NCDOR
NC-4EZ
Filing Status
Single or Married Filing Separately
Head of Household
Married Filing Jointly or Surviving Spouse
Social Security Number
First Name
M.I.
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For Instructions - Please review the NCDOR NC-4EZ form linked on the Town of Burgaw Website.
1. Total number of allowances you are claiming (Enter zero (0). or the number of allowances from the table)
2. Additional amount, if any, you want withheld from each pay period (Enter whole dollars)
4. I certify that I am exempt from North Carolina withholding because I meet both of the following: (1) Last year I was entitled to a refund of all State income tax withheld because I had no tax liability, AND (2) This year, I expect a refund of all State income tax withheld because I expect to have no tax liability
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5. I certify that I am exempt from North Carolina withholding because I meet the requirements set forth in the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act and Veterans Benefits and Transition Act.
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If an exemption on Line 3 or Line 4 applies to you, enter the year the exemption became effective.
CAUTION: If you furnish an employer with an Employee's Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a penalty of 50% of the amount not properly withheld.
I certify, under penalties provided by law, that I am entitled to the number of withholding allowances claimed on Line 1 above, or if claiming exemption from withholding, that I am entitled to claim the exempt status on Line 3 or 4, whichever applies.
Employee's Signature
Date
/
Month
/
Day
Year
Date
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