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Deparment of the Treasurp—interna] Revanus Bervice Employeo’s Withholding Exemption Certificate : rom Wel {Rev, Cee, 1971) Typa-or print fult nano Tomes address act and st streat or ru Ty — ot town, State and 2IP code . lt yyy Cig aye _L Veteley, oe ae Mazltat status-—check one (if marriod but logatly separated, of spouse 1s a nonresident allen, check Single’): Single (] Martiod H you cxpect to owe tore tax than wil! be withheld, you moy either claim fewer or zero exemptions of ask tor additional wit molding on tine 8. Py 1 Fezsonal exemption for yourself, Vila “Lib claimed 6 6 2 we ee kk rs Pee 4 2 It nsartied, personal exemption for your wifo (ar husband} If not separately clalmed by her (or him). Wilto “PR Ut claimed 2. rs er fi 3 Speetal withholding allowance.’ (Seo instruction 2.) Write "L" if calmed 2... Lo. Ly eee \ rs ren 4 fCxomptlons for ogo and biindness (opplicadic onty to you and your wife but not to dependents): ar {a} Hf you or your wife will bo G5 yoars of ogo or older at tha end of the year, and you claim 720 b& wilta “2: gADBR will $6 65 of older, and you elatm doth of these exemptions, write "2". 0. 1. 1k ke Oakey rs Peres . an . {5} Hf you or your wifa ava Blind and you claim thls exemplion, write “2; if both are 9% end a exe hos, wilte “g" rr rer , 3 Exemptions for dependants. (00 noi claim an exemption for a dependent unlasa you at ac ree UE - 688 feeeesence G Additlonal withholding stlowsncos for ltemizod deductions. See tebla on reverso. . ase or . 7 Add the exemptions and stlowances (if any) which you have claimed above and enter total. 2. . eeu a Cc ; ’ B_Additicasl withholding per pay parlod under ogroomont with employee. . . a re . @ Vader ihe ponsities of perjury, t cartity that tho sonter of withhaiding War and allowances clalmed of Ihis cortilsts doom nol exceed tha gumdse ts waich | ess eatitied, - (Date) leaped wanes wa Pena lid lin bem LAL alii tae ree eT terete rt teers er eter ee eee ry Peer ery