Part 86, page 69

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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