Federal W-4 and Virginia VA-4 withholding exemption certificates for Jack Coffelt

FORM W-4 (Rev. Jan. 1967) U.S. Treasury Department Internal Revenue Service Type or print full name: JACK COFFELT Home address: 4206 - 80, 12 th Rd. City: ARLINGTON State: Va. ZIP code: 22204

EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE Social Security Number: 513-26-7480

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If SINGLE (or if married and wish withholding as single person), write "1." If you claim no exemptions, write "0". . . O 2. If MARRIED, one exemption each is allowable for husband and wife if not claimed on another certificate. (a) If you claim both of these exemptions, write "2"; (b) If you claim one of these exemptions, write "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 "1"; If both will be 65 or older, and you claim both of these exemptions, write "2" (b) If you or your wife are blind, and you claim this exemption, write "1"; if both are blind, and you claim both of these exemptions, write "2" . . . 4. If you claim exemptions for one or more dependents, write the number of such exemptions. (Do not claim exemption for a dependent unless you are qualified under Instruction 4 on other side.). . . 5. If you claim additional withholding allowances for itemized deductions fill out and attach Schedule A (Form W-4), and enter the number of allowances claimed (if claimed file new Form W-4 each year) . . . 6. Add the exemptions and allowances (if any) which you have claimed above and write total . . . . . . . . . 0 7. Additional withholding per pay period under agreement with employer. (See Instruction 1.) . . . . . . $

I CERTIFY that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. (Date) [illegible] /3 , 19 7/ (Signed) Jack [illegible] Coffelt

o15-16-70051-1

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Form VA-4 (Rev. 1-1-68) Department of Taxation

VIRGINIA EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE

EMPLOYEE: File this form with your employer.

Print full name: JACK COFFELT al Security count Number: 5/3-26-7480 Print home address in full detail: 4208 86 12 th Rd. Arli[illegible]Gton, Va.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If you are neither 65 nor blind, enter $1,000 for yourself; if either 65 or blind, enter $1,600; if both 65 and blind, enter $2,200 .................................................. $ O 2. If you are married and your wife (or husband) has no gross income, or if you and your wife (or husband) intend to file a joint return, and if your wife (or husband) is neither 65 nor blind, enter $1,000 for her (or him); if either 65 or blind, enter $1,600; if both 65 and blind, enter $2,200. If your wife (or husband) has in- come subject to Virginia income tax withholding and claims own exemption on own withholding exemption certificate, do not make any entry here............................................ $ 3. If for the year you will provide more than one-half of the support of a dependent relative (see Instruction 5 on back), enter the number here ____, multiply the number by $300, and enter result here ..................... $ 4. If you are an UNMARRIED person, and among the dependents claimed in Line 3 above, there is your father, mother, son, daughter, sister or brother, enter here $700 for only one such dependent............................ $ 5. Add the amounts of exemptions which you have claimed above and enter the total here.......................... $ O

I CERTIFY that the amount of withholding exemptions claimed on this certificate does not exceed the amount to which I am entitled. (Date) [illegible] /3................, 19 7/ (Signed) Jack Coffelt

1. NUMBER OF EXEMPTIONS.—Do not claim more than the correct number of exemptions. However, if I expect to owe more income tax than will be withheld, a smaller [number] of exemptions may be claimed or you may enter into an agreement with your employer to have additional amounts withheld. Note this if you have more than one employer, or if both husband and wife are employed.

2. ITEMIZED DEDUCTIONS.—See Schedule A (Form W-4) for instructions on claiming additional allowances based on large itemized deductions.

3. CHANGES IN EXEMPTIONS.—You may file a new certificate 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 because: (a) Your wife (or husband) for whom you have been claiming exemption is divorced or legally separated, or claims her (or his) own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is taken over by someone else, so that you no longer expect to furnish more than half the support for the year. (c) You find that a dependent for whom you claimed exemption will receive $600 or more of income of his own during the year (except your child who is a student or who is under 19 years of age).

The death of a wife or a dependent, does not affect your withholding until the next year, but requires the filing of a new certificate. If pos-

sible, file a new certificate by December 1 of the year in which the death occurs.

For further information [co]nsult your local District Director of Internal Revenue or your employer.

4. DEPENDENTS.—To qualify as your dependent (line 4 on other side), a person (a) must receive more than one-half of his or her support from you for the year, and (b) must have less than $600 gross income during the year (except your child who is a student or who is under 19 years of age), and (c) must not be claimed as an exemption by such person's husband or wife, and (d) must be a citizen or resident of the United States or a resident of Canada, Mexico, the Republic of Panama or the Canal Zone (this does not apply to an alien child legally adopted by and living with a United States citizen abroad), and (e) must (1) have your home as his principal residence and be a member of your household for the entire year, or (2) be related to you as follows: Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son-in-law, or daughter-in-law; Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law; Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law, or sister-in-law; Your uncle, aunt, nephew, or niece (but only if related by blood).

5. PENALTIES.—Penalties are imposed for willfully supplying false information or willful failure to supply information which would reduce the withholding exemptions.

U.S. GOVERNMENT PRINTING OFFICE o46—16—70061-1

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1. IF YOU FAIL to file this certificate with your employer, he must withhold Virginia income tax from your wages without exemption. If an employer believes that an employee is claiming an excessive amount of exemptions, [he] will advise the Department of Taxation.

2. AMOUNT OF EXEMPTIONS.—Do not claim more than the correct amount 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 amount of exemptions or you may enter into an agreement with your employer to have additional amounts withheld.

3. EMPLOYEES WITH TWO OR MORE EMPLOYERS.—If you have more than one employer and wish to increase your withholding to an amount nearer your correct income tax you should claim a smaller amount or no exemptions on each Form Va.—4 filed with all employers other than your principal employer.

4. CHANGES IN EXEMPTIONS.—You may file a new certificate at any time if the amount of your exemptions INCREASES. You must file a new certificate within 10 days if the amount of exemptions previously claimed by you DECREASES for any of the following reasons: (a) Your wife (or husband) for whom you have been claiming exemption is divorced or legally separated, or claims her (or his) own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is

taken over by someone else, so that you no longer expect to furnish more than half the support for the year. 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.

5. DEPENDENTS.—Do not claim any dependent in Line 3 (on other side) unless he or she meets all four of the following tests: (a) He or she is receiving over one-half of his or her support from you for the taxable year, and (b) he or she is "closely related" to you, and (c) 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 (d) 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.

If you are a married person, do not make any entry whatsoever in Line 4 (on other side).

6. PENALTIES.—Penalties are imposed for willfully supplying false information or willful failure to supply information which would reduce the withholding exemption.

EMPLOYER.—KEEP THIS CERTIFICATE WITH YOUR RECORDS.

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DB Cooper-37914