 90 Tz (mother-in-law;) Tj -281.282 7.2 Td 91 Tz (\(b\) The support of a dependent for whom you claimed exemption is taken over) Tj -12.24 -9.598 Td 94 Tz (by someone else, so that you no longer expect to furnish more than half the sup-) Tj 305.28 -9.122 Td 92 Tz (Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-) Tj -305.28 -0.958 Td 90 Tz (port for the year.) Tj 293.28 -9.6 Td 91 Tz (law, or sister-in-law;) Tj -281.52 -1.199 Td 93 Tz (OTHER DECREASES in exemption, such as the death of a spouse or depen-) Tj -11.999 -10.559 Td 90 Tz (dent, do not affect your withholding until the next year, but require the filing of a new) Tj 305.28 0.717 Td (Your uncle, aunt, nephew, or niece \(but only if related by blood\).) Tj -305.52 -10.559 Td 92 Tz (certificate by December 1 of the year in which they occur.) Tj /F0 8 Tf 294 -0.24 Td 89 Tz (PENALTIES) Tj /F2 8 Tf -282.002 -10.8 Td 99 Tz (Any correspondence concerning this form should be sent to the Alabama) Tj -11.52 -9.6 Td 94 Tz (Department of Revenue, Individual and Corporate Tax Division, Withholding Tax) Tj -0.238 -9.6 Td 92 Tz (Section, P.O. Box 327480, Montgomery, AL 36132-7480 or telephone \(334\) 242-) Tj 305.759 19.202 Td 91 Tz (Penalties are imposed for willfully supplying false information or willful failure to) Tj -12.48 -10.08 Td 92 Tz (supply information which would reduce the withholding exemption.) Tj /F0 8 Tf 0.482 -10.559 Td 90 Tz (HEAD OF FAMILY) Tj /F2 8 Tf -293.04 -8.64 Td 83 Tz (1300 \(fax \(334\) 242-0112\).) Tj 305.039 -2.16 Td 95 Tz (Employers: If you are computing Alabama withholding tax using the formula) Tj -11.999 -9.119 Td 89 Tz (method and an employee claims ''H'' \(head of family\), the deduction allowed in item) Tj -0.24 -9.119 Td 94 Tz (''A'' of the formula is 20% limited to $2,000. The deduction allowed in item ''C'' for) Tj /F0 8 Tf -293.28 8.878 Td 91 Tz (EXCLUSION FROM WITHHOLDING TAX) Tj /F2 8 Tf 11.76 -11.279 Td 93 Tz (''No tax liability last year'' means that your previous year's tax return indicated) Tj 281.52 -9.36 Td 91 Tz (employees claiming ''H'' is $3,000.) Tj -293.28 0 Td (no tax liability for that taxable year. Therefore, if you had Alabama income tax with-) Tj 0 -10.32 Td 95 Tz (held or paid estimated tax, all of this tax must have been refunded to you. If any) Tj 0 -10.32 Td 98 Tz (portion of the tax paid last year was not refunded, you may not qualify for this) Tj 305.52 9.842 Td 93 Tz (If you are computing tax using the tax tables and an employee claims ''H'', the) Tj -12.48 -8.88 Td 91 Tz (''M'' column \(along with the appropriate number of dependents\) should be used.) 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