Indiana WH4

Enter Personal Information

Last Name:

First Name:

Middle Initial:

Social Security Number:

Address:

City:

State:

Zip Code:

Indiana County of Residence as of January 1:

Indiana County of Principal Employment as of January 1:

You are entitled to one exemption. Check the box to claim it.

If you are married and your spouse does not claim his/her exemption, Check the box to claim it.

You are allowed one (1) exemption for each dependent. Enter number claimed.

I am 65 or older.
I am legally blind.
My spouse is 65 or older.
My spouse is legally blind.

Here are the maximum personal allowances that you may choose to claim:

You are entitled to claim an additional exemption for each qualifying dependent. An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a son, stepson, daughter, stepdaughter, foster child, and/or child for whom you are a legal guardian.

Enter the amount of additional state withholding (if any) you want withheld each pay period:

Enter the amount of additional county withholding (if any) you want withheld each pay period:

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