STATE OF FLORIDA

OFFICE OF THE COMPTROLLER

BUREAU OF STATE PAYROLLS	W-4	EMPLOYEE:

PLEASE COMPETE

UNSHADED AREAS ONLY
SOC. SEC. NUM. (9)	FIRST NAME (14)	M.I. (1)	LAST NAME (16)
ADDRESS (30)	CITY (15)	STATE (2) ZIP CODE (5 or 9)	OR FOREIGN COUNTRY (13)

BIRTH DATE	RACE

CODE

(SEE

BELOW)	SEX

(M=MALE)

(F=FEMALE)
MARITAL STATUS

(S=SINGLE)

(M=MARRIED)

(X=MARRIED CLAIMING SINGLE)	NUMBER OF W/H

ALLOW.

(2)	ADDITIONAL

AMOUNT

WHOLE DOLLARS	FOR AGENCY USE ONLY
ORGANIZATION
MM	DD	YYYY
OLO

(4)	L2

(2)	L3

(2)
.00
EXEMPTION FROM WITHHOLDING MAY BE CLAIMED ONLY IF:

Last year you had a right to a refund of ALL Federal income tax withheld because you had NO tax liability; AND

This year you expect a refund of ALL Federal income tax withheld because you expect to have NO tax liability.;

If you meet both of the above conditions enter year effective and "EXEMPT".

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RACE	1 = WHITE (NOT HISPANIC)	2 = BLACK (NOT HISPANIC)

CODES	3 = HISPANIC	4 = ASIAN OR PACIFIC	5 = AMERICAN INDIAN OR	ISLANDER

ALASKAN NATIVE	8 = OTHER

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If your last name differs from that on your social security card, check here and call

1-800-772-1213 for more information…………………………………………
I claim exemption from withholding and I certify that I meet ALL of the conditions for exemption:	EFFECTIVE

YEAR	"EXEMPT"	FOR COMPTROLLER USE ONLY
<================>
<================>
UNDER PENALTIES OF PERJURY, I CERTIFY THAT I AM ENTITLED TO THE NUMBER OF WITHHOLDING ALLOWANCE S CLAIMED ON THIS CERTIFICATE OR ENTITLED TO CLAIM EXEMPT STATUS.

I UNDERSTAND THAT ANY EXEMPTION FROM WITHHOLDING EXPIRES ON FEBRUARY 15TH OF THE FOLLOWING CALENDAR YEAR.

/	/
ATTACH A COPY OF SOCIAL SECURITY CARD HERE.

(DAA003 REV. OCT. 30, 1997)	OMB NO. 1545-0010
MM DD	YYYY

SIGNATURE	DATE SIGNED

STATE OF FLORIDA

J0JEM

2001-07-09

mcgillj

FDLES J&B OIT