Employee's Withholding Certificate

First name and middle initial Last name Social security number Address City or town, state, and ZIP code Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head of household 3(a) Qualifying children x $2,200 3(b) Other dependents x $500 3 Total (add 3(a) and 3(b)) 4(a) Other income 4(b) Deductions 4(c) Extra withholding Date