Part 86, page 34

Transcript

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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