Virginia Employee's Withholding Exemption Certificate (Form VA-4) with instructions
Title revised to match the document’s own text.
Original title: Virginia Employee's Withholding Exemption Certificate (Form VA-4) for Jack Coffelt with instructions
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Id: Cooper-Part-86:034-035
Subject: Cooper Files: Cooper-Part-86:034-035 Document: Virginia Employee's Withholding Exemption Certificate (Form VA-4) with instructions Id: Cooper-Part-86:034-035 Page: https://cooper.theunsolved.net/documents/Cooper-Part-86%3A034-035 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
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FBI 164-81, Vault Part 86 pp. 34–35 (DB Cooper-37878–37879), Form — cooper.theunsolved.net/documents/Cooper-Part-86%3A034-035
Form VA.—4 (Rev. 1-1-72) Department of Taxation
VIRGINIA EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE
Print full name: [guess: Collett] [guess: J. K.] [guess: Bryant] ............Social [guess: Security] No. 573-46-2490 Print home address: [guess: 1209] [guess: 3] [guess: 1300] [guess: W] City: [guess: Christiansburg] .........State: [guess: VA] ........ZIP Code: [guess: 22064]
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EMPLOYEE: File this exemption certificate with your employer.
EMPLOYER: Keep exemption certificates with your records. Certificates may be on this form, or a similar form. If the employee is believed to have claimed too many exemptions, notify the Virginia Department of Taxation.
HOW TO CLAIM WITHHOLDING EXEMPTIONS
1. If SINGLE, and you claim an exemption, write the figure "1" . . . . . . . . . . . . 0 2. If MARRIED, one exemption each for husband and wife if not claimed on another certificate. (a) If you claim both of these exemptions, write the figure "2" (b) If you claim one of these exemptions, write the figure "1" (c) If you claim neither of these exemptions, write "0" 3. Exemptions for age and blindness (applicable only to you and your wife but not to dependents): (a) If you or your wife will be 65 years of age or older at the end of the year, and you claim this exemption, write the figure "1"; if both [guess: are] 65 or older; and you claim both of these exemptions, write the figure "2" (b) If you or your wife are blind, and you claim this exemption, write the figure "1"; if both are blind, and you claim both of these exemptions, write the figure "2" 4. If you claim exemptions for one or more dependents, write the number of such exemptions . . . 5. Add the number of exemptions which you have claimed above and write the total . . . . . . 6. Additional withholding per pay period under agreement with employer . . . . . . . . $........
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I CERTIFY that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. (Date): [guess: Aug 9] ............, 19[illegible] (Signed): [guess: Collett] [illegible signature]
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DB Cooper-37878
A. IF YOU FAIL to file this certifi[cate] with your employer, he must withhold Virginia income tax [from] your wages without exemption. If an employer believes that an employee is claim- ing an excessive number of exemptions, he will advise the Department of Taxation.
B. NUMBER OF EXEMPTIONS.—Do not claim more than the correct number of exemptions. However, if you expect to owe more income tax for the taxable year than will be withheld if you claim every exemption to which you are entitled, you may increase the withholding by claiming a smaller number of ex- emptions or you may enter into an agreement with your em- ployer to have additional amounts withheld.
C. EMPLOYEES WITH TWO OR MORE EMPLOYERS.—If you have more than one employer and wish to increase your with- holding to an amount nearer your correct income tax you should claim a smaller number or no exemptions on each Form Va.—4 filed with all employers other than your principal employer.
D. CHANGES IN EXEMPTIONS.—You may file a new certifi- cate at any time if the number of your exemptions INCREASES. You must file a new certificate within 10 days if the number of exemptions previously claimed by you DECREASES for any of the following reasons:
(1) Your wife (or husband) for whom you have been claiming exemp- tion is divorced or legally separated, or claims her (or his) own exemp- tion on a separate certificate.
(2) The support of a dependent for whom you claimed exemption is
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taken over by someone so that you no longer expect to furnish more than half the support [for the] [tax] year.
(3) You find that a dependent for whom you claimed exemption will receive $600 or more of income of his own during the taxable year.
OTHER DECREASES in exemption, such as the death of a wife or a dependent, do not affect your withholding until the next year, but require the filing of a new certificate by December 1 of the year in which they occur.
E. DEPENDENTS.—Do not claim any dependent in Line 4 (on other side) unless he or she meets all four of the follow- ing tests: (1) He or she is receiving over one-half of his or her support from you for the taxable year, and (2) he or she is "closely related" to you, and (3) he or she will not have as much as $600 gross income of his or her own during the taxable year (if a son, daughter, stepson, or stepdaughter is a full time student at an educational institution, this limitation does not apply), and (4) if married, her or his exemption is not claimed by her husband or his wife. "Closely related" means your children (including stepchildren and legally adopted children) and grandchildren; your parents and grandparents; your brothers and sisters; your immediate "in-laws" (mother-, father-, son-, daughter-, brother-, sister-in-law); your blood related uncles, aunts, nieces, and nephews.
F. PENALTIES.—Penalties are imposed for willfully supplying false information or willful failure to supply information which would reduce the withholding exemption.
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DB Cooper-37879
Serials: 37879