Federal Form W-4 — Employee's Withholding Certificate

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IRS Form W-4 collection wrapper for new hires and mid-year changes. Captures filing status, multiple-jobs adjustment, dependents, deductions, and additional withholding under IRC § 3402.

BTL-PBL-05.011

Form

Vol 05 — Human Resources & Talent

Step 1 — Personal Information

Full name *

Social Security Number *— Required by IRS. Verify against Social Security card.

Home address & ZIP *

Filing status *— (a) Single or Married filing separately · (b) Married filing jointly or Qualifying surviving spouse · (c) Head of household.

Step 2 — Multiple Jobs or Spouse Works (complete only if applicable)

Method used— (a) IRS Estimator at irs.gov/W4App · (b) Multiple Jobs Worksheet on p. 3 · (c) Check box 2(c) if there are only two jobs total.

Check box 2(c) — only two total jobs, similar pay

Yes / N/A

Step 3 — Claim Dependents & Other Credits

Qualifying children under 17 × $2,000

Other dependents × $500

Other credits (add total)

Total Step 3

Step 4 — Other Adjustments (optional)

4(a) Other income (not from jobs)

4(b) Deductions (above the standard deduction)

4(c) Extra withholding per pay period

Step 5 — Employee Signature

Under penalties of perjury, I declare this certificate is true, correct, and complete. *

Yes / N/A

Employee signature *

Date *

Employer Use Only

Employer name & address

First date of employment *— Reported to state new-hire directory within 20 days (42 U.S.C. § 653a).

Employer EIN

Prepared by

Name · Title · Date

Reviewed by

Name · Title · Date

Approved by

Owner · Katheryn L. Wilkins · Date

Controlled document — BTL-PBL-05.011. Complete all required fields (marked *). Retain per Volume 15 retention schedule.