Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Step 1: Marital Status

Please select one.

Single or Married Filing Separately

Married Filing Jointly or Qualifying Widow(er)

Head of Household

Step 2: Multiple Jobs

Did you place a checkmark on Item (c)?

Yes

Georgia G-4 Line 3 Marital Status

Check only the status you are wishing to claim. Make a note of the number of allowances you are claiming as you will enter it in section 7 below).

SELECT ONE

A. Single (Enter 0 or 1)

B. Married Filing Joint, both spouses working (Enter 0 or 1)

C. Married Filing Joint, one spouse working (Enter 0 or 1 or 2)

D. Married Filing Separate (Enter 0 or 1)

E. Head of Household (Enter 0 or 1)

Georgia G-4 Line 8 Exempt

If you are claiming an exemption, you MUST complete a printed copy of this form and provide it to your manager.

a) I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year.

b) I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act as provided on page 2.

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