Exemption From Withholding

Form W-4E (of Federal Income Tax)

For use by workers who incurred no tax liability for the
2004
preceding year and anticipate no tax liability for the current year
Type or print Full Name Social security number (optional)

Mailing address

City, State (do not abbreviate), U.S. postal ZIP code (optional) I want to cancel my claim of exempt status
for income taxes.

Worker.—File this certificate with the hiring Worker’s certification.—I certify that I incurred no liability for Federal
entity. Otherwise, the entity may withhold income tax for the preceding year and that I anticipate that I will
income tax from your earnings. incur no liability for Federal income tax for the current year.

Hiring Entity.—Keep this certificate with your

records. Workers qualified to claim the
(Signature)
exemption may use this certificate instead of
Form W-4.
(Date)

Instructions
Who May Claim Exemption from Withholding of Taxes.—You may be
entitled to claim exemption from withholding and deducting of Federal
income taxes from pay when you incurred no liability for income tax for
the preceding year and you anticipate that you will incur no liability for
income tax for the current year. When you claim this exemption, the
hiring entity will not withhold Federal income tax nor deduct social
security tax imposed by the Federal Insurance Contributions Act from
your pay.
When You Must Revoke this Exemption.—You must revoke this
exemption certificate: (1) within 10 days from the day you anticipate
you will incur Federal income tax liability for this year or (2) on or
before December 1, when you anticipate you will incur Federal
income tax liability for the next year.
When you want to discontinue or revoke this exemption, you must
file a new Form W-4E with the entity indicating the cancellation.

When to Claim Exemption.—File this certificate with the hiring entity Liability for Estimated Tax.—When you instruct the entity to not
as soon as you determine you are entitled to claim the exemption. You withhold income tax or deduct social security tax from your pay and
must file a certificate each year when you wish to continue to claim the you incur Federal income tax liability, you may be required to pay
exemption. estimated tax and be subject to the penalty if it is not paid.

Multiple Entities.—When you work for more than one entity, you may
claim the exemption from withholding with each entity, provided that
the total of your anticipated pay will not cause you to incur any liability
for Federal income tax for the current year and you incurred no liability
for Federal income tax for the preceding year.
Expiration Date of Exemption.—This certificate will expire April 30.
When you still qualify for exempt status next year, complete and file a
new Form W-4E by that date.
Federal Statutory Law.—This form fulfills the requirements of
26 § USC 3402(n). To claim exemption from withholding and
deducting of taxes, Form W-4E is the correct form to use for that
purpose and not IRS Form W-4.
This form is legal and is appropriate for any hiring entity that may
be subject to 26 USC Subtitle C taxes.

Form W-4E 2004